Point of care

Last updated

Clinical point of care (POC) is the point in time when clinicians deliver healthcare products and services to patients at the time of care. [1]

Contents

Clinical documentation

Clinical documentation is a record of the critical thinking and judgment of a health care professional, facilitating consistency and effective communication among clinicians. [2]

Documentation performed at the time of clinical point of care can be conducted using paper or electronic formats. This process aims to capture medical information pertaining to patient's healthcare needs. The patient's health record is a legal document that contains details regarding patient's care and progress. [3] The types of information captured during the clinical point of care documentation include the actions taken by clinical staff including physicians and nurses, and the patient's healthcare needs, goals, diagnosis and the type of care they have received from the healthcare providers. [4]

Such documentations provide evidence regarding safe, effective and ethical care and insinuates accountability for healthcare institutions and professionals. Furthermore, accurate documents provide a rigorous foundation for conducting appropriate quality of care analysis that can facilitate better health outcomes for patients. [5] Thus, regardless of the format used to capture the clinical point of care information, these documents are imperative in providing safe healthcare. Also, it is important to note that electronic formats of clinical point of care documentation are not intended to replace existing clinical process but to enhance the current clinical point of care documentation process.

Traditional approach

One of the major responsibilities for nurses in healthcare settings is to forward information about the patient's needs and treatment to other healthcare professionals. [6] Traditionally, this has been done verbally. However, today information technology has made its entrance into the healthcare system whereby verbal transfer of information is becoming obsolete. [7] In the past few decades, nurses have witnessed a change toward a more independent practice with explicit knowledge of nursing care. [8] The obligation to point of care documentation not only applies to the performed interventions, medical and nursing, but also impacts the decision-making process; explaining why a specific action has been prompted by the nurse. [8] The main benefit of point of care documentation is advancing structured communication between healthcare professionals to ensure the continuity of patient care. [9] Without a structured care plan that is closely followed, care tends to become fragmented. [9]

Electronic documentation

Point of care (POC) documentation is the ability for clinicians to document clinical information while interacting with and delivering care to patients. [10] The increased adoption of electronic health records (EHR) in healthcare institutions and practices creates the need for electronic POC documentation through the use of various medical devices. [11] POC documentation is meant to assist clinicians by minimizing time spent on documentation and maximizing time for patient care. [12] The type of medical devices used is important in ensuring that documentation can be effectively integrated into the clinical workflow of a particular clinical environment. [13]

Devices

Mobile technologies such as personal digital assistants (PDAs), laptop computers and tablets enable documentation at the point of care. The selection of a mobile computing platform is contingent upon the amount and complexity of data. [14] To ensure successful implementation, it is important to examine the strengths and limitations of each device. Tablets are more functional for high volume and complex data entry, and are favoured for their screen size, and capacity to run more complex functions. [14] [15] [16] PDAs are more functional for low volume and simple data entry and are preferred for their lightweight, portability and long battery life. [14]

Electronic medical record

An electronic medical record (EMR) contains patient's current and past medical history. The types of information captured within this document include patient's medical history, medication allergies, immunization statuses, laboratory and diagnostic test images, vital signs and patient demographics. [17] This type of electronic documentation enables healthcare providers to use evidence-based decision support tools and share the document via the Internet. Moreover, there are two types of software included within EMR: practice management and EMR clinical software. Consequently, the EMR is able to capture both the administrative and clinical data. [18]

Computer physician order entries

A computerized physician order entry allows medical practitioners to input medical instructions and treatment plans for the patients at the point of care. CPOE also enable healthcare practitioners to use decision support tools to detect medication prescription errors and override non-standard medication regimes that may cause fatalities. Furthermore, embedded algorithms may be chosen for people of certain age and weight to further support the clinical point of care interaction. [19] Overall, such systems reduce errors due to illegible writing on paper and transcribing errors. [20]

Mobile EMRs mHealth

Mobile devices and tablets provide accessibility to the Electronic Medical Record during the clinical point of care documentation process. [21] Mobile technologies such as Android phones, iPhones, BlackBerrys, and tablets feature touchscreens to further support the ease of use for the physicians. Furthermore, mobile EMR applications support workflow portability needs due to which clinicians can document patient information at the patient's bedside. [22]

Advantages

Workflow

The use of POC documentation devices changes clinical practice by affecting workflow processes and communication. [23] [24] With the availability of POC documentation devices, for example, nurses can avoid having to go to their deskspace and wait for a desktop computer to become available. They are able to move from patient to patient, eliminating steps in work process altogether. Furthermore, redundant tasks are avoided as data is captured directly from the particular encounter without the need for transcription.

Safety

A delay between face-to-face patient care and clinical documentation can cause corruption of data, leading to errors in treatment. [10] Giving clinicians the ability to document clinical information when and where care is being delivered allows for accuracy and timeliness, contributing to increased patient safety in a dynamic and highly interruptive environment. [10] Point of care documentation can reduce errors in a variety of clinical tasks including diagnostics, medication prescribing and medication administration. [25] [26]

Collaboration and communication

Ineffective communication among patient care team members is a root cause of medical errors and other adverse events. [27] Point of care documentation facilitates the continuity of high quality care and improves communication between nurses and other healthcare providers. Proper documentation at the point of care can optimize flow of information among various clinicians and enhances communication. Clinicians can avoid going to a workstation and can access patient information at the bedside. It will also enable the timeliness of documentation, which is important to prevent adverse events. [28]

Nurse-patient time

Literature from various studies show that approximately 25-50% of a nurse's shift is spent on documentation. [24] [28] As most documentation is done in the traditional manner, that is using paper and pen, enabling a POC documentation device could potentially allow 25-50% more time at the bedside. Using speech recognition and information has been studied . [29] as a way to support nurses in POC documentation with encouraging results: 5276 of 7277 test words were recognised correctly and information extraction achieved the F1 of 0.86 in the category for irrelevant text and the macro-averaged F1 of 0.70 over the remaining 35 nonempty categories of the nursing handover form with our 101 test documents.

Disadvantages

Complexities

Numerous point of care documentation systems produce data redundancies, inconsistencies and irregularities of charting. [7] Some electronic formats are repetitious and time-consuming. [30] Moreover, some point of care documentation from one setting to another without a standardized pattern, and there are no guidelines for standards to documenting. [7] Inaccessibility also causes time to be lost in searching for charts. [7] These issues all lead to wasted time, increasing costs and uncomfortable charting. [7] A study adopted both qualitative and quantitative methods have confirmed complexities in point of care documentation. The study has also categorized these complexities into three themes: disruption of documentation; incompleteness in charting; and inappropriate charting. [7] As a result, these barriers limit nurses competence, motivation and confidence; ineffective nursing procedures; and inadequate nursing auditing, supervision and staff development. [7]

Privacy and security

When examining the use of any type of technology in healthcare its important to remember that technology holds private personal health information. As such, security measures need to be in place to minimize the risk for breaches of privacy and patient confidentiality. Depending on the country you live in its important to ensure that legislation standards are met. According to Collier in 2012, privacy and confidentiality breaches are rising largely attributed to the lack of appropriate encryption technology. [31] For successful implementation of any health technologies it is vital to ensure adequate security measures are used such as strong encryption technology.

Countries

Canada

Ontario

The adoption of electronic formats of clinical point of care documentation is particularly low in Ontario. Consequently, provincial leaders such as eHealth Ontario and Ontario MD provide financial and technical assistance in supporting electronic documentation of clinical point of care through EMR. [32] Furthermore, currently more than six million Ontarians have EMR; however, by 2012 this number is expected to increase to 10 million citizens. Conclusively, continued efforts are being made to adopt charting of patient information in electronic format to improve the quality of clinical point of care services [33]

See also

Related Research Articles

<span class="mw-page-title-main">Health informatics</span> Computational approaches to health care

Health informatics is the study and implementation of computer structures and algorithms to improve communication, understanding, and management of medical information. It can be viewed as a branch of engineering and applied science.

<span class="mw-page-title-main">Electronic health record</span> Digital collection of patient and population electronically stored health information

An electronic health record (EHR) is the systematized collection of patient and population electronically stored health information in a digital format. These records can be shared across different health care settings. Records are shared through network-connected, enterprise-wide information systems or other information networks and exchanges. EHRs may include a range of data, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal statistics like age and weight, and billing information.

<span class="mw-page-title-main">Telehealth</span> Health care by telecommunication

Telehealth is the distribution of health-related services and information via electronic information and telecommunication technologies. It allows long-distance patient and clinician contact, care, advice, reminders, education, intervention, monitoring, and remote admissions. Telemedicine is sometimes used as a synonym, or is used in a more limited sense to describe remote clinical services, such as diagnosis and monitoring. When rural settings, lack of transport, a lack of mobility, conditions due to outbreaks, epidemics or pandemics, decreased funding, or a lack of staff restrict access to care, telehealth may bridge the gap as well as provide distance-learning; meetings, supervision, and presentations between practitioners; online information and health data management and healthcare system integration. Telehealth could include two clinicians discussing a case over video conference; a robotic surgery occurring through remote access; physical therapy done via digital monitoring instruments, live feed and application combinations; tests being forwarded between facilities for interpretation by a higher specialist; home monitoring through continuous sending of patient health data; client to practitioner online conference; or even videophone interpretation during a consult.

<span class="mw-page-title-main">Telenursing</span> Nursing care through telecoms

Telenursing refers to the use of information technology in the provision of nursing services whenever physical distance exists between patient and nurse, or between any number of nurses. As a field, it is part of telemedicine, and has many points of contacts with other medical and non-medical applications, such as telediagnosis, teleconsultation, and telemonitoring. The field, however, is still being developed as the information on telenursing isn't comprehensive enough.

Computerized physician order entry (CPOE), sometimes referred to as computerized provider order entry or computerized provider order management (CPOM), is a process of electronic entry of medical practitioner instructions for the treatment of patients under his or her care.

A clinical decision support system (CDSS) is a health information technology that provides clinicians, staff, patients, and other individuals with knowledge and person-specific information to help health and health care. CDSS encompasses a variety of tools to enhance decision-making in the clinical workflow. These tools include computerized alerts and reminders to care providers and patients, clinical guidelines, condition-specific order sets, focused patient data reports and summaries, documentation templates, diagnostic support, and contextually relevant reference information, among other tools. CDSSs constitute a major topic in artificial intelligence in medicine.

A personal health record (PHR) is a health record where health data and other information related to the care of a patient is maintained by the patient. This stands in contrast to the more widely used electronic medical record, which is operated by institutions and contains data entered by clinicians to support insurance claims. The intention of a PHR is to provide a complete and accurate summary of an individual's medical history which is accessible online. The health data on a PHR might include patient-reported outcome data, lab results, and data from devices such as wireless electronic weighing scales or from a smartphone.

Continuity of Care Record (CCR) is a health record standard specification developed jointly by ASTM International, the Massachusetts Medical Society (MMS), the Healthcare Information and Management Systems Society (HIMSS), the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), and other health informatics vendors.

Patient safety is a discipline that emphasizes safety in health care through the prevention, reduction, reporting and analysis of error and other types of unnecessary harm that often lead to adverse patient events. The magnitude of avoidable adverse events, often known as patient safety incidents, experienced by patients was not well known until the 1990s, when multiple countries reported significant numbers of patients harmed and killed by medical errors. Recognizing that healthcare errors impact 1 in every 10 patients around the world, the World Health Organization (WHO) calls patient safety an endemic concern. Indeed, patient safety has emerged as a distinct healthcare discipline supported by an immature yet developing scientific framework. There is a significant transdisciplinary body of theoretical and research literature that informs the science of patient safety with mobile health apps being a growing area of research.

Medcin, is a system of standardized medical terminology, a proprietary medical vocabulary and was developed by Medicomp Systems, Inc. MEDCIN is a point-of-care terminology, intended for use in Electronic Health Record (EHR) systems, and it includes over 280,000 clinical data elements encompassing symptoms, history, physical examination, tests, diagnoses and therapy. This clinical vocabulary contains over 38 years of research and development as well as the capability to cross map to leading codification systems such as SNOMED CT, CPT, ICD-9-CM/ICD-10-CM, DSM, LOINC, CDT, CVX, and the Clinical Care Classification (CCC) System for nursing and allied health.

SBAR is an acronym for Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and appropriate communication. This communication model has gained popularity in healthcare settings, especially amongst professions such as physicians and nurses. It is a way for health care professionals to communicate effectively with one another, and also allows for important information to be transferred accurately. The format of SBAR allows for short, organized and predictable flow of information between professionals.

Health information technology (HIT) is health technology, particularly information technology, applied to health and health care. It supports health information management across computerized systems and the secure exchange of health information between consumers, providers, payers, and quality monitors. Based on a 2008 report on a small series of studies conducted at four sites that provide ambulatory care – three U.S. medical centers and one in the Netherlands, the use of electronic health records (EHRs) was viewed as the most promising tool for improving the overall quality, safety and efficiency of the health delivery system.

Patient participation is a trend that arose in answer to medical paternalism. Informed consent is a process where patients make decisions informed by the advice of medical professionals.

The Clinical Care Classification (CCC) System is a standardized, coded nursing terminology that identifies the discrete elements of nursing practice. The CCC provides a unique framework and coding structure. Used for documenting the plan of care; following the nursing process in all health care settings.

Barcode technology in healthcare is the use of optical machine-readable representation of data in a hospital or healthcare setting.

A medical scribe is an allied health paraprofessional who specializes in charting physician-patient encounters in real time, such as during medical examinations. They also locate information and patients for physicians and complete forms needed for patient care. Depending on which area of practice the scribe works in, the position may also be called clinical scribe, ER scribe or ED scribe, or just scribe. A scribe is trained in health information management and the use of health information technology to support it. A scribe can work on-site or remotely from a HIPAA-secure facility. Medical scribes who work at an off-site location are known as virtual medical scribes.

Digital health is a discipline that includes digital care programs, technologies with health, healthcare, living, and society to enhance the efficiency of healthcare delivery and to make medicine more personalized and precise. It uses information and communication technologies to facilitate understanding of health problems and challenges faced by people receiving medical treatment and social prescribing in more personalised and precise ways. The definitions of digital health and its remits overlap in many ways with those of health and medical informatics.

<span class="mw-page-title-main">Adoption of electronic medical records in U.S. hospitals</span>

The adoption of electronic medical records refers to the recent shift from paper-based medical records to electronic health records (EHRs) in hospitals. The move to electronic medical records is becoming increasingly prevalent in health care delivery systems in the United States, with more than 80% of hospitals adopting some form of EHR system by November 2017.

<span class="mw-page-title-main">OpenNotes</span> American healthcare research initiative

OpenNotes is a research initiative and international movement located at Beth Israel Deaconess Medical Center.

Federal and state governments, insurance companies and other large medical institutions are heavily promoting the adoption of electronic health records. The US Congress included a formula of both incentives and penalties for EMR/EHR adoption versus continued use of paper records as part of the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the, American Recovery and Reinvestment Act of 2009.

References

  1. ↑ Ebell, M. (1999). "Information at the point of care: answering clinical questions". The Journal of the American Board of Family Practice. 12 (3): 225–235. doi:10.3122/jabfm.12.3.225. ISSN   0893-8652. PMID   10395420.
  2. ↑ "Clinical Documentation— Putting the House in Order" (PDF). usask.ca. Marsh’s Risk Consulting Practice. 2006. Archived from the original (PDF) on August 1, 2014.
  3. ↑ "Documentation Guidelines for Registered Nurses" (PDF). College and Association of Registered Nurses of Alberta. 2006. Archived from the original (PDF) on 2012-04-24.
  4. ↑ "Documentation, Revised 2008" (PDF). College of Nurses of Ontario. 2008. Archived from the original (PDF) on 2012-09-13.
  5. ↑ Hughes, G; Hughes, Ronda G (2023-10-31). "Patient Safety and Quality". Agency for Healthcare Research and Quality (US). PMID   21328752 . Retrieved 2024-08-08.
  6. ↑ Caruso E. M. (2007). "The Evolution of Nurse-to- Nurse Bedside Report on a Cardiology Unit". Medsurg Nursing. 16 (1): 17–22. PMID   17441625.
  7. 1 2 3 4 5 6 7 Cheevakasemsook A.; Chapman Y.; Francis K.; Davies C. (2006). "The study of nursing documentation complexities". International Journal of Nursing Practice. 12 (6): 366–74. doi:10.1111/j.1440-172X.2006.00596.x. PMID   17176310.
  8. 1 2 Hellesø R.; Ruland C. M. (2001). "Developing a module for nursing documentation integrated in the electronic patient record". Journal of Clinical Nursing. 10 (6): 799–805. doi:10.1046/j.1365-2702.2001.00557.x. PMID   11822852.
  9. 1 2 Wu M.-W.; Lee T.-T.; Tsai T.-C.; Lin K.-C.; Huang C.-Y.; Mills M. E. (2012). "Evaluation of a Mobile Shift Report System on Nursing Documentation Quality". Computers, Informatics, Nursing. 31 (2): 85–93. doi:10.1097/NXN.0b013e318266cac3. PMID   22990575. S2CID   24253862.
  10. 1 2 3 Kohle-Ersher A.; Chatterjee P.; Osmanbeyoglu H. U.; Hochheiser H.; Bartos C. (2012). "Evaluating the Barriers to Point-of-Care Documentation for Nursing Staff". Computers, Informatics, Nursing. 30 (3): 126–33. doi:10.1097/NCN.0b013e3182343f14. PMID   22024972. S2CID   27823118.
  11. ↑ Carlson E.; Catrambone C.; Oder K.; Nauseda S.; Fogg L.; Garcia B.; Brown F. M.; et al. (2010). "Point-of-Care Technology Supports Bedside Documentation". The Journal of Nursing Administration. 40 (9): 360–5. doi:10.1097/NNA.0b013e3181ee4248. PMID   20798618. S2CID   37694508.
  12. ↑ Lee T.-T. (2007). "Patients' Perceptions of Nurses' Bedside Use of PDAs". Computers, Informatics, Nursing. 25 (2): 106–11. doi:10.1097/01.NCN.0000263980.31178.bd. PMID   17356332. S2CID   7693151.
  13. ↑ Smith K.; Smith V.; Krugman M.; Oman K. (2005). "Evaluating the Impact of Computerized Clinical Documentation". Computers, Informatics, Nursing. 23 (3): 132–8. doi:10.1097/00024665-200505000-00008. PMID   15900170. S2CID   2514906.
  14. 1 2 3 Silvey G. M.; Macri J. M.; Lee P. P.; Lobach D. F. (2005). "Direct Comparison of a Tablet Computer and a Personal Digital Assistant for Point-of-Care Documentation in Eye Care". AMIA Annual Symposium Proceedings. 2005: 689–693. PMC   1560810 . PMID   16779128.
  15. ↑ Quesada-González, Daniel; Merkoçi, Arben (2018). "Nanomaterial-based devices for point-of-care diagnostic applications". Chemical Society Reviews. 47 (13): 4697–4709. doi:10.1039/C7CS00837F. ISSN   0306-0012. PMID   29770813.
  16. ↑ Quesada-González, Daniel; Merkoçi, Arben (June 2017). "Mobile phone-based biosensing: An emerging "diagnostic and communication" technology". Biosensors and Bioelectronics. 92: 549–562. doi:10.1016/j.bios.2016.10.062. ISSN   0956-5663. PMID   27836593.
  17. ↑ "Electronic Health Records Overview" (PDF). National Institutes of Health. April 2006. Archived from the original (PDF) on 2012-04-04.
  18. ↑ Butler, E.S.; Lathram, C.J. (2005). "Electronic Medical Records: The Future is Now" (PDF). Archived (PDF) from the original on 2012-04-26.
  19. ↑ Santell, J.P (2004). "Computer-related Errors: What Every Pharmacist Should Know" (PDF). USP Center. Archived from the original (PDF) on December 17, 2008. Retrieved 2006-06-20.
  20. ↑ Baldauf-Sobez W., Bergstrom M., Meisner K., Ahmad A., Haggstrom M. (2003). "How Siemens' Comperized Physician Order Entry Helps Prevent the Human Error". Electromedica. 71 (1).{{cite journal}}: CS1 maint: multiple names: authors list (link)
  21. ↑ Hauser S. E., Demner-Fushman D., Jacobs J. L., Humphrey S. M., Ford G., Thoma G. R. (2007). "Using wireless handheld computers to seek information at the point of care: an evaluation by clinicians. [Electronic version]". Journal of the American Medical Informatics Association. 14 (6): 807–15. doi:10.1197/jamia.M2424. PMC   2213482 . PMID   17712085.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  22. ↑ Skov M. B., Hoegh R.T. (2006). "Supporting Information Access in a Hospital Ward by a Context-Aware Mobile Electronic Patient Record. [Electronic version]". Personal and Ubiquitous Computing. 10 (4): 205–214. doi:10.1007/s00779-005-0049-0. S2CID   34087386.
  23. ↑ Courtney K. L.; Demiris G.; Alexander G. L. (2005). "Information Technology". Nursing Administration Quarterly. 29 (4): 315–322. doi:10.1097/00006216-200510000-00005. PMID   16260995. S2CID   29697269.
  24. 1 2 Duffy, William J.; Kharasch, Morris S.; Du, Hongyan (2010). "Point of care documentation impact on the nurse-patient interaction". Nursing Administration Quarterly. 34 (1): E1–E10. doi:10.1097/NAQ.0b013e3181c95ec4. ISSN   1550-5103. PMID   20023554.
  25. ↑ Schiff G. D.; Bates D. W. (2010). "Can Electronic Clinical Documentation Help Prevent Diagnostic Errors?". The New England Journal of Medicine. 362 (12): 1066–9. doi:10.1056/NEJMp0911734. PMID   20335582. S2CID   11318427.
  26. ↑ Briggs B (2004). "Patient Safety Driving Point-of-Care I.T. Plans". Health Data Management. 12 (10): 56. PMID   15536825.
  27. ↑ Mendoca E. A.; Chen E. S.; Stetson P. D.; McKnight L. K.; Lei J.; Cimino J. J. (2004). "Approach to mobile information and communication for health care". International Journal of Medical Informatics. 73 (7–8): 631–638. doi:10.1016/j.ijmedinf.2004.04.013. PMID   15246044.
  28. 1 2 Yeung M. S.; Lapinsky S. E.; Granton J. D.; Doran D. M.; Cafazzo J. A. (2012). "Examining nursing vital signs documentation workflow: barriers and opportunities in general internal medicine units". Journal of Clinical Nursing. 21 (7–8): 975–982. doi:10.1111/j.1365-2702.2011.03937.x. PMID   22243491.
  29. ↑ Suominen H.; Zhou L.; Hanlen L.; Ferraro G. (2015). "Benchmarking Clinical Speech Recognition and Information Extraction: New Data, Methods, and Evaluations". JMIR Medical Informatics. 3 (2): e19. doi: 10.2196/medinform.4321 . PMC   4427705 . PMID   25917752.
  30. ↑ Whittaker A.; Aufdenkamp M.; Tinley S. (2009). "Barriers and facilitators to electronic documentation in a rural hospital". Journal of Nursing Scholarship. 41 (3): 293–300. doi:10.1111/j.1547-5069.2009.01278.x. PMID   19723278.
  31. ↑ Collier R (2012). "Medical Privacy Breaches Rising". Canadian Medical Association Journal. 184 (4): E215-6. doi:10.1503/cmaj.109-4116. PMC   3291691 . PMID   22311942.
  32. ↑ Dermer M., Morgan M. (2010). "Certification of primary care electronic medical record" (PDF). Journal of Health Informatics Management. 24 (3). Archived from the original (PDF) on 2012-04-26. Retrieved 2011-11-23.
  33. ↑ "Moving Forward with Electronic Health Records". Ministry of Health and Long-Term Care. July 6, 2011. Archived from the original on February 3, 2012. Retrieved November 21, 2011.
This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.