Impacting Care and Treatment of the Burn Patient Conversion to Electronic Documentation

Abstract

Improving patient care through enhanced electronic communication among health care providers is aimed at reducing the number of medication and medical errors. The American Reinvestment and Recovery Act (ARRA) was signed into law in 2009, supporting the federal government's commitment to the improvement of health care quality, safety, and efficiency through requirements to implement an electronic health record by October 2015 or hospitals and eligible providers potentially realizing penalties or reduced reimbursement rates. In addition to ARRA, Congress presented another initiative to further advance the delivery of high-quality health care, the Health Information Technology for Economic and Clinical Health Act (HITECH), leading to the authorization of $27 billion to encourage health care providers to achieve meaningful use of the electronic health record. However, the conversion of the paper medical records to an electronic version has been challenging, particularly in specialty departments. The burn unit of a tertiary hospital located in the Pittsburgh area experienced such challenges. A project plan, developed in 2009 prior to the electronic medical record going live, involved a multidisciplinary team, consisting of providers, nurses, and information system builders who came together to determine how to capture the totality of the burn unit documentation. The goal of the project was to develop an electronic documentation tool and provide a system to accurately and efficiently evaluate documentation compliance with the staff. The Lund Browder documentation tool, used with the paper medical record, was the selected tool for the electronic conversion. This tool has been regarded by most health care organizations as being the most accurate in measuring the extent and degree of the burn. With the paper documentation tool, the staff was, on average, 74% compliant with the Lund Browder tool. The electronic version and availability of the tool increased compliance to 100% in the fourth quarter of 2015.

The Analyzation of Change in Documentation due to the Introduction of Electronic Patient Records in Hospitals—A Systematic Review

“…Although the hospital setting was an inclusion criterion, the hospital setting still varies. There are differences in specialty (e.g., burn unit or orthopedic surgical ward) [ 13 , 14 ], size (e.g., 700 beds or 1,200 beds) [ 15 , 16 ], academical teaching activity, and one hospital which was not further specified [ 17 ]. Derived from that, all included studies investigate the documentation through the lens of a certain use case like for example operation reports or discharge instructions [ 14 , 18 ].…”

“…There are differences in specialty (e.g., burn unit or orthopedic surgical ward) [ 13 , 14 ], size (e.g., 700 beds or 1,200 beds) [ 15 , 16 ], academical teaching activity, and one hospital which was not further specified [ 17 ]. Derived from that, all included studies investigate the documentation through the lens of a certain use case like for example operation reports or discharge instructions [ 14 , 18 ]. The number of analyzed records varies from a minimum of 40 records (20 paper records vs. 20 electronic records) [ 19 ] to a maximum of 20,848 records (9,236 paper records vs. 11,612 electronic records) [ 20 ].…”

“…The most commonly analyzed outcomes were completeness [ 15 , 17 , 20 , 21 , 23 , 25 , 26 ], guideline adherence [ 13 , 14 , 18 , 22 ], and volume of documentation [ 11 , 16 , 17 , 19 ]. Of all included studies, 11 of 17 proved a positive effect of the introduction of the EPR on documentation.…”

Not another box to check! Using the UTAUT to explore nurses' psychological adaptation to electronic health record usability

“…Multiple contributing sources of patient data and the unique characteristics of patient health records contribute to a high degree of EHR complexity 49 . EHRs can improve the way patient information is stored, shared with others, and managed by healthcare professionals involved in the delivery of patient care 33 .…”

A Computer System for Classification of Burns and Determination of Fluid and Nutritional Needs for Burn Patients

“…Moreover, and irrespective of the complex care provided to burn patients, the extensive documentation was practically a deterrent to achieve compliance with evaluation and management needs. The amount of documentation needed to sufficiently reflect the amount of care provided to burn patients is quite extensive, but most surgeons are less familiar with the documentation requirements for evaluation and management services [3] . The revolution in the computer's development has already affected our everyday lives and we are now at the stage where we must take active steps to identify this and integrate the information storage and processing ability of computers in different burn units around the world and to provide training for all staff about it [4] .…”