Nutrition Care and the Electronic Health Record (EHR)
In what way(s) do you feel the use of EHR for documenting nutritional care contributes to meaningful use?
The development and implementation of the electronic health record (EHR) has tremendously changed the way we approach healthcare and treat patients. The annual healthcare savings predicted by Rand Corporation per year by using EHR rather than paper records is somewhere around $81 billion per year (Hoggle, et. al, 2006). One way that nutrition care documentation in the EHR contributes to its meaningful use is by allowing other providers to easily access nutrition notes and use these in patient evaluation. By allowing doctors, nurses, pharmacists, other dietitians and other providers to access our nutrition notes, information and data gathered by RD’s can travel faster to the team working with a patient, leading to quicker patient care. In my work experience as a casual coverage dietitian, I often rotate floors and am unfamiliar with patients, as I do not typically follow them on one floor for more than a day at a time. The EHR allows other RD’s to communicate patient information through chart notes to each other which helps the coverage RD to understand the patient’s course of nutrition care and direction of care. This ultimately leads to better continuity of care between providers.
EHR use in nutrition care also contributes to its meaningful use by saving time (a lot!!) when reviewing patients. Multiple people can access the patient’s chart at the same time, meaning more people can properly review and plan for that patient’s care. One example of this in my experience, is charting educations that patients receive. Every patient who is admitted and followed by a dietitian must be provided with education of some sort prior to discharge at the hospital where I work. When reviewing a new patient’s chart, I check to see what education they received last time they were in the hospital, if they got education at an outpatient appointment, or if they have no record of education. This will help guide what sort of education I provide the patient during their admission based on their education history in the EHR.
Nutrition care in the EHR also contributes to meaningful use by keeping patients safe. For example, when entering tube feed orders in an EHR for a patient, they will be legible and layed out in an organized manner. Paper handwritten notes with orders are easily misread, misinterpreted, or get lost. By using EHR to manage tube feed or parenteral nutrition orders, everything is written legibly and typically in organized fashion that is easy to send straight to pharmacy or to the nutrition associates handling the tube feed delivery. Overall, this improves safety for patients and reduces the chance of error in orders.
When considering the provision of nutritional care, what do you feel are the benefits of the EHR? Why do you consider them beneficial?
One major benefit of the EHR in nutrition care is safety in patient care. An example that comes to mind when thinking about safety and the benefit of the EHR is the warning boxes that will pop up on the EHR when patients have contraindications to a tube feed. For example, there are particular medications that cannot be taken with tube feed running at the same time, therefore, the patient’s tube feed regimen must be changed. This is a safety issue that the EHR brings to attention and changes can be made, whereas a paper chart does not have this feature. Calculators on the EHR are another benefit in nutrition care safety, because they may be used to calculate total parenteral nutrition (TPN) and actually have shown to reduce calculation errors and adverse drug events in patients (Lehmann, et. al, 2004).
Another benefit of the EHR in nutrition care is the structured data and standardized language/terminology based on Academy’s Nutrition Care Process (NCP) that is seen in the form of chart notes, flowsheets, and educations (Molinar, et. al, 2017). Structured data can more easily be transferred to data collection systems and used in research. Having structured data as well as standard language allows for more research opportunities and lead to more quantitative analysis (Menachemi, 2011). Also, registered dietitian (RD) notes are structured in a template so they all include the same components (or at least this is the method I have seen many hospitals use for RD’s to create continuity in charting). This helps RDs as well as other providers to quickly look at a nutrition care note and understand where to find specific data/information rather than having to read through an unorganized essay of a chart note.
Coordination of care is another important benefit of EHR in nutrition care. Often times, RDs are involved in the coordination of care between patients, providers, and sometimes other facilities or home infusion companies when a patient discharges. Having EHRs containing feeding tube information or calorie count data easily accessible is very helpful in coordinating care and makes the process much smoother.
What features aren’t currently available in the EHR that would be helpful for providing nutritional care? Why?
One particular feature that I wish was available in the EHR automatically is the treatment team contact information. Often times, (at least in my experience) the team of MDs, RN, surgeon, etc. do not have contact information in the patient’s chart. This information is often times manually entered in as a “sticky” note for providers to view. However, sometimes the information is not entered manually and this adds an extra step of looking at chart notes, figuring who the primary team is (if not defined), and then figuring who would be the best first contact within the primary team for a patient. All of that time spent could be used elsewhere if EHRs somehow had features to “pull in” primary team contact information.
Another feature that would be helpful to have in the EHR is a drawing tool for MDs/surgeons to draw pictures of patients’ anatomy who have a history of gastric surgery. Often times, I see patients with bowel resections but the location of the resection or re-routing of the bowel is not defined clearly in the operative note or any notes. This can be frustrating and time consuming when trying to gather this information from surgeons. This information is pertinent for RDs to know because a patient’s nutrition intervention can change drastically depending on what parts of the bowel are present or missing.
Overall, the EHR has drastically transformed the way we approach healthcare and treat patients. There are always improvements that can be made to the EHR systems, but the big picture shows that EHRs are more efficient, more secure and safe, improve continuity of patient care, and provide more structure in patient information gathering. We will see how EHRs evolve in the future and how this will impact nutrition care!
Sources:
Hoggle, L. B., Michaell, M. A., Houston, S., & Ayres, E. J. (2006). Electronic Health Record: Where Does Nutrition Fit In? Journal of the American Dietetic Association, 106(10), 1688-1695.
Lehmann, C. U., Conner, K. G., & Cox, J. M. (2004). Preventing Provider Errors: Online Total Parenteral Nutrition Calculator. Pediatrics, 113(4), 748-753.
Menachemi, N., & C. (2011). Benefits and drawbacks of electronic health record systems. Risk Management and Healthcare Policy,47
Molinar, L. S., Childers, A. F., Hoggle, L., Kent, S., Porter, H., & Rusnak, S. (2017). Informatics Initiatives at the Academy of Nutrition and Dietetics. Journal of the Academy of Nutrition and Dietetics, 117(8), 1293-1301.
The development and implementation of the electronic health record (EHR) has tremendously changed the way we approach healthcare and treat patients. The annual healthcare savings predicted by Rand Corporation per year by using EHR rather than paper records is somewhere around $81 billion per year (Hoggle, et. al, 2006). One way that nutrition care documentation in the EHR contributes to its meaningful use is by allowing other providers to easily access nutrition notes and use these in patient evaluation. By allowing doctors, nurses, pharmacists, other dietitians and other providers to access our nutrition notes, information and data gathered by RD’s can travel faster to the team working with a patient, leading to quicker patient care. In my work experience as a casual coverage dietitian, I often rotate floors and am unfamiliar with patients, as I do not typically follow them on one floor for more than a day at a time. The EHR allows other RD’s to communicate patient information through chart notes to each other which helps the coverage RD to understand the patient’s course of nutrition care and direction of care. This ultimately leads to better continuity of care between providers.
EHR use in nutrition care also contributes to its meaningful use by saving time (a lot!!) when reviewing patients. Multiple people can access the patient’s chart at the same time, meaning more people can properly review and plan for that patient’s care. One example of this in my experience, is charting educations that patients receive. Every patient who is admitted and followed by a dietitian must be provided with education of some sort prior to discharge at the hospital where I work. When reviewing a new patient’s chart, I check to see what education they received last time they were in the hospital, if they got education at an outpatient appointment, or if they have no record of education. This will help guide what sort of education I provide the patient during their admission based on their education history in the EHR.
Nutrition care in the EHR also contributes to meaningful use by keeping patients safe. For example, when entering tube feed orders in an EHR for a patient, they will be legible and layed out in an organized manner. Paper handwritten notes with orders are easily misread, misinterpreted, or get lost. By using EHR to manage tube feed or parenteral nutrition orders, everything is written legibly and typically in organized fashion that is easy to send straight to pharmacy or to the nutrition associates handling the tube feed delivery. Overall, this improves safety for patients and reduces the chance of error in orders.
When considering the provision of nutritional care, what do you feel are the benefits of the EHR? Why do you consider them beneficial?
One major benefit of the EHR in nutrition care is safety in patient care. An example that comes to mind when thinking about safety and the benefit of the EHR is the warning boxes that will pop up on the EHR when patients have contraindications to a tube feed. For example, there are particular medications that cannot be taken with tube feed running at the same time, therefore, the patient’s tube feed regimen must be changed. This is a safety issue that the EHR brings to attention and changes can be made, whereas a paper chart does not have this feature. Calculators on the EHR are another benefit in nutrition care safety, because they may be used to calculate total parenteral nutrition (TPN) and actually have shown to reduce calculation errors and adverse drug events in patients (Lehmann, et. al, 2004).
Another benefit of the EHR in nutrition care is the structured data and standardized language/terminology based on Academy’s Nutrition Care Process (NCP) that is seen in the form of chart notes, flowsheets, and educations (Molinar, et. al, 2017). Structured data can more easily be transferred to data collection systems and used in research. Having structured data as well as standard language allows for more research opportunities and lead to more quantitative analysis (Menachemi, 2011). Also, registered dietitian (RD) notes are structured in a template so they all include the same components (or at least this is the method I have seen many hospitals use for RD’s to create continuity in charting). This helps RDs as well as other providers to quickly look at a nutrition care note and understand where to find specific data/information rather than having to read through an unorganized essay of a chart note.
Coordination of care is another important benefit of EHR in nutrition care. Often times, RDs are involved in the coordination of care between patients, providers, and sometimes other facilities or home infusion companies when a patient discharges. Having EHRs containing feeding tube information or calorie count data easily accessible is very helpful in coordinating care and makes the process much smoother.
What features aren’t currently available in the EHR that would be helpful for providing nutritional care? Why?
One particular feature that I wish was available in the EHR automatically is the treatment team contact information. Often times, (at least in my experience) the team of MDs, RN, surgeon, etc. do not have contact information in the patient’s chart. This information is often times manually entered in as a “sticky” note for providers to view. However, sometimes the information is not entered manually and this adds an extra step of looking at chart notes, figuring who the primary team is (if not defined), and then figuring who would be the best first contact within the primary team for a patient. All of that time spent could be used elsewhere if EHRs somehow had features to “pull in” primary team contact information.
Another feature that would be helpful to have in the EHR is a drawing tool for MDs/surgeons to draw pictures of patients’ anatomy who have a history of gastric surgery. Often times, I see patients with bowel resections but the location of the resection or re-routing of the bowel is not defined clearly in the operative note or any notes. This can be frustrating and time consuming when trying to gather this information from surgeons. This information is pertinent for RDs to know because a patient’s nutrition intervention can change drastically depending on what parts of the bowel are present or missing.
Overall, the EHR has drastically transformed the way we approach healthcare and treat patients. There are always improvements that can be made to the EHR systems, but the big picture shows that EHRs are more efficient, more secure and safe, improve continuity of patient care, and provide more structure in patient information gathering. We will see how EHRs evolve in the future and how this will impact nutrition care!
Sources:
Hoggle, L. B., Michaell, M. A., Houston, S., & Ayres, E. J. (2006). Electronic Health Record: Where Does Nutrition Fit In? Journal of the American Dietetic Association, 106(10), 1688-1695.
Lehmann, C. U., Conner, K. G., & Cox, J. M. (2004). Preventing Provider Errors: Online Total Parenteral Nutrition Calculator. Pediatrics, 113(4), 748-753.
Menachemi, N., & C. (2011). Benefits and drawbacks of electronic health record systems. Risk Management and Healthcare Policy,47
Molinar, L. S., Childers, A. F., Hoggle, L., Kent, S., Porter, H., & Rusnak, S. (2017). Informatics Initiatives at the Academy of Nutrition and Dietetics. Journal of the Academy of Nutrition and Dietetics, 117(8), 1293-1301.
This comment has been removed by the author.
ReplyDeleteI love that we named our blog's similarly. I agree completely that the EHR has vastly improve continuity of care. While I was working at the hospital we would often cross-cover floors and it was a tremendous help to know what had been being done for the patients by other RD's previously. I also found it helpful that I could access previous hospitalizations and see the anthropometrics to evaluate previous and current nutritional status and treatment. I found this to be especially helpful in patients whose malnutrition status I was concerned about. I completely agree that having calorie count and composition available is especially helpful and safer for patients. I have worked with some EHR that have the ability for the doctors or nurse to circle affected areas. This is especially helpful in wound care and often has a picture attached to it. When patients get sent for tests such as barium swallow it is helpful to have access to the report and in some cases the actual video to assist in diet planning.
ReplyDeleteI like that you point out the difficulty of contacting the treatment team when the information isn't provided. I was often able to see what service the patient was on, but would still need to go into a separate text-page system to reach the providers for questions and clarifications. I found that more providers are moving into the SOAP note format which can increase standardization across the chart and make it easier to read. Part of the reason this is happening is probably due to insurance asking for easier to read information to decide on reimbursements. Thank you for your insight.
Therese,
ReplyDeleteI think you brought up a couple great points that I had not thought of. First, your suggestions of always having the care team noted in the patient’s chart when they are in in-patient. Most of my experience has been in a small SNF, so I did not even consider this as an issue, since we knew everyone! Your suggestion would be simple to implement and most likely save time (and money) by not having to track down the care team.
I found it interested that you noted that areas of surgery are not always specific in charting notes by the surgeons. Could this be corrected with more training on “proper” charting by the surgeons? However, the anatomy-drawing note that you had also could be helpful. I imagine it would be similar to how a coroner indicates areas of the body (?).
In trying to find a relevant article to share on clinician charting education for the EMR, I came across a related article that I found of interest.1 One point that I want to highlight is that patients reported the lack of eye contact, both in paper and in electronic charts.1 I think a good discussion topic may be, if we are using the EHR, when do we use it? I have been at a general “check up” appointment, where the CMA/nurse and the doctor are almost entirely reading off of the screen, rather than talking to me. How does this impact other patients? For me, I felt as though they weren’t really listening to me and just “going through a checklist”. What is the best way to address this? Do you work off of the computer while in patients’ rooms, or chart afterwards?
1. Shaw N. Medical Education & Health Informatics: Time to join the 21st Century? Stud Health Technol Inform. 2010:160(1):567-571.
file:///Users/anastasiaseverson/Downloads/SHTI160-0567.pdf
Hi Therese,
ReplyDeleteI like that you brought up the previous educational experiences. This is definitely a great point. If we went in and talk to the patient same thing the previous RD did, the patient might not be beneficial, as well as it would be a waste of time for the RD! The repeating education would be considered inappropriate! However, knowing what the patient was taught and confirm the patient's knowledge might be a good way to test patient's learning. And if necessary, offering the repeated education or expand the education.
Another great point you brought up was the coordination of care. Especially when monitoring those who are at high risk for malnutrition (ex. burn patient) or when determining whether or not patient need nutritional support, calorie count and feeding information would be super helpful!
In addition to features that aren't currently available, I love the idea of having the image of patient's anatomy. Not only for the resections, but also radiologist can draw arrows to indicate where exactly the tip of the feeding tube could also help RDs to rule out reasons for complications.