PICOT Question: Electronic Health Record

As noted by Dehghan, Dehghan, Sheikhrabori, Sadeghi, and Jalalian (2013), the electronic health record (EHR), is a critical source of information in healthcare, and nurses bear the greatest burden in maintaining this extremely valuable resource. The documentation created by nurses provides primarily tracks patient progress, but it also serves a number of other important functions (Dehghan et al., 2013).  The EHR is often the primary method of communication between clinicians, it can provide justification for procedures and help clarify billing, and serves as a legal document that may be subject to discovery and review during court proceedings (Dehghan et al., 2013). Multiple studies have clearly demonstrated that the quality of nursing documentation in the EHR is directly correlated with patient outcomes, including mortality (Collins et al., 2013). The proper maintenance of the EHR is perhaps more important in at home nursing care than it is in inpatient care; clinicians rarely see each other and rely on the data in the EHR to make clinical decisions (Irani, Hirschman, Cacchione, & Bowles, 2018; Obioma, 2017). Unfortunately, previous studies have found significant flaws in the management of EHRs in at home care settings (Gjevjon & Hellesø, 2010; Obioma, 2017; Sockolow, Bowles, Adelsberger, Chittams, & Liao, 2014; Yang, Bass, Bowles, & Sockolow, 2019). With a rapidly aging populace, the need to improve at home care will become ever more important over the coming decade; as of 2019 there are more people over the age of 65 in the United States than under the age of five (Landers et al., 2016; Romagnoli, Handler, & Hochheiser, 2013). This paper will build on a previous document proposing an educational intervention to improve the quality of EHR documentation in an at home care setting; two possible PICOT questions will be proposed and discussed. 

PICOT Question 

The unique population and setting for this intervention afford the construction of two PICOT-formatted questions, both of which can be answered by the same study. It is not uncommon for a study to answer more than one research question, so this is not a novel nor disruptive concept. The two possible questions are: 

1. In a population of nurses working in an at home care setting for a single at home care agency (P), how does a single-session retraining on inputting appropriate documentation into each patient’s EHR (I) as compared to documentation entered prior to the training (C) impact the quality and content of EHR documentation (O) measured over a period of one month prior and one month after the educational session using the Nurse and Midwifery Content Audit Tool (NMCAT) (T). 

2. In a population of patients being served by the nurses of a single at home nursing agency (P), how does a single-session retraining on inputting appropriate documentation into each patient’s EHR for their attending nurses (I) as compared to their perception of care quality prior to the training (C) affect the each patient’s perception of care quality after the training (O) measured one month prior and one month after the educational session using a custom-designed Likert-like survey or a previously developed survey for patient satisfaction in an at home care population (T). 

As noted by Ellenbecker, Samia, Cushman, and Alster (2008), quality documentation is a critical component of preserving patient safety in at home nursing practice, but although it might be possible to measure the impact of documentation training as a function of reduced adverse patient events, there are too many confounding variables to make such an approach practical for this intervention. It would be necessary, for instance, to build a database of adverse patient events in the target population and then filter the results by cause, assuming the cause for each event was known so that a pre-hoc comparison data set could be created. Thus, measuring the quality of the documentation and e-monitoring coupled with measuring the patient perception of care is a good starting point for addressing this topic. The intervention is evidence-based; educational interventions have been demonstrated to be effective in improving documentation quality and content, including in at home care setting (Obioma, 2017). As noted by Collins et al. (2013), nursing documentation is a fundamental part of the basic nursing skillset and thus the intervention is a direct reflection of nursing practice. Finally, since all of nursing should be patient-centered, the intervention is designed to measure patient satisfaction with care to determine if the improved focus on proper documentation leads to better care in general.

References

Collins, S. A., Cato, K., Albers, D., Scott, K., Stetson, P. D., Bakken, S., & Vawdrey, D. K. (2013). Relationship between nursing documentation and patients' mortality. American Journal of Critical Care: An Official Publication, American Association of Critical-Care Nurses, 22(4), 306–313. doi:10.4037/ajcc2013426

Dehghan, M., Dehghan, D., Sheikhrabori, A., Sadeghi, M., & Jalalian, M. (2013). Quality improvement in clinical documentation: does clinical governance work? Journal of Multidisciplinary Healthcare, 6, 441–450. doi:10.2147/JMDH.S53252

Ellenbecker, C.H., Samia, L., Cushman, M.J., & Alster, K. (2008). Patient Safety and Quality in Home Health Care In Patient Safety and Quality: An Evidence-Based Handbook for Nurses Hughes, R.G. Ed. Rockville, MD: Agency for healthcare research and quality (US). Retrieved from: www.ncbi.nlm.nih.gov/books/NBK2631/

Gjevjon, E., & Hellesø, R. (2010). The quality of home care nurses’ documentation in new electronic patient records. Journal of Clinical Nursing, 19(1‐2), 100-108.

Irani, E., Hirschman, K. B., Cacchione, P. Z., & Bowles, K. H. (2018). Home health nurse decision-making regarding visit intensity planning for newly admitted patients: A qualitative descriptive study. Home Health Care Services Quarterly, 37(3), 211–231. doi:10.1080/01621424.2018.1456997

Landers, S., Madigan, E., Leff, B., Rosati, R. J., McCann, B. A., Hornbake, R., … Breese, E. (2016). The Future of Home Health Care: A strategic framework for optimizing value. Home Health Care Management & Practice, 28(4), 262–278. doi:10.1177/1084822316666368

Obioma, C (2017). Improving the quality of nursing documentation in home health care setting (Dissertation). Walden Dissertations and Doctoral Studies Collection at ScholarWorks. Retrieved from scholarworks.waldenu.edu/cgi/viewcont ent.cgi?article=4603&context=dissertations

Romagnoli, K. M., Handler, S. M., & Hochheiser, H. (2013). Home care: More than just a visiting nurse. BMJ Quality & Safety, 22(12), 972–974. doi:10.1136/bmjqs-2013-002339

Sockolow, P. S., Bowles, K. H., Adelsberger, M. C., Chittams, J. L., & Liao, C. (2014). Impact of homecare electronic health record on timeliness of clinical documentation, reimbursement, and patient outcomes. Applied Clinical Informatics, 5(2), 445–462. doi:10.4338/ACI-2013-12-RA-0106

Yang, Y., Bass, E. J., Bowles, K. H., & Sockolow, P. S. (2019). Impact of home care admission nurses' goals on electronic health record documentation strategies at the point of care. Computers, Informatics, Nursing: CIN, 37(1), 39–46. doi:10.1097/CIN.0000000000000468