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Science & the Public

Electronic Records: A Way to Stretch Nurses

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One development that the new president campaigned on last year — and reinterated in his first televised press conference tonight — is a comprehensive national transition to electronic medical records. The generalities I’ve read about such a program left me dubious about whether its benefits would necessarily outweigh costs. However, after what I’ve heard this weekend on a visit with family in Chicago, I’m becoming a convert.

My folks live in a retirement community whose residents appreciate comfort in their golden years. Many settled here after being business leaders, academics, artists — even engineers or research physicists. They tend to expect efficient services, not to mention a detailed accounting of what they’re paying for.

Which explains, in part, a residents’ meeting this morning (which I watched on closed-circuit TV in my folks’ apartment). There, Chris Andersen, health center administrator of the Beacon Hill Retirement Community, described the first wave of its transition to electronic medical records. Like the 10 other members of the Des Moines-based nonprofit Life Care Retirement Communities, this facility just outside Chicago has plenty of records. And it’s become the company’s guinea pig for computerizing them all.

People here tend to be in their mid-80s (with at least four centenarians in their midst), ages at which body parts become increasingly unreliable. So the facility runs a medical center that offers care for those who are recuperating from major illnesses and surgeries, need long-term palliative care, or require custodial attention for dementia.

Needless to say, problems big and little plague most residents. And in any given year, Andersen says, perhaps 20 percent of the residents make use of at least some services of the 108-bed med center.

In its effort to maximize care, minimize errors and keep costs under control, this retirement complex — which includes 397 apartments — began training its medical personnel in the new technology last fall. The program formally rolled out on Nov. 18.

It relies on customized software. An initial survey by its developer found that although some medical staff were initially reluctant to learn the technology and change their ways, within three weeks of using it, 93 percent said they now “loved” the new system. The satisfaction rating by Beacon Hill’s staff, Andersen says, “is probably 100 percent” — and most here would never want to go back to paper charting of patient records.

One reason: Recordkeeping can consume the majority of a nurse’s day. Each shift, Andersen told me, the new system “will save roughly three hours of mundane charting on paper [i.e. medical recordkeeping] per nurse, per shift.” Bottom line: The staff now has more time for patients. Indeed, for a five-nurse team per shift, it’s like getting the hands-on care of an additional two nurses.

Each nurse’s aide carries a PDA-size hand-held computer to input new real-time data into a patient’s file. For instance, when charting skin problems and wounds, an aide would call up a little outline of a human body and map with a dot where each of the patient’s skin problems existed. Data about each wound, rash, mole or whatever would then be wirelessly transmitted to the nurses’ computers and inserted into the patient’s file. Afterward, those time-stamped files would be linked to the appropriate dot on the body map, and could be called up by touching that spot on the body diagram.

The long-term-care industry is heavily regulated, Andersen notes. Indeed, he quips, it’s second only to the nuclear power industry in that respect. Being able to justify that the care a center offers is appropriate and timely requires heavy documentation. And nurses have traditionally had to draft “narrative” explanations of a patient’s care, each shift.

Now, software allows them to answer questions from a detailed list of options: like the number of wounds, size of each (from a list of ranges), whether there’s an associated discharge, color of any discharge, and more. Afterward, the software generates a written narrative describing Mrs. Smith’s condition: “She had a 3-cm wound on left hip. No drainage noted. Color of wound was pale pink.”

Or perhaps a doctor has prescribed the administration of a particular heart drug, like digitalis, but only if the patient’s blood pressure isn’t too low. The new system would alert the nursing staff to get a blood-pressure reading, log it into the computer, and confirm that it justified the heart medicine before the drug could be dispensed.

That’s part of a electronic-medication portion of the new records system, which is due to be phased in here next month. All new prescriptions will soon be sent automatically to a local pharmacy, which drops off the meds as needed around the clock. All results from offsite labs or facilities performing diagnostic procedures will be automatically sent to a patient’s file. So there’s no need for phone calls or faxes to be charted, and the data will become available to staff as part of a patient’s file at this complex within minutes of their being available.

Oh yeah, there’s also the issue of clarity. Doctors’ handwriting is notorious for being inscrutable — at least to we civilians. It turns out that sometimes it’s hard to interpret by medical staff as well. Not so when they’re typed and then emailed or otherwise electronically downloaded to a patient’s file.

There are still problems of doctors and other staff being tired or careless. Automation won’t eliminate either. But the new systems rolling out, like those here at Beacon Hill, could provide automatic checklists that reduce the risk that inattentiveness or sloppiness will lead to patient harm.

I also worry about privacy. Once records enter the cyber world, they are theoretically available to hackers and on-staff snoops. And they’re potentially easier to find, lay your virtual hands on, and copy or alter than the old-style paper records were.

But the big benefit, as I see it, is allowing nurses to do what they trained to do. Attend to the sick and injured.

My sis is a nurse who works days at a hospital and every other weekend at a special facility for the critically injured. It’s at this second so-called “skilled-care” center that she experiences the most stress as the only nurse attending to a ward having perhaps 18 acute-care patients. Some are on IV-antibiotics, a handful will have tracheotomy-tubes and at least as many may have gastric tubes for feeding.

Sis noted yesterday that she spent all day Saturday  — clocking in at 6:24 a.m. and out at 5:41 p.m. —  running around administering meds, re-dressing wounds, getting patients formally discharged and informing families of their loved ones’ status. She brought lunch but had no time to microwave it and eat it. Her only meal all day: a piece of candy offered by a patient’s visiting family.

There’s a critical nationwide shortage of floor nurses — the ones that attend directly to a patient’s needs for care and comfort. And documentation of patient care can be extremely distracting of administering that care, further diminishing the effective number of nurses available. Or vice versa.

In fact, my sister mentioned that one colleague on another ward where she works a second job told her that the admitting details for one patient who came in Friday didn’t get fully charted for more than 24 hours — three shifts. That’s “uncalled for” the nurse had complained to management. What these places need are a willingness to hire more nurses, and doling out their precious skills as effectively as possible.

Perhaps computerized patient recordkeeping will improve a patient’s chance of gaining quality time with his or her nurses — and allow my already too-trim sister a chance to eat her lunches.

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