1. Padden, Joni DNP, APRN, BC, CPHIMS

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The necessity of recording and detailing care is clear, but clinicians usually prefer to spend time with patients as opposed to documentation. Given the exponentially increasing amount of data available on even the simplest patient encounter, clinicians need the information they enter to be focused.1 They also need to view the information in a synthesized, manageable way. Improvement in outcomes will only be sustained if the information can be distilled to an understandable, concise format that is easily and readily accessible.


As care has become more sophisticated, the documentation of care has followed suit. The increasing requests and requirements of nursing documentation have been branded burdensome,2 which can be thought of as a load heavier than average. As documentation has advanced, it has been forced to carry with it antiquated concepts such as care plans, static screening tools, and manual checklists to document that something was documented elsewhere, often resulting in redundant work. These ever-increasing documentation requirements, coupled with additional clinical functions such as invoked rules and alerts, or driving analytics and predictive tools, contribute to the growing problem of documentation burden.1 In fact, a recent study revealed that many healthcare providers identified documentation as a primary area for improvement.3


The other facet of documentation burden is cognitive burden. Cognition is the mental process of perception, memory, judgment, and reasoning.4 Cognitive load is defined as the effort being used by working memory.4 The cognitive burden of clinicians is formidable given the amount of information available for them to access and may result in unbalanced thought patterns for skilled clinicians. This burden may result in ignoring safety features or alerts, nonadherence to workflows, inability to focus on details, and ultimately errors. Furthermore, the current state of information within the clinical setting is chaotic. Information is found in a variety of places, and it is often challenging to prioritize. Reports, notes, flowsheets, and integrated devices fail to offer a clear picture, all contributing to cognitive burden.


The rallying cry for every informaticist should be to decrease documentation and cognitive burden. Analytics and research on what documentation makes the most difference for improving patient outcomes need to be a priority. A strong evidence base of documentation elements clearly shown to improve outcomes will go a long way to help evolve documentation. It should also drive the retirement of "we have always documented that" items. For example, if how many feet a patient walked is shown to directly impact length of stay, then that needs to be a priority to capture, possibly through direct integration with a pedometer or other wearable device. Documentation should be assessed for value. If documenting a nursing diagnosis on a care plan is shown to have no impact at all on any patient outcome, then it should no longer be part of the record or a regulatory requirement. Clinicians are too busy to document information with low value.


Integration of data can significantly reduce the burden of staff documentation. For instance, the automatic uploading of information from vital sign devices, smart IV pumps, ventilators, and hemodynamic monitors greatly reduces the drudgery of documentation and increases the data points that can be used for predictive analytic programs.5 The value of integrated data can be realized in its ability to show trends when larger amounts of information are entered more frequently and consistently. These kinds of trends may illustrate patterns and trends, showing such things as potential eclampsia in laboring mothers or early signs of sepsis in an emergency room patient. With effective clinical decision support, the clinician could intervene early to prevent untoward events.


While integration of data is helpful, it comes with its own set of burdens if not managed well. The list of devices that can integrate data into the electronic health record grows every day. Integrated data save the staff from keying in information, but they do not stop their responsibility to validate the data or to be aware of the information the device is providing.6 There are associated security risks with outside devices such as wearable fitness trackers, smart watch applications, and other personal medical devices, whose data are uploaded into the chart. Finding the best ways to package the information and provide guidance needs to be a core competency for informaticists.


The cognitive burden of documentation is a problem that threatens to undo the benefits of a robust electronic health record. Sophisticated healthcare demands a sophisticated record. The clinician should be provided easy to understand and organized snapshots relevant to patient condition. These snapshots need to be able to drill down by layers to allow the clinician to go as deep into the data as they need but not force them to dig to see the big picture. Clean ways to see medication and treatment impact on condition, clear ways to recognize deterioration sooner, and improved ways to guide clinical judgment toward evidence-based care are needed.6 This kind of shift in managing a patient record, and not merely documenting in it, means stepping away from static order sets and moving to a data-mining model that provides patient-specific information at the point of ordering to help drive optimal choices. It should be the burden of the record to pull the elements of patient history, allergy, genetics, and other key factors to be able to recommend the most appropriate medication. The choice should always be that of the provider, but the provider should have confidence the record is giving them all the facts the clinician memory can no longer retain.


As informaticists, it is important to advocate for change to advance the body of knowledge. Part of this advocacy is to be courageous enough to say when concepts are no longer relevant, such as care plans and discipline-specific diagnosis. It is the patient's record, and clinicians need to speak the same language as a team. The opportunities lie in evidence-based care models that depend on the entire team to hit key milestones and in predictive models that help prevent bad outcomes. It is time to pay attention to what the record can do to decrease burden and improve how data can support clinical judgment.




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