( Originally Posted on Medium.com)
I recently read an article about communication in healthcare. The article by Brian Russel Davis of Axiom88 can be found here.
When Brian wanted to communicate important information about a child’s care, he knew that the best way to ensure the communication took place was to take drastic measures. He chose to sleep overnight at the hospital and personally deliver his handwritten notes to the child’s provider.
Systemized Storytelling
I would love for information to be communicated to all who need said information in a way that has a 100% success rate. As a registered nurse, I am unsure what other options Brian had to make sure the child’s provider knew what soothed his trauma.
For example, one person could be under the care of many specialists. Take patients living with Lupus; they may be treated by cardiology, nephrology, rheumatology and others. Yet while in the hospital, they will have one nurse. Our view of the person’s response to disease is holistic. Communicating the concerns among the person receiving care and the many specialists back to the nurse providing care and treatment can be challenging. Communicating the softer messages of comfort back to the provider can be nearly impossible and may not be appreciated due to the curative nature of medicine.
My ideal electronic medical record (EMR) would read like a narrative. We communicate life within a context. As a care coordinator, even a request for medication refills is not that straightforward. I need to see if this medication requires monitoring lab results. These results tells us if the medication has been effective or if changes in dosing are required. This lab information also lets us know if there is an early toxic response to the medication. Finding recent lab work requires searching through several screens, and maybe making a few phone calls when the lab work is not in the EMR. If the lab tests have been done at a facility that is not connected to our system, finding recent lab work may even require the use of a fax machine. Once I confirm that recent lab work shows no changes are needed, I note that the requested refill is different from the last visit note. This requires another workflow process to reconcile the change in medication dosing. This task may be further delayed if there is a change in insurance or if it is time for the medication to go through a prior authorization process.
There is only but so much an EMR can do to support the care I deliver. Let’s look at this from another point of view. My mom is a registered nurse as well. In looking at patterns around deaths that have resulted from sepsis, she noticed something. While many times physicians are blamed for their delay in ordering the standard antibiotic, my mom noticed another concern. Her 30-plus years of nursing experience caused her to look at “something else." This something else prompted a system-wide nurse education program. While this is amazing, how is it scalable? How can we create an EMR with a nurse’s brain?
He is alive because his dad is Brian
Brian was caring for his son who was sick and had tests ordered, yet his child was cleared for travel and they left town together. Did Brian know what usually happens to lab results after discharge? Was he familiar with the challenges around post-discharge communication?
I am not sure. To cut a long story short, a few days later, the labs showed a concern that required prompt medical treatment. How effectively was this information transmitted to the location where the child was now staying? How promptly was care delivered? Let’s just say that this child is alive because his father is Brian Russel Davis.
Response to Treatment vs. Cure
A nurse’s focus is beyond finding a cure for an episodic event. We care about the person’s response to illness as well as the response to treatment. Let’s look at the discharge orders that will never be implemented and will result in a readmission. Due to the pace of a typical unit, there are parts of the story that will not be communicated to the people who need to make clinical decisions. I have not seen a field in an EMR that asks about known barriers to implementing orders. While I am sure some EMRs have this, I have not seen one. Where do I enter that the child has sensory disorders and will not swallow the tablets and that another form of medication will be needed?
Beyond Adherence to Medical Orders
The mom of said child will go home, take the medication out of the bag, attempt to follow the orders and learn what a nurse already knew. She will then try to time administration of the medication for when she has support to help soothe her child during this experience. This effort will have a variable measure of success and the result may be that the family will be labeled as “non-adherent to medical orders." This label may impact the type of care the family receives in the future.
Similar stories happen around other challenges. For example, the person with slow healing wounds may not have the dexterity or family support to carry out the discharge wound care orders. Again, this patient’s limb depends on a nurse’s brain to look beyond the screens and see if the person is responding to treatment and then addressing the barriers to care. In short, I am unsure how an EMR that does not support my workflow can enhance the care that I provide. What can change the outcome of these stories? There are many people who are working to empower families with needed information. Brian’s article mentioned a possibility. In the meantime, take a look at a type of personal health record offered by the Lifespeed team.
Too Many Clicks Not Enough Time
Is getting to pertinent information convenient? Not really. My iPod and iPad get me. They do not require me to do much more than three clicks to get to the required information. While EMRs are a long way from minimal clicks to get to information, I am encouraged that there is at least conversation about improving nurse workflows. If you have managed to read this so far, I would love for you to end with the best part, head over to Brian’s article and take a look at the full story.
If you are one of the over 3 million end users of an EMR? I would love to hear your thoughts!