Poster Presentation
Sunday, November 4, 2007
10:30 AM - 11:45 AM
Sunday, November 4, 2007
1:30 PM - 2:45 PM
215
Evidence Based Practice: the Computerized Patient Record
Patricia A. Heale, MSN, RNC, Maternal-Child Health, Newton-Wellsley Hospital, Newton, MA, USA
| Learning Objective #1: define the process of implementing a computerized patient record through the use of the ACE Star Model of Evidence Based Practice. |
| Learning Objective #2: identify the benefits and challenges of implementing a computerized patient record in the perinatal/acute care setting. |
Regulatory agencies and hospital networks have called for an alternative to paper medical records. The federal government through HIPAA, the Joint Commission on Accreditation of Healthcare Organizations, and Partners Health care, an integrated health system in Massachusetts, have called for the replacement of paper medical records with a Computerized Patient Record (CPR). The CPR would allow providers to access patient medical records on any computer within the hospital system. Besides regulatory pressure other benefits were identified for this practice change including, medical record legibility, archive and retrieval of fetal monitor strips on DVD storage, retrieval of large amounts of statistical information that had previously been done by hand, cost-effectiveness, increased productivity, and decision support. In order to meet the evolving guidelines from within and without the institution the problem of continued documentation on paper was identified. After a thorough literature review, consultation with business partners, road trips to neighboring institutions who had implemented the CPR, and the guidance of an in-house multidisciplinary team the decision was made to move forward with the CPR. Nurses have resisted Evidence-Based Practice and for years have performed routine procedures according to traditional practices with little or no scientific evidence to support those practices. Though nursing research has evolved into a sophisticated network of available scientific information, translating such research evidence into bedside practice has proven to be difficult. Several impediments exist to bringing the scientific evidence to the clinical nurse for use at the bedside. Specific challenges to implementing CPR have included fear of change, distrust of computers, and a negative attitude towards standardization. To promote a positive attitude towards Evidence-Based Practice it was essential to identify champions and super users from among the staff. It was necessary to use a model for change as a guide to excite, enliven, and encourage the nursing staff that change, in general was good and specifically the CPR was an Evidence-Based Practice change for the better. Over the past several years many strategies have been developed to integrate research evidence into nursing practice at the point of care. One of these Evidence-Based Practice strategies, the ACE Star model, provided the basis for the integration of the CPR into the perinatal setting. The ACE Star model consists of five components, Discovery, Summary, Translation, Integration, and Evaluation. In this instance, the ACE Star model was used to bring about a significant change in nursing practice; that is a change from documenting in a paper medical record to the use of a computerized patient record in a Labor and Delivery setting. Through the use of the ACE Star Model a problem was identified, the research evidence was reviewed; a change in the nursing care model was defined, integrated into practice, and evaluated via two outcome measures. Though the nursing staff held a fear of both change and technology use of the ACE Star model and a carefully designed integration plan provided for an uneventful implementation. Key supporting elements included one-to-one training, 24-hour clinical and technical support, and the enthusiasm of nursing management and the super user community. The quantitative outcome measures showed improved clarity, legibility, and standardization in documentation. The qualitative outcomes measure showed improved satisfaction among nurses related to the decrease in time spent charting allowing for greater time providing labor support.