Point-of-Care Technology Supports Bedside Documentation

Carlson, Elizabeth A.; Catrambone, Cathy; Oder, Karl; Nauseda, Susan; Fogg, Louis; Garcia, Brian; Brown, F. Martin; Johnson, Mary E.; Johnson, Tricia J.; Llewellyn, Jane

doi:10.1097/nna.0b013e3181ee4248

Cited by 21 publications

(14 citation statements)

References 3 publications

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“…Ward et al studied the effect of the transition from paper-based emergency care records to EHR and found that there are problems with time stamps of the data [ 28 ], and further a study on blood pressure measurement registrations in emergency departments also indicated problems with currency [ 36 ]. If the systems used for documentation are not available to the staff at the point of care registrations will be delayed [ 37 , 38 ]. We would argue that the point of care documentation concept would need to include mobility as patients and staff in a busy emergency department are on the move.…”

Section: Discussionmentioning

confidence: 99%

How to improve vital sign data quality for use in clinical decision support systems? A qualitative study in nine Swedish emergency departments

Skyttberg

Vicente

Chen

et al. 2016

BMC Med Inform Decis Mak

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BackgroundVital sign data are important for clinical decision making in emergency care. Clinical Decision Support Systems (CDSS) have been advocated to increase patient safety and quality of care. However, the efficiency of CDSS depends on the quality of the underlying vital sign data. Therefore, possible factors affecting vital sign data quality need to be understood.This study aims to explore the factors affecting vital sign data quality in Swedish emergency departments and to determine in how far clinicians perceive vital sign data to be fit for use in clinical decision support systems. A further aim of the study is to provide recommendations on how to improve vital sign data quality in emergency departments.MethodsSemi-structured interviews were conducted with sixteen physicians and nurses from nine hospitals and vital sign documentation templates were collected and analysed. Follow-up interviews and process observations were done at three of the hospitals to verify the results. Content analysis with constant comparison of the data was used to analyse and categorize the collected data.ResultsFactors related to care process and information technology were perceived to affect vital sign data quality. Despite electronic health records (EHRs) being available in all hospitals, these were not always used for vital sign documentation. Only four out of nine sites had a completely digitalized vital sign documentation flow and paper-based triage records were perceived to provide a better mobile workflow support than EHRs. Observed documentation practices resulted in low currency, completeness, and interoperability of the vital signs. To improve vital sign data quality, we propose to standardize the care process, improve the digital documentation support, provide workflow support, ensure interoperability and perform quality control.ConclusionsVital sign data quality in Swedish emergency departments is currently not fit for use by CDSS. To address both technical and organisational challenges, we propose five steps for vital sign data quality improvement to be implemented in emergency care settings.Electronic supplementary materialThe online version of this article (doi:10.1186/s12911-016-0305-4) contains supplementary material, which is available to authorized users.

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Section: Discussionmentioning

confidence: 99%

How to improve vital sign data quality for use in clinical decision support systems? A qualitative study in nine Swedish emergency departments

Skyttberg

Vicente

Chen

et al. 2016

BMC Med Inform Decis Mak

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“…Beyond the laptop, mobile devices and suitable applications offer exciting potential not only to facilitate clinical workflow, but to enable patients and families to engage in their healthcare in ways that are integrated into their daily lives [58,59]. Significant benefits will be realized in the inpatient setting where providers are responsible for multiple patients in disparate locations; however, it is expected that mobile applications will allow ambulatory practitioners to complete sequential tasks efficiently as well.…”

Section: Mobile Devices and Applicationsmentioning

confidence: 99%

Electronic health records: current and future use

Peters

Khan

2014

J. Comp. Eff. Res.

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This paper provides an overview of the current state of the electronic medical record, including benefits and shortcomings, and presents key factors likely to drive development in the next decade and beyond. The current electronic medical record to a large extent represents a digital version of the traditional paper legal record, owned and maintained by the practitioner. The future electronic health record is expected to be a shared tool, engaging patients in decision making, wellness and disease management and providing data for individual decision support, population management and analytics. Many drivers will determine this path, including payment model reform, proliferation of mobile platforms, telemedicine, genomics and individualized medicine and advances in 'big data' technologies.

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“…In this case, the nursing division of a large tertiary -quaternary Australian health service conceived of a modular, electronic audit tool to allow data collection at the bedside. Data collection at the bedside using a range of devices is a topic of interest amongst nursing staff given the nature of their work [13]. In this case, the senior nursing staff had a vision of a system that would dramatically improve the efficiency and validity of the audit process, as well as of resultant intelligence about care that could improve outcomes for patients in a range of dimensions.…”

Section: Introductionmentioning

confidence: 99%

Meeting National Safety and Quality Health Service Standards – The Role of the Point-of-Care (POC) Audit Application

Bain¹

2013

IJEEEE

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We designed and deployed a point-of-care (POC) clinical information system on a Motion tablet to allow data collection at the bedside by specialist auditors in support of organizational clinical audit objectives. This initiative has been undertaken in the context of the new National Safety and Quality Health Service (NSQHS) Standards for Australia. Collected data was then warehoused in a Microsoft SQL Server Environment in real time, allowing immediate feedback through corporate level reporting. The reporting framework consists of self-service non-interactive reports and scorecards, and self-service interactive reports (or dashboards) where users can seek detailed information from an organizational level down to a patient level. Information is presented both numerically and graphically, including in a traffic light paradigm, to highlight clinical risks and their relative urgency. This paper examines the implementation of this system, its drivers, and the lessons learned from this unique initiative.

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Point-of-Care Technology Supports Bedside Documentation

Cited by 21 publications

References 3 publications

How to improve vital sign data quality for use in clinical decision support systems? A qualitative study in nine Swedish emergency departments

How to improve vital sign data quality for use in clinical decision support systems? A qualitative study in nine Swedish emergency departments

Electronic health records: current and future use

Meeting National Safety and Quality Health Service Standards – The Role of the Point-of-Care (POC) Audit Application

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