1
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7
KEYWORDS
Functionality
Policy
Clinical practice
Efficiency
Optimization
Copy forward
Hardware
Mobile
Portable devices
Criteria for selection
Storage
Power
Hallway
Fire codes
State regulation
QUESTIONS
What issues should be considered related to
‘copy forward’?
What are current practices related to use and storage of mobile documentatio n devices such as rolling computer carts?
ANSWER
Copy forward may be used very carefully. Clear policies covering this use should be available.
When making this decision, the following should be considered:
Stakeholders in the decision: CNO’s,
Practice Councils, Risk Management,
Legal department.
Review of software to determine functionality – clinical IT and clinicians
Is ‘copy forward’ present in any application currently?
What data is copied forward – and what is not allowed to be brought forward?
Is there a standard in place?
How is validation accomplished? How the caregiver is assured that the data is not simply copied forward, but is reviewed prior to storing the data?
To be considered:
Instruct staff to move mobile devices from hallways into alcove or nurses’ station to comply with fire/state regulations.
For design/redesign, consider creating elevated floor with outer perimeter docking or alcoves that includes power/network drops.
Consider wireless.
How are devices flexed in response to staff or patient census. What area is
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Melissa Barthold
Lisa Bove
Jim Cato
Brenda Kulhanek
Brenda Kulhanek
Lisa Bove
Melissa Barthold
Portia Towns
DATA OR
EVIDENCE?
Evidence and data-
Survey
Results:
(date)
Data
Page 1 of 20
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REFERENCE/SOURCE http://journal.ahima.org/2
008/06/04/an-appropriateuse-of-copy-forward-witha-caveat/
Discussion on CARING list
DATE
April,
2009
CARING list July 2009

3
REF # KEYWORDS QUESTIONS
Fire
Regulation
Design
Ergonomics
Physiological data
Monitors
Data validation
Interface data capture
Policy
Practice
Optimization
Are mobile carts (COW’s,
WOW,s, etc.) allowed in the hallway?
Should physiologic data imported from monitors be validated before data is it stored in the EMR?
ANSWER available for parking the devices to maintain power?
Place outlets/network drops at an ergonomic height.
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DATA OR
EVIDENCE?
Any physiological data imported from monitors into an electronic documentation system must be approved or validated by the nurse prior to its storage in the EMR.
Issues: Validating that data is correct coming across an interface
Ensures clinician evaluation of the data prior to storage and provides the ability to observe trending or to correct technical issues, such as lead artifact or monitor/interface issue.
Brenda Kulhanek
Lisa Bove
Melissa Barthold
Portia Towns
Data-
CARING list
Further questions for investigation
2 Electronic
Signature
HIPPA
Documentatio n
Policy
Practice
How is the electronic signature defined?
Electronic signature is legal in all
50 States and the security standards of electronic signatures are addressed in the security and privacy provision of the Health
Insurance Portability and
Accountability Act (HIPAA).
It can be an electronic sound, symbol, or process associated with a record.
It can be an automatic signature added by a system when an entry is saved by the user or it can be an intentional act of signing an electronic document.
It is an electronic indicator added
Melissa Barthold
Brenda Kulhanke
Trish Gallagher
Lisa Bove
Portia Towns
Portability and
Accountability
Act (HIPAA)
NUMBER OF
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Page 2 of 20
REFERENCE/SOURCE
Discussion on CARING list
Portability and
Accountability Act
(HIPAA). http://www.hhs.gov/ocr/priv acy/hipaa/administrative/st atute/hipaastatutepdf.pdf.
DATE

4
REF # KEYWORDS QUESTIONS ANSWER
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DATA OR
EVIDENCE? to the electronic medical record, including flowsheets, orders, notes, etc. that indicates signature of the licensed provider.
It may not require additional separate action (such as re-entry of a password) – it may be as simple as the act of saving the data entered is the ‘signature’.
HIPAA-covered entities that use electronic signatures for transactions must adhere to U.S.
Department of Health and Human
Services electronic signature standards. The software program must provide:
 Nonrepudiation - assurance that the signer cannot deny signing the document in the future,
 User authentication - verification of the signer's identity at the time the signature was generated, and
 Message integrity - certainty that the document has not been altered since it was signed.
Documentatio n
Standards
Policy
What should be considered when designing
When making this decision, the following should be considered:

Build documentation that reflects
Melissa Barthold
Brenda Kulhanke
Trish Gallagher
Lisa Bove
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REF # KEYWORDS QUESTIONS
Practice
Requirements
Design
Minimum data sets electronic documentatio n?
ANSWER
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DATA OR
EVIDENCE? standard practice and regulatory requirements. Examples: Minimum data sets from nursing organizations, Joint Commission,
CMS and the Bureau of Vital
Statistics.

Who is going to view/utilize the data? Only collect data that is used by the care team or regulatory requirements.

Purpose of documentation: o Communication among caregivers o Support of billing o Potential for research o Longitudinal record of patient’s health status and treatments

Support documentation of assessments and treatments that reflect the standard of patient care as established by local, state and national regulations
 Guides staff to document the “right things” by preventing documentation of the “wrong things” through proper design
 Guides staff to document the “right things” by preventing documenta tion of the “wrong things” through proper design
Suggestions:

Documentation Categories:
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5
REF # KEYWORDS QUESTIONS
What type of format should be used to indicate errors or changed documentatio n?
“Error explanations– changes – how much should be in
ANSWER
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DATA OR
EVIDENCE? o Assessments o Interventions o Biometric data o Summary/Evaluation data o Progress Notes o Care Plans o Demographic data o Patient education o Communication to members of the patient care team o Communication between members of the patient care team

Format of documentation o Easily viewed o Supports efficient documentation o Ability to obtain data for reporting (limited free-text fields) o Consider all disciplines- documentation needs and access needs
Is this vendor specific? Can it be configured to one standard?
CHIT standard?
HIM standard?
Risk Management?
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6
8
9
REF #
24
KEYWORDS QUESTIONS ANSWER
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DATA OR
EVIDENCE? strikethrough format? Or should it be in that format?”
What policies should be addressed prior to electronic documentatio n design/imple mentation?
What are the best devices and device configurations that support nursing workflow?
When making this decision, the following should be considered:
Do you support point of care (real-time at the patient’s side) charting?
What applications are currently in use and what are planned?
If you are using electronic medication records with bar coding, do you need a place to store individual medications?
What is the best practice for maintaining the power supply on mobile devices?
How is the appropriate number of documentatio n devices
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REFERENCE/SOURCE DATE

REF #
10
11
KEYWORDS
Charting
Real time
Point of care
Documentatio n
Devices
QUESTIONS ANSWER
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DATA OR
EVIDENCE? determined?
How is
‘timeliness of charting’ defined?”
How is this affected by the constraints of documentatio n technology?
Are ‘default’ answers in forms permitted?
When making this decision, the following should be considered:
Was there a ‘timeliness of documentation’ policy before automation? Any such policy needs to be reexamined or created prior to implementation of electronic documentation.
Has timeliness been defined in other applications such as medication administration or ancillary charting?
What type of device (WOW, tablet, compute in the room, desktop, etc.) does the user have access to?
Generally, prior to automation,
‘timeliness of charting’ was defined by the expectation that the clinician would complete documentation prior to the end of their shift. With automation, the focus has moved to ‘real-time’, although ‘real-time’ can vary based on the type of device that a clinician uses.
Late charting has been defined anywhere from 30 minutes (often based on medication administration policies) to 4 hours (batch charting twice a shift).
However defined, the policy needs to match practice.
When making this decision, the following should be considered:
Do you allow defaults on paper forms
Melissa Barthold
Brenda Kulhanke
Trish Gallagher
Lisa Bove
NUMBER OF
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Page 7 of 20
REFERENCE/SOURCE DATE

REF #
12
13
KEYWORDS
Trish
Trish
QUESTIONS ANSWER
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DATA OR
EVIDENCE?
How is the scope of default answers determined?
What processes are used to document during a computer downtime?
What data entry recovery and backfill processes are used after a computer downtime?
What are the decision making processes to determine what data gathered during a downtime is backfilled into the computer system? What timeframes are used to determine what data is backfilled into the system and when the or in other applications?
Part of the project implementation should include a multidisciplinary focus group to determine downtime processes based on different types of downtime (ie Network, EMR clinical repository, ancillary systems that are interfaced etc). The main focus in determining what information is entered after a downtime should be centered around ensuring that risk to the patient is minimized after a downtime. It is important to consider:
1.
The type of information.
Information such as allergies, height and weight for
Pharmacy orders and medication information should always be back entered since this is information required for the care of the patient.
2.
Who uses the information? Is the information only used by one ancillary department or is it reviewed by numerous providers to make clinical decicions?
Brenda Kulhanek Data
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REF #
14
KEYWORDS QUESTIONS backfill must be completed?
Lisa What is current practice for
ANSWER
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DATA OR
EVIDENCE?
3.
How long has the system been down? A downtime which impacts a change in care providers (ie over a shift change) may be handled differently than one that does not. Often a downtime that is
4 hours or less may be handled differently than one which extends longer than 4 hours.
4.
Shat is the impact to it not being available in the EMR? If the patient is readmitted, will the information be valuable to have in the EMR (ie home medications, allergies, history etc)? Is the information related to the medication administration process? This high risk process may need to be handled differently since it involves a higher risk to the patient.
5.
What risk exists for the patient if the information is not entered?
6.
Is there a mechanism to denote a downtime occurred in the EMR so providers reviewing the information know to reference the paper chart
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REF #
15
16
KEYWORDS QUESTIONS ANSWER
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DATA OR
EVIDENCE? communicatio n of downtimes to clinical areas?
What is current practice for communicatio n of systemrelated changes, enhancement s or downtimes?
Does charting-byexception support best practice? Is it legally defensible?
Charting by exception has been successfully implemented in many organizations. Important considerations:
1. Clearly define normals in documentation policy or in documentation system
2. Clearly define proper charting process and content for abnormals
3. This method of charting cannot be used to document teaching
4. changes in the patient’s condition, while still within the normal range, should be documented
5. Chart on time
6. Charting by exception has been associated with a decrease in nursing charting time of up to 75%
7. Meets JC Standards for individualization of patient care
Melissa Barthold
Brenda Kulhanke
Trish Gallagher
Lisa Bove
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RESPONSES
REFERENCE/SOURCE
"Ladies & gentlemen of the jury, I present... the nursing documentation".
Full Text
Available (includes abstract); Austin S;
Nursing, 2006 Jan; 36 (1):
56-64 (journal article - case study, CEU, exam questions) ISSN: 0360-
4039 PMID: 16395021
CINAHL AN: 2009089387
American Journal of
Nursing:
March 1999 - Volume 99 -
Issue 3 - p 24G, 24J
(http://journals.lww.com/ajn online/Fulltext/1999/03000/
Charting_by_Exception__A
_timely_format_for_you_.1
6.aspx)
Charting by Exception
Applications: Making It
Work in Clinical Settings by
Laura J. Burke and Judith
DATE
Page 10 of 20

REF # KEYWORDS QUESTIONS
17
18 Brenda
What is current practice for enhancement request prioritization?
How are clinical enhancement requests reviewed?
Does the review of clinical enhancement requests include an assessment of the clnical impact of the changes?
What documentatio
ANSWER
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REFERENCE/SOURCE
A. Murphy (Ring-bound -
Jan 15, 1995)
Charting by Exception: A
Cost Effective Quality
Approach (A Wiley medical publication) by
Laura J. Burke and Judy
Murphy ( Paperback - Oct
19, 1988
Charting by exception: http://allnurses.com/nursin g-student-assistance/helpplease-charting-
296172.html
DATE
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REF #
19
KEYWORDS QUESTIONS ANSWER
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DATA OR
EVIDENCE? n by nonlicensed staff is permitted in the EMR?
What is current practice related to RN co-signature of documentatio n entered by non-licensed staff? Is the practice or policy enforced through technology or policy alone?
What is current practice related to managing clinical students’ access to clinical documentatio n systems?
It seems that typically, prior to the beginning of each semester, the instructor contacts the IT department to assign user names and passwords to the students. The access administrator receives a list of students who will need information from or be entering information into the patients electronic medical record then assigns usernames and passwords to the instructor. This access typically has an expiration based upon the end of the clinical course. It is apparently a lot of work to manage all the different clinical students who train in the hospital so some hospitals are assigning username and passwords for the entire time the student is enrolled in their respective
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CARING
DATE

REF #
20
KEYWORDS QUESTIONS
How is the future state included in the planning and execution of current implementatio ns or enhancement s? How are technology decisions analyzed that may negatively impact future enhancement s/building?
How are decisions made when an urgent need is addressed in a future enhancement that is not an organizational priority? What is the current best practice window for future
ANSWER
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DATA OR
EVIDENCE? nursing school, medical school, rt, pt, ot, etc. Some hospitals give nursing students full security rights as they would have as registered nurses while others restrict their security rights to a student nurse status.
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REF #
21
22
23
24
25
KEYWORDS
Portia
Jim
QUESTIONS technology planning?
What is current practice for training staff.
What is the current practice for training and utilizing
SuperUsers?
How are
SuperUsers best utilized as a resource?
What QA is necessary for electronic systems?
Who should do QA?
How is standardizatio n of practice documentatio n analyzed, implemented and measured?
What is the current state of EHR use in mental health?
How are ancillary departments
ANSWER
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REF #
26
27
KEYWORDS
Mark
QUESTIONS ANSWER
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DATA OR
EVIDENCE? trained to use the EHR?
What is the best practice for use of computer protective equipment such as keyboard covers, and computer cleaning for computers used in patient care areas
What is the best way to plan and manage ongoing change between IT and the clinical areas?
Simple Answer: The best way to plan and manage ongoing change between
IT and Clinical Areas is to have an IT
Adoption Methodology that promotes change management along with a supportive organizational culture.
Six key principles of effective, sustainable change management include: (See Graphic)
1. Need for Change – the need for change (“Why?”) needs to be clearly articulated, documented and communicated. Without a need for change there will not be any action
2. Shared Vision – often times organizations function in disparate, departmental silo’s. Having a common/shared vision for where the organization is headed is a key success
Mark Data
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Page 15 of 20
REFERENCE/SOURCE
Multiple documents
DATE
9-4-09

REF # KEYWORDS QUESTIONS ANSWER
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DATA OR
EVIDENCE? factor to effective Change
Management. Without a shared vision there will be a “fast start that fizzles” as other competing priorities take over.
3. Leadership Commitment – the organizations entire leadership team (not just certain individuals) must be committed to the change.
Anxiety and frustration will result without a unified leadership team to drive the change.
4. Employee
Involvement/Commitment – employees will be resistant to any change that they feel has been forced upon them. Early involvement of employees and a demonstrated commitment to change is essential
5. Integrated Organizational
Change – invariably a change in one area of the organization will trigger a change in another. Integrating change across departmental prevents a
“siloed” view of the change.
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REF #
28
KEYWORDS
29
QUESTIONS
How is emergency access to the
HIS available?
ANSWER
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DATA OR
EVIDENCE? data For staff members, such as those from
Organ Procurement provided 2/47?
Identify staff who may be using the system.
Preferred: Create logins for all agency staff members.
Create one ID for each agency and require a member to call the help desk, where the date/time/name of the staff member is recorded prior to issuing a password. The password expires in a defined time frame.
REVIEWED BY
(TASKFORCE MEMBER)
Melissa Barthold
Brenda Kulhanke
Trish Gallagher
Lisa Bove how you manage sound on computers in your hospital setting. We are having discussions about enabling sound on select devices where possible for nursing and patient education
(products like
Elsevier, etc).
How do your hospitals handle staff and patient education? Do you have sound-enabled devices at certain locations? If so, how is your patient
Page 17 of 20
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8-14-09
CARING list 8-18-09

REF #
30
KEYWORDS
Melissa
QUESTIONS ANSWER
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DATA OR
EVIDENCE? education material approved? Do you have sound at devices in nursing stations
How are CPOE order sets best created?
Like most things in our increasingly complex lives - one size doesnt fit all for CPOE implementation. There are significant differences between critical access hospitals vs regional hospitals vs tertiary care facilities. Vertically integrated systems have different issues than do horizontal systems. Below, I provide some recommendations:
1) Situational Awareness theory says that the more you automate a process - the less aware you become of the process being automated. There can be an increased incidence of providers becoming reliant on the orderset to guide their decision making verses facilitating their decision making. Make sure your ordersets are clear, unambiguous and provide sufficient ability for choice - without making it too broad or too restrictive.
Data
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Caring List
DATE
8-7-09

REF # KEYWORDS QUESTIONS ANSWER
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2) Study, study, study. Make sure you understand how the organization and all its parts work - and why. The more you know - the more you can produce competent tools and drive change.
3) Standardize, standardize, standardize. Use a style guide that defines what words mean, where orders are found, in what order they appear, how they are name etc. Ordersets should be predictable - so that regardless of the clinical situation, providers can order safely and efficiently.
4) Know the technology - what it can do and can not do.
5) Test, test, test. Do exhaustive testing with complictated and high-risk workflows, like: blood transfusion, titrations, pre-ops and oncalls, sedation, lab based admins etc
6) Ordersets and CPOE isnt just about physicians! The order/orderset must meet physician workflow AND the departments that complete
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REF #
31
KEYWORDS QUESTIONS ANSWER
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DATA OR
EVIDENCE? them.
7) Confusing or error prone paper based work flows make confusing and error prone CPOE workflows. Fix policy and workflow BEFORE going live with CPOE.
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