MODULE 2 ENTRY
At work, I have been involved several ways with our computer information system. When we first started with EHR, I was involved in creating templates for our EHR system for the nurse practitioners and myself. The physicians were resistant to using the NP templates. They felt it was too much charting and because they wanted to document "normal" - instead of objective descriptions - as part of the objective data. However, when the Case Management committee refused to reimburse or pay for their referrals due to lack of adequate charting then they got on board for using some of the templates and descriptions.
I was also involved in setting up a template for the clinic nurses to use to document encounters. The clinic nurses had been using free text instead of SOAP charting and the template was helpful for that.
One of the more current projects I was involved in was being able to retrieve data on the pediatric clients with BMI's greater than the 95% on the peds charts. For some reason, we were getting extraordinarily low numbers off EHR that did not reflect what we saw in clinic. I actually (with the help of my nurse) started to compare data taken by hand with the EHR data for almost a month. We found there was a major discrepancy with our data reflecting rates in the 50% to 60% for ages 2 to 5 years and data off EHR was showing only 10% for the same age group and time. I was working with the IT person about this to determine what may have been entered incorrectly to make the computer unable to retrieve this information accurately. Since the Diabetes team (I was the medical consult for the peds part of this grant) had a grant to facilitate and implement programs to treat and prevent peds obesity we wanted to make sure we were capturing data correctly. Unfortunately, I resigned my position before this was completed. I have heard the problem still exists with data inaccuracies.
I was also involved with GPRA coordination of screening. My goal was to have the nurses utilize the same methodology for screening for GPRA questions. I was also in this process when I left and unfortunately, this mantle has not been assumed by anyone else so the nurse are counting GPRA numbers inaccurately. For example, a nurse may ask a client "are you depressed?" when doing an intake and count that as "screening for depression" under GPRA instead of uysing a standardized set of questions.
It is all very interesting but I wish I had this class knowledge BEFORE I had tried to implement any of those programs or changes.
A typing class for all the providers would have helped also :)
Excellent comments Bridget! I cannot tell you how may times I have heard the comment "nurses chart too much" from physicians. But you find that some like the narrative because it gives them a clear picture. We had to add narrative function to our current system because physicians asked that it be included.
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