eHealth:
Impact of
Missing
Documentation
Noreen Frisch, PhD, RN
Professor and Director
School of Nursing
University of Victoria
Faculty/Presenter Disclosure
 Faculty:
Noreen Frisch
 Relationships




with commercial interests:
Grants/Research Support: NONE
Speakers Bureau/Honoraria: NONE
Consulting Fees: NONE
Other: NONE
Disclosure of Commercial
Support


This program has received NO financial support.
This program has received NO in-kind support.
 Potential for conflict(s) of interest:
 Noreen Frisch has NOT received payment or funding
from any organization for this program and/or from
any organization whose products are being
discussed.
 Organizations that hold the copyrights and
intellectual property rights to any of the standardized
terminologies discussed may benefit from the
sales/licenses of these terminologies.
Mitigating Potential Bias
 The
material presented here is drawn from
an extensive literature review – all
information presented is publically
available.
 Professor Frisch is an academic presenting
her own views on the topic of ‘missing
documentation’ Complete reference lists
are available for those interested.
We are at risk of missing data
in EHRs

Documentation of the full scope of nursing
and allied health contributions to health care
practice

Full scope:

Naming or labeling of conditions addressed by
nursing allied health professionals

i.e. each discipline’s “phenomenon of concern”
Identification of the professional interventions
enacted related to these conditions
 Documentation of patient of client care
outcomes associated with the practice of
nursing and allied health

Documenting the ‘full scope’

What is recommended by various disciplines



Nursing – use of standardized terminologies
[such as the ICNP] to record the breadth of
professional nursing practice (ICN)
Dietetics – use of the Nutrition Care Process and
the International Dietetics and Nutrition
Terminology [IDNT]
Physical Therapy and Speech Language – use
of the International Classification of Functioning,
Disability and Health [ICF]
What is in our EHRs?

Medical terminologies

ICD – International Classification of Diseases
 SNOMED-CT

Systematized Nomenclature of MedicineClinical Terms
 Problem

Lists
Issues that must be addressed by the care
team
Interface and Reference
Terminologies
 Interface

terminology –
Used for clinical documentation
 Reference

terminology –
functions as a background terminology, or
one that takes terms from clinical
documentation and behind the screencan
map words/phases to common concepts
that allow data aggregation when different
terminologies are used
Literature Review
 Using
CINAHL as a database, a search
was done to retrieve the literature on
electronic documentation for Nursing,
Physical Therapy Practice , Dietetics and
Speech Pathology and Audiology.
For Nursing
 Using
[Nursing] and [standardized
languages] - CINAHL retrieved 153
documents published between 1995 and
present, of which 132 were directly
relevant to documenting the full scope of
nursing practice
 Using [Nursing] and [electronic] and
[documentation] CINAHL retrieved 409
articles, and 184 were directly related to
use of electronic health records
Nursing and SNLs (most
frequent)
 40
papers on use for specific patient
populations
 23 on defining SNLs and teaching them
 21 on implementation projects
 20 on how SNLs can increase
professionalism and visibility of Nursing
 13 on development of SNLs
 11 on use in EHRs, mapping, coding
Nursing and Electronic
Documentation (most
frequent)






65 papers address the scope of nursing practice/
care planning and criteria for evaluation of nursing
practices
33 address specifics health conditions or disease
states (pressure ulcers/pain/ speciality practice
areas)
23 address nursing workflow and management
issues
21 report actual integration/implementation
projects
18 address education
17 on nurses’ attitudes about EHRs
Physical Therapy

Searching for [physical therapy] and [standardized
language] resulted in only two papers



One related to the ICF
One related to use of NNN terminology for PT, OT and
Speech Pathology
Searching for [physical therapy] and [electronic
documentation] yielded 7 papers




1 on falls assessment (interdisciplinary)
1 on PT and OT in hospital EHRs
1 on electronic order entry
Others r/t home health, PT retention, rates or reasons
for non-Rx with PTs, and moving to electronic
documentation
Grey Literature on PT
 American


PT Association
Endorses the ICF as a framework for PT
practice and did so in 2010
The ICF which is the International
Classification of Functioning, Disability and
Health is a WHO classification system that
was designed to partner with ICD so that
ICD and ICF could (together) provide a
more comprehensive view of health
For Dietetics


Searching for [dietetics] and [standardized
language] resulted in 8 papers – all related to
the Nutrition Care Process (NCP) and the INDT
the International Dietetics and Nutrition
Terminology
Grey Literature – CANADIAN PERSPECTIVES
ON THE NUTRITION CARE PROCESS AND
INTERNATIONAL DIETETICS AND NUTRITION
TERMINOLOGY (2010) supports the use of the
NCP and the INDT
For Audiology/Speech and
Hearing
 Virtually
no publications retrieved related
to the discipline and electronic health
records of standardized languages
 Grey Literature

From the International Encyclopedia of
Rehabilitation – language disorders follow
the DSM terms
What does this literature tell
us?
Summary:



Nursing and Dietetics have developed
discipline-specific standardized languages to
document the full scope of the professional
practice
PT identifies ICF as a framework for
documenting its practice and in some cases
the ICF also represents
speech/communication disorders.
Another set of communication disorders is
represented in the DSM.
So – what did we learn?
In Nursing
 In
locations where there is use of
discipline-specific terms, the visibility of the
profession has increased
 Use of discipline-specific terms have also
increased the nurses’ sense of
professionalism
 Use of discipline-specific terms is thought
to influence quality of care.
Sansoni, J & Guistini, M. (2006) More than
terminology: using the ICNP to enhance
nursing’s visibility in Italy, International Nursg
Review 53, 21-17
 In
validating the ICNP for use in Italy,
researchers found nursing visibility was
enhanced through outcome measures as
well through their study of nursing
documentation through use of a
common language.
Of the nursing papers on
implementations
about half addressed organizational
requirements for uptake of use of
electronic nursing documentation
 what authors report :

von Krogh, G & Naden, D (2008) A nursingspecific model of EPR of nursing
documentation. J Nursg Scholarship 40(1) 6875




Experience in Norway where nursing
documentation is guided by a Health Personnel
Act
Nursing modules in the EPR require process
documentation – in form of a care plan and
record notes in form of free text.
Presented challenges for vendors
Solutions included use of NNN for user interface
and SNOMED for reference terminology and
also incorporated the NMDS
Muller-Staub, M, Needham, I. Odenbreit, M.,
Lavin, M, and van Acherberg, T. (2008).
Implementing Nursing diagnosis effectively. J
Advanced Nrsg. 63(6), 208-212.
 Nurses
have a need for education and
learning about diagnostic reasoning
 An interactive learning method – guided
clinical reasoning -- was instrumental in
establishing nursing electronic records
Noah, P. (2011) Implementing electronic
documentation. Critical Care Nursing Quarterly,
34(3) 208 – 212.



Clinical ownership of the record is vital
Describes how Nursing and IT worked
collaboratively to meet nursing
requirements to document aspects of care
(pain management)
Planned change processes are essential as
is strong leadership
Klehr, J. et al. (2009) Implementation of
standardized nomenclature in the EMR,
International J Nursing Terminologies and
Classifications 20(4) 169 – 180.



Describes with an EPIC system to enable
documentation of NNN within the system
Identifies challenges with incorporating a
reference terminology into a system that at that
time could not be imported into the system
The organization pursued licenses with NANDA-I,
NIC and NOC for care plan master files and
their Epic administrators handbuilt problems,
goals, or interventions that did not fit with
available nursing terminology.
Of the allied health papers
 Like
in Nursing, a clear call for
documentation of full scope of practice
 Unlike Nursing, less writing about the
supports and barriers to documentation n
electronic records.
Take Home Messages
 Need
for systematic and integrated
literature review

Reasonable from an academic/scholarly
perspective
 Need
for action in the area of
procurement and system design (and
possible regulation)

Reasonable from a practical perspective
Conclusions



There are numerous studies that document
that use of Nursing terminologies raise the
visibility of the discipline and contribute to
quality of care (N = 20)
EHRs in Canada and elsewhere need
capacity to document the full scope of
practice form nursing and allied health
Attention to the interface terminologies is
critical - how do our systems use and receive
nursing and allied health terms?
Conclusions
 Discussions
with vendors and others must
include how disciplines other than
medicine be represented in the record

Problems lists are not sufficient to document
the scope of the practice of these
professionals
 Nurses
and those at executive levels must
be involved in procurement decisions
Are we preparing nurse leaders for
information age activities in our
practice settings?
 Only
1/3 have any preparation at all in
informatics and need for electronic
documentation*
 Probable similar results for other future
managers/executives

*Review of curricula, west coast graduate
programs : by Mary Oakes, RN, MSN; Pamela
Potter, RN, DNSc; Holly Shadburne, RN, BScN; (U of
Portland) and Noreen Frisch, RN, PhD, and
Elizabeth Borycki, RN, PhD
Prominence of Physician
documentation
 In
2006, we had a call for expanding
emphasis to more than physician practice
in our electronic records
 Hagland,
M. (2006) Nursing takes center
stage: hospitals are realizing that a singular
focus on the needs of physicians leave
nursing out in the cold. Healthcare
Informatics, 23(4) 46.
 Where
did that call take us?
Where is Nursing in the
Electronic Health Record?
 Published

paper in 2009
UVic: Mitchell, B, Petrovskaya, O,
MmcIntyre, M and Frisch N Stud Health
Technol Inform. 2009;143:202-6.
Parting words
 Nursing
may find support in reaching out
to other health professions in efforts to
include all interface terminologies in our
records
 Nursing must advocate for presence in
EHRs beyond lists of activities
 Nursing and allied health need to be
proactive in procurement and
implementation actions
Noreen Frisch
 nfrisch@uvic.ca