In 2011 and 2013 reports, the Joint Commission stated that ineffective communication is the primary cause of errors in healthcare delivery. The reports argued that handoff communication inefficiency represented over 80% of the errors in communication thus resulting in the risking the lives of the patients (Pabbathi, Schaeffer, Goldberg & Rocha, 2017). Past records depicted that errors caused by the handoffs result in over 1.5 million deaths or wrong medication. The Joint Commission proposed the standardization and embracement of technology to enhance handoff communication within an organization (Pabbathi, Schaeffer, Goldberg & Rocha, 2017). This proposal intended to improve the patient-based service delivery and eliminate the errors that result in wrong medication, errors in theatres that increase the probability of death or long-term suffering for the patients. Pabbathi, Schaeffer, Goldberg & Rocha, (2017) argued that past studies focus on shift-to-shift inefficiency in nursing, however, failure to account for the unit-to-unit limits the ability of these studies application in the real clinical setting due to the integration within hospitals. The essence that nurses must communicate with doctors, receptionists, emergency department (ED), discharge, pharmacy, and follow-up of the patient.
According to Friesen, White, and Byers (2008), the Institute of Medicine (IOM) argued that the safety risks that dominate the researches on handoffs fail to address the gaps in handoffs. The authors define handoffs as the transfer of information during a transition in care across the continuum. The study depicted that handoff should enable asking questions, clarity, and confirmation. Therefore, handoffs that do not enable the three factors to limit the communication ability that they are intended to perform. The study argues that based on the definition of communication, the ability to send and receive information that is understood by both the people. Therefore, organizations should change their culture, structures and design their clinics to allow the effective communication (Friesen, White, & Byers, 2008). According to Jiang et al. (2017), handoffs is an exchange of patient-related information between the healthcare practitioners. The move by the most government to enhance EHRs in their healthcare sector in the bid to limit the failures of the ineffective handoffs existing in the health sector. Computerized documentation and workflow integrated into the EHRs systems to enhance the communication (Jiang et al., 2017). The use of Clinical Decision Support Systems (CDSS) is the computerized tools that enable the designing of supported decision-making, improve documentation and eliminate the errors in healthcare provision
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Background
Electronic Health Records (EHRs) enables the storage of the medical records of the patients. The implementation of EHRs enables the hospitals to ensure preserve patient records that are retrievable by a click of a button. This simplicity enables fast retrieval of data, prevent the confusion or administering medications that the patient in is allergic to, and ensure that the health practitioners access information in an emergency without consulting the family or the family. During emergencies, such a terrorist attack or accidents, patients’ inability to respond to questions reduces the ability of the health professionals to save lives but with data electronically available, such issues are limited.
According to past studies, ED and ICUs errors that result in death and errors that endanger the lives of the patients are caused by ineffective communication. Surgeons stated that over two-thirds of the miscommunication in handoff (Pabbathi, Schaeffer, Goldberg & Rocha, 2017: Santos, Campos & Silva, 2018). The studies also argued that paperwork and shift-to-shift handoff limits asking questions, clarification, and confirmation due to the workload of the nurses. Nurses are the most important taskforce in hospitals; however, the lack of hiring of more nurses increases the workload of the nurses. The fatigue, stress, and caring for more than ten patients increases minor and major errors. For instance typing error when filling out the patient’s records results in confusion for the other nurse who takes over following the first nurse shift end.
The errors can be minor depending on whether the second nurse spots the error and seeks clarification; however, in a busy working environment spotting such errors is difficult leading to overdose among other errors (Pabbathi, Schaeffer, Goldberg & Rocha, 2017). Therefore, the implementation of electronic handouts enhances standardization that enables the nurse to understand the people to note any errors made. Electronic documentation involves the use of electronic devices or software integrated into the EHRs to record and retrieve patients’ records.
Meditech Documentation System Integration for Nursing Handoff Communication
Meditech is an EHR vendor that has been in the market for over 30 years. The company is among the top three EHR vendors with its applications applicable to small and midsized hospitals. Hospitals with 1,200 beds have also used Meditech 6.0 platforms meaning that the company is moving towards accessing the large-size hospitals (Meditech Expanse, 2017). The company has a complete and fully integrates mega-suite that include patient access, revenue cycle, EHRs, and clinical functionality to enhance patient-based healthcare provision. The company competes by gaining a competitive advantage in that it does not link to other EHRs vendors but the over 75% satisfaction for its loyal customer’s means that it is effective in most of its tasks (Freriks, 2014). The company also focuses on efficiency and eliminating the errors by enabling accurate and updated data records. However, fears about the difficulty of using the 6.0 platform show the need to train the workers. Meditech EHR contains the different components such as the critical care solution (CCS) that enable the clinicians to access data for all patients and monitor their progress. The integrated CCS supports different workflows depending on the environment or the requirements of the users. For instance, within an integrated CCS, a nurse can use it to document all types of data and change after signing up.
The functionality of Meditech documentation involves the ability of the user to access and utilize the flowcharts offered by the integrated CCS. For instance, the CCS flowsheet brings the patient data in a central location thus enabling the nurse or the user to access or implement changes where required. Once logged in, the nurse is able to access the centralized data on a certain patient. The flowsheet is single, interactive and unified thus limiting the time taken to access different flowsheets to access various information. The single flowsheet contains stat orders, next task, and bedside bulleting below the name, code and other patient’s information that is not health related. Each of the three categories is time sensitive and contains all the medical history and current record of the patient (Meditech Expanse, 2017). By expanding the multiple issues such as physical assessments, diagnostic imaging among other health condition such as allergies enables the nurse and the physicians to understand the patient before beginning their treatment.
At the furthest right, flowsheet, the nurse can access the entire patient list thus making it easier to move from one patient to another under his or her care. This section also includes the patient messages, results, vital signs, EMR, laboratory, plan care, work list, discharge plan, and a section to write notes that other practitioners can refer to when they access the patient’s record (Meditech Expanse, 2017). The CCS also enables the nurses to capture the image and use it to engage with the patient using the printed image to verify different issues. The monitoring of all patient health history and real-time trends promote access to all data records thus diminishing the errors of handoff miscommunication. Clinicians everywhere are able to view the same report, which makes the nurses conscious when filling out the data as the information demonstrates the person who updates the page (Meditech Expanse, 2017). In case the patient after discharge access medication from a hospital or clinic that is outside the network, the CCD Exchange Suite alerts the physicians or the network with direct messages to enable everyone stays informed for future use.
The CCS flowsheet inhibits a nurse to ignore the alerts as they remain on the flowsheet as new orders, results or communications. The new results or orders makes the nurse view the updates for instance lab results without losing the work she or he was performing before the alert. The different colors for the updates or alerts make it possible for the nurse to see and access to understanding the meaning of the alert.
The Architecture of Meditech Documentation
Meditech documentation platforms are knowledge-based systems that enable the logical conditions preferable to the experts because they enable the unification and interactive data depiction of the patient. The direct connection the documentation flowsheet to the EHR network makes it possible for the information to stream into the flowsheet without having to seek other documents (Meditech Expanse, 2017). The knowledge-based system also enables structural representation that promotes expressions or alerts that are difficult to confuse or miss.
The system also contains the inference engine that increases the reasoning of the users by ensuring that past data records of the patient are used to determine the patient-specific rules. These rules enable the use of conditional-based decision-making. Lastly, the inbuilt communication method of the CCS enables the users to make notes or request results from the lab with the results filled directly from the lab. It limits the use of paperwork because the lab inputs the results and the system updates the new data.
The CCS enables authoring, EMR database, query engine, learning and user interface. These additional components increase the interaction of the system with the user. The system is partially automatic in the streaming and alerts but does not inhibit the participation of the nurses. These elements ensure that the system is able to monitor the errors through the standardized settings but does not make the decision (Freriks, 2014). Nurses and practitioners use the patient data in the flowsheet and with the help of the system, which anticipates the conditions and outcomes. The nurse learns to diagnose epidemics and errors during handoff in the ICU, pharmacy, discharge of the patient, among other issues.
Market Penetration
As earlier stated, Meditech is among the top three EHR vendors in the world. The market was $410.5 million as of 2015 with the 2016-2022 predictions showing a 21.5% increase (Market Future, 2018). However, according to Globe Newswire results, the growth from 2018 to 2023 is 12% resulting in the market forming over $1,764.93 million by 2023 (Market Future, 2018). The study argued that the current competition is not dependent on the size of the company but on the ability to enhance data-driven healthcare models. These models provide support to the practitioners thus boosting and improving the quality of the patient-oriented care. However, the level of competition in the EHRs industry is high with past studies demonstrating that Epic is the most used EHRs vendor in all hospital sizes whereas Meditech comes second.
However, the study demonstrated that most the users termed Meditech as less effective and productive compared to Cerner and Epic but it was better than all other vendors are in terms of productivity and efficiency. Meditech 5.9, 6.0, and 6.1 platforms have improved the product in handoff communication (Market Future, 2018). The cost of changing the vendors has resulted in most hospitals maintaining loyalty to a vendor. Therefore, based on costs vendors with large market share benefit from low rates of migration. The changes in preference of data-driven EHRs portrays that most companies are moving towards the employment of integrated CDSS for instance, the Meditech’s CCS that is a move by the company anticipates the changing market projection towards integrated platforms. The growth of the market led to the change in preference from passive to active CDSS segments with 75% of the market dominated by the active CDSS segment as of 2017 (Market Future, 2018).
According to Monica (2017), a recent KLAS report argued that Medicare is the leading company in developing solution. The company’s move to introduce ICU and ambulatory care within its CCS enhanced Meditech popularity among the large and medium-sized hospitals. The embracement of EHRs in Asia and Africa means that the market is shifting from America and Europe to Asia and Africa (Monica, 2017). The ability of the top companies to exploit these markets will determine the global market share for the big three vendors but in the current situation, America is still the reading market for the EHRs and its components.
CDSS Impacts on Advanced Nursing Practice Decision-making
According to Lam, Abdullah, and Supreyanto (2013), CDSS vendors must ensure that their software and hardware do not replace but complement the healthcare practitioners. The study argued that fully automatic systems result in passive engagement and demotivation of the task force. Therefore, using a system that interacts with the nurses is essential in eliminating the generalized types of symptoms and characteristics in diagnostics by noting that the difference in individual increases errors there is no human insights (Lam, Abdullah & Supriyanto, 2018). Lastly, the study argued that a great and effective CDSS should enable the nurses to advance their experience and knowledge. Based on Lam, Abdullah, and Supriyanto (2013) arguments, it is evident that Meditech integrated CCS enables these requirements. The direct connection of the CCS to the EMR, proposing outcomes and the access of past doctor’s notes in the patient’s history, promote the advanced nursing practice. The nurse acquires evidence-based information from engaging in handoffs of multiple patients.
Application of CDSS in Real World Hospitals
In a past study on patient handoff communication in Bartlett Regional Hospital, it was evident that the hospital utilized Meditech version 5.61 for the inpatient and T-systems for the ED patients. The use of T-System was also used in admitting patients and provide computed tomography scans and magnetic resonance imaging on printed papers (Benjamin, Hargrave & Nether, 2016). The failure to employ the same system for all the activities in the hospital resulted in handoff problems of failure of the nurse or physicians to attach slips at the patient’s bedside. The ED and admitting individuals with the failure to update the patient’s results or x-ray limiting efficiency in care provision. The paper demonstrated that once the T-system was embedded into the Meditech version 5.61 to allow online transmission and filling of data communication handoff improved.
It was evident that learning to ask and seek clarification enabled the ED practitioners to seek data about the patient and prepare the nurses in the events of admitting ED patients (Benjamin, Hargrave & Nether, 2016). Santos, Campos, and Silva (2018) depicted that knowledge-based system with the ability to enhance efficiency in handoff is essential in reducing the errors caused by communication breakdown. The study proved that integrating a single form of handoff is vital in increasing efficiency in handoff communication. The failure to use a single system results in conflicting handoff, for instance, forgetting to update results if the hospital allows paperwork. In such a case, the EHRs system lacks the time-sensitive information that is vital in determining the progress of the patient.
Conclusion
The essay focused on demonstrating the effects of electronic documentation in nursing handoff. The paper used Meditech CCS to discuss the effects of CDSS on the nursing handoff. Unlike most CDSS, Meditech’s integrated CCS is a form of CDSS that allows documentation and analysis of the patient’s information for nurses to use. It was evident that CCS single, unified, and knowledge-based platform boost handoff and complements advanced nursing practices.
References
Benjamin, M., Hargrave, S., & Nether, K. (2016). Using the Targeted Solutions Tool ® to Improve Emergency Department Handoffs in a Community Hospital. The Joint Commission Journal On Quality And Patient Safety , 42 (3), 107-AP4.
Freriks, G. (2014). EHR Systems - Future Developments. SSRN Electronic Journal .
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Jiang, S., Murphy, A., Heitkemper, E., Hum, R., Kaufman, D., & Mamykina, L. (2017). Impact of an electronic handoff documentation tool on team shared mental models in pediatric critical care. Journal Of Biomedical Informatics , 69 , 24-32.
Lam, J., Abdullah, M., & Supriyanto, E. (2018). Architecture for clinical decision support system (cdss) using high risk pregnancy ontology. ARPN Journal Of Engineering And Applied Sciences , 10 (3), 1229-1240.
Market Future. (2018, August 8). Clinical Decision Support System (CDSS) Market $1764.93 Mn Revenue at 12% CAGR Expected To Reach by 2023 | Market Research Future. Retrieved September 23, 2018, from https://globenewswire.com/news-release/2018/08/08/1549022/0/en/Clinical-Decision-Support-System-CDSS-Market-1764-93-Mn-Revenue-at-12-CAGR-Expected-To-Reach-by-2023-Market-Research-Future.html
Meditech Expanse. (2017). The Benefits of an Integrated Approach to Critical Care. Retrieved September 23, 2018, from https://ehr.meditech.com/.../create-true-continuity-with-meditech-s-integrated -critical-care-solution
Monica, K. (2017, November 9). Cerner, MEDITECH Offer Most EHR Solutions Across Care Continuum. Retrieved on September 23, 2018 from https://ehrintelligence.com/news/cerner-meditech-offer-most-ehr-solutions-across-care-continuum
Pabbathi, D., Schaeffer, M., Goldberg, H., & Rocha, B. (2017). Screening Consolidated Clinical Document Architecture (CCDA) Documents for Sensitive Data Using a Rule-Based Decision Support System. Applied Clinical Informatics , 08 (01), 137-148.
Santos, G., Campos, J., & Silva, R. (2018). Handoff communication in intensive care: links with patient safety. Escola Anna Nery , 22 (2).
