Nurse practitioners, electronic records, and standardized nursing language
As the healthcare arena changes rapidly in the development and utilization of electronic medical records, there is an opportunity to enhance the visibility of advanced nursing practice and its impact on patient outcomes. The Initiative on the Future of Nursing (Institute of Medicine, 2011) highlights the importance of advanced practice nursing and information technology to meet present and future healthcare needs. Nurse practitioners (NPs) are continuing to fill primary care roles and manage not only chronic illnesses, but prevent acute care episodes and disease. In order to meet these needs, NPs will increase the use of technological tools to aid in analysis and synthesis of information to improve the quality and effectiveness of care delivered to their patients.
Electronic health records (EHRs) are one of the tools to manage the complexities of healthcare data. The Health Information Technology for Economic and Clinical Health Act (HITECH Act), passed in 2009, encouraged healthcare organizations and providers to adopt and effectively utilize certified EHRs (Committee on Ways and Means, 2009). The HITECH Act outlines criteria to achieve “meaningful use” of certified electronic records. These criteria must be met in order for providers to receive financial incentives to promote adoption of EHRs as an integral part of their daily practice.
The Institute of Medicine's definition of the EHR is a set of components in which patient records are created, used, stored, and retrieved, usually located in a healthcare setting. It involves people, data, roles, procedures, processing, storage devices, communication, and support facilities (Steen & Detmer, 1997). EHRs have the potential to improve the quality, safety, and efficiency of clinical practice due to their ability to deliver legible and timely access to patient information to multiple users, as well as the ability to provide users with decision support. Unlike paper documentation, use of the EHR allows practitioners to aggregate data, and provides the opportunity to subsequently turn data into knowledge, and knowledge into wisdom (American Nurses Association, 2001). In order to build knowledge of clinical practice from the aggregation of data, the right data must be collected and stored in a retrievable format. Generally, a controlled terminology such as International Statistical Classification of Diseases and Related Health Problems (ICD-9) codes are used for the collection and storage of the desired clinical practice data. Current ambulatory EHRs include medical diagnoses using (ICD-9) codes and medical interventions using Current Procedural Terminology (CPT) codes as reimbursement for services is tied to these terminologies. Historically, nursing care has not been directly reimbursed, particularly in the ambulatory care setting. Currently, the data documented in EHRs by NPs captures the medical aspects of care provided, but does not reflect the nursing components.
A controlled terminology that captures data to reflect nursing care delivered is known as a standardized nursing language (SNL). According to Keenan (1999), SNL is a “common language, readily understood by all nurses, to describe care” (p. 12). Since 1973, 13 SNLs have been recognized by the American Nurses Association (ANA). These SNLs include two minimum datasets, seven nursing-specific languages, and two standardized languages, which are used by other disciplines as well as nursing. The Patient Care Data Set (PCDS) has been retired (Rutherford, 2008). Currently, nursing has not adopted one language to reflect all aspects of nursing care, nor have nurses consistently used a standardized language in their documentation.
In 2010, the ANA in the Principles for Nursing Documentation clearly articulated the importance of standardized terminology in Principle 6, which states:
Because standardized terminologies permit data to be aggregated and analyzed, these terminologies should include the terms that are used to describe the planning, delivery and evaluation of the nursing care of the patient or client in diverse settings (ANA, 2010, p. 14).
To fully reflect the nursing component of NP practice, the EHR should incorporate SNLs to document the nursing process, which includes nursing diagnoses, interventions, and outcomes. SNLs can be captured as discrete data, which can then be retrieved in an electronic format. However, most ambulatory care EHRs are based on the medical model and do not include SNLs. Why is SNL absent in patient records, including the EHR? There is a lack of data on the perceived value of documenting nursing as well as the medical aspects of NP practice in the electronic record. Identification of ambulatory care NP perceptions of barriers to documentation of the nursing portion of their practice could be useful in promoting the use of standardized language in EHRs.
The purpose of the study was to identify the perceived barriers to documentation of nursing practice utilizing SNL in the electronic medical record by ambulatory care NPs in the United States.
Review of literature
The NP as a user of electronic records could be a barrier to the incorporation of nursing language in the EHR. Dumas, Dietz, and Connolly (2001) surveyed 200 NPs to determine their use of electronic medical records. Over 83% of the NPs used computers at work, but the researchers concluded that NPs underused computer applications that would improve client care in their practice.
Over time, use of computers by advanced practice nurses has increased, but most NPs are still uncomfortable with informatics competency. Gaumer, Koeniger, Donohue, Friel, and Sudbay (2007) described the use of information technology after surveying 519 NPs. Ambulatory care NPs made up 43% of the respondents. Over 90% of NPs utilized computers at work, but most of them had low self-perception of information technology competence. The NPs indicated that initial training at the work site and academic preparation for information technology was inadequate.
Another NP user barrier to documentation in the EHR is familiarity with SNL to reflect nursing practice. Familiarity with and attitudes toward ANA-approved standardized languages was studied by Thede and Schwiran (2011) with an online survey of 1268 RNs. Over half of the respondents had neither knowledge of, nor experience with eight of the 12 standardized languages. North American Nursing Diagnosis Association (NANDA) was the most recognizable standardized language reported, but over one third of the RNs indicated that they had used it during their nursing education program but not since. Significantly more nurses reported familiarity with NANDA who had licensure post-1990 as compared with pre-1990 licensure. There was no difference in familiarity with the SNL between clinical and academic nurses, nor between informatics and noninformatics nurses.
Lack of a single, recognized standard language that reflects all of nursing practice has hampered efforts to include nursing language documentation in medical records. In the review of literature by Saranto and Kinnunen (2009) evaluating nursing documentation, standardized terminology, classifications, and codes were found to be vitally important to use EHRs efficiently. The authors also identified a “body of opinion in the literature that no single terminology can provide a comprehensive coverage for the domain of nursing” (p. 465).
Studies reflecting NP use of SNLs began with adult NP students. O'Connor, Hameister, and Kershaw (2000a) studied adult NP students in primary care practice and identified the seven most common nursing diagnoses and linked them to medical diagnoses. In a separate article, O'Connor, Hameister, & Kershaw (2000b) reported the most common Nursing Interventions Classification (NIC) interventions used to document the distinct practice of the adult NP in primary care. Keenan, Stocker, Barkauskas, Treder, and Heath (2003) identified valid subsets of the most clinically useful nursing diagnoses, interventions, and outcomes for adult NP practice in an effort to collect a common nursing dataset across settings. Haugsdal and Scherb (2003) surveyed 1190 NPs who identified the 20 most frequently used nursing interventions using the NIC. The authors found that NIC reflected outcomes commonly used in NP practice.
In this study, the evaluation of the barriers to documentation of NP practice in EHRs was based on the organizing framework by Androwich, Bickford, Button, Hunter, Murphy, and Sensmeier (2003), which identifies components of the clinical information system (CIS). This framework summarizes the variables/inputs, which ultimately determine the availability of data and information about professional nursing practice in an EHR (italicized phrases below correspond to Figure 1).
The understanding of the professional nursing practice process enables the definition of the functional requirements needed in an information system for nursing practice. NPs as advanced practice nurses combine medical as well as nursing diagnoses, interventions, and outcomes to define their practice. To reflect the full scope of NP practice, inclusion of SNL as well as medical terminology should be included in the information system. Technology provides the means for the functional requirements of the information system. However, EHRs are just beginning to incorporate and report discrete nursing data elements. Policy, regulation, and standards such as the recent governmental incentives for utilizing electronic records, can influence all concepts in this framework. The HITECH Act will influence adoption of electronic records by providing economic incentives for attaining meaningful use. Documentation included in electronic records will be driven by meeting the standards for meaningful use and for reimbursement for care. However, human factors, defined as the set of characteristics that underlie a user's interaction with a system, influence technology adoption and utilization of the information system. Perceived value of documentation of nursing practice, familiarity and use of SNL, as well as computer competence and confidence of the NP are human factors that affect utilization of the EHR. If the information system is not utilized, data and information about professional nursing practice are negatively impacted and nursing is unable to report the effect of the nursing process on patient outcomes. This study focused on identifying the barriers in each component of the CIS as perceived by NPs regarding documentation of their care in patient records, particularly EHRs.
- What are the perceptions of the ambulatory care NP regarding documentation of nursing practice in the medical record?
- Ambulatory NPs are most familiar with which SNL?
- Do ambulatory care NPs use SNL?
- What are the perceived barriers to using SNL in EHR?
- Is there a relationship between perceptions regarding nursing documentation related to age of NP, years of NP practice, geographic location, size of population served, practice setting, and level of education?
A computer-randomized sample of members who practice in ambulatory care settings in the United States was obtained from American Academy of Nurse Practitioners (AANP). The operational definition of ambulatory care NP was AANP members who do not practice in a hospital in-patient or long-term healthcare facility, resulting in an estimated 25,000 members who meet these criteria. The Madonna University Institutional Review Board reviewed and approved the study prior to collection of data. Completion and return of the survey was an indication of the responder's consent to be in the study.
A survey was developed by the researcher to address the research questions. The survey was reviewed by an expert panel of informatics nurses to determine the appropriateness and completeness of each survey question in each of the content areas to determine content validity of the survey (Niederhauser & Mattheus, 2010).
Data collection procedure
The survey was mailed to 1997 NPs with a stamped, return-addressed envelope. The survey was also created online electronically using Skylight Matrix Survey System. A link to secure entry by the sample members was included in the cover letter to allow the participants to respond electronically instead of returning the paper survey by mail. A follow-up reminder mailing was sent ten days after the first mailing. Data were collected over a 4-week period in early 2011.
Survey data were analyzed using the Statistical Package for the Social Sciences (SPSS), version 18.0, and included descriptive statistics and correlations between all Likert-scaled variables using Spearman's r. For this study, p values of < .05 were considered statistically significant.
Characteristics of the sample
The surveys were mailed to 1997 members of the AANP and 731 were returned; of these six were returned as undeliverable and 22 were excluded due to exclusion criteria for practice setting or forms returned blank. A total of 703 surveys fulfilled the inclusion criteria for ambulatory care NP in their primary or secondary practice setting, for a response rate of 35% and a greater than 99% confidence level for the sample size. See Table 1 for characteristics of the respondents and Table 2 for practice and location demographics.
Perceptions regarding documentation of nursing practice in the patient record
The data from this study revealed that more ambulatory NPs indicated that they believe that medical care should be included in their practice (98%), while 86% believed that nursing care should be included. Even fewer NPs felt that nursing care documentation should be included in the patient record (83%). Approximately 61% felt that that the full scope of their nursing practice was reflected in the patient record (Figure 2). However, 38% indicated that nursing care was omitted from their documentation. Reasons that nursing care was omitted included: no easy way to document nursing care (26%), no reimbursement for nursing documentation (23%), and lack of time to document (21%) (Table 3). However, 82% of NPs indicated that they included nursing interventions at least “sometimes” in their documentation and 69% felt that they included nursing outcomes at least “sometimes.” The majority (64%) never document nursing diagnoses in the patient record. One respondent summed up her experience stating, “As far as I know nursing diagnoses are not billable. EHR is time consuming enough, more charting is not realistic. Even though I don't chart NANDA diagnosis, my plan of care is still based on my nursing skills. As practitioners with physicians, we have to incorporate nursing and medical care.”
Familiarity and use of SNL
Ambulatory care NPs are unfamiliar with SNL. Only 17% indicated that they currently use SNL with NANDA cited as the language used most frequently. NANDA also was the language that almost half (45%) had heard of and used in the past. Attitudes toward SNL were mixed with 32% who disagreed or strongly disagreed that SNL could be used to reflect the nursing portion of their practice and 25% who disagreed/strongly disagreed that SNL was important to document nursing care. Overall, 30% of NPs did not think that SNL was important to their practice and therefore was a barrier to utilizing SNL in the EHR (Table 4).
Perceived barriers to using SNL in the EHR
The first barrier to overcome in using electronic records is to have the technology available in practice. Over 63% of the NP respondents stated that they currently use an EHR in their practice and over 54% stated that they felt confident in using the EHR to document patient care. Of those who were not currently using an EHR, 29% indicated that their practice is planning to implement an EHR.
The most frequently cited barrier to using SNL in the EHR was lack of availability of SNL in the electronic record (39%) followed by lack of familiarity of SNL (33%). Only 29% felt that difficulty in use of SNL in the electronic record was a barrier. However, 30% felt the barrier to using SNL in the EHR was their belief that SNL was not important to their practice (Table 4). Written opinions included that SNL was not appropriate to NP practice because these languages were “burdensome, cumbersome, out-dated and awkward terminology.”
Relationship between perceptions regarding nursing documentation and demographics of the sample
The barriers to nursing documentation identified as well as current use of the EHR were not significantly correlated to any of the demographics of the sample including gender, age, years of NP practice, level of education, or population size.
Ambulatory NPs from across the country contributed to this survey. At a time when EHRs are emerging as the predominant form of documentation of patient care, NPs are embracing this tool for their practice. However, current EHRs are based on the medical model of documentation, coding, and reporting of care outcomes. Most lack the ability to include SNL to document nursing care. There are many complex barriers to the use of SNL in ambulatory NP documentation, which relate to the components of the CIS framework (see Table 5).
Factors affecting documentation include perceptions of the individual NP regarding the nature of professional advanced nursing practice. NPs draw from both nursing and medical fields to provide an integrated practice to benefit their patients. One barrier to documentation of the nursing portion of NP practice identified was that practicing NPs may value the medical portion of their practice more than the nursing care that they may provide. This is evident in the greater proportion of respondents who indicate that NPs should include medical care (98%) versus the 86% who believed that nursing care should be included in their practice. These data are not mutually exclusive but indicate that there is an overlap in opinions regarding breadth of NP practice and that the majority of NPs value both the medical and nursing aspects of their practice. Currently, NPs are reimbursed for medical portions of their practice because ICD-9 and CPT codes are used for billing in their records as opposed to including nursing documentation that is not reimbursed. Consequently, the effect of nursing practice on patient outcomes remains invisible, as discrete nursing elements are not available for reporting and research. Lack of data ultimately affects policy regarding reimbursement for quality, cost-effective care by NPs.
Saba and Taylor (2007) state that we must use standardized, coded nursing language to enhance nursing visibility. SNL is the vehicle to capture the nursing process in documenting diagnoses, interventions, and outcomes as discrete data that can be retrieved and reported in EHRs. Though the majority of NPs in this survey indicated that they included nursing interventions and outcomes in the patient record, this is not in the form of SNL. Currently practicing ambulatory NPs expressed a lack of familiarity with standardized language and only 17% currently use it in practice. Formal and continuing education programs are needed to educate current and future NPs on the means to document their nursing practice in a retrievable format using SNLs. Keenan, Stocker, Barkauskas, Treder, & Heath (2003) noted that further identification of the most clinically useful nursing language for NP practice may be helpful to gain “buy-in” by advanced practice nurses. Collection of nursing data that promotes evidence-based practice by clearly identifying the effect of nursing on patient outcomes can be achieved through documentation and retrieval of discrete data elements in the EHR.
Information system/technology barriers to use of SNL in EHRs include lack of availability and ease of use of SNL in current EHR products. Though SNLs exist, incorporation of the languages as discrete data by EHR vendors continues to be a barrier. Currently, many SNLs are being mapped in the reference terminology called the Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT). As EHR vendors include SNOMED-CT in their products, this may be the vehicle needed to provide access to SNL in EHRs. Lang (2008) has described a 5-year vision for the transformation of nursing practice and research utilizing computerized CISs with reference terminologies such as SNOMED-CT to document nursing care, to enhance decision making, and to improve nurse-sensitive outcomes for patients across patient care settings.
Ambulatory care NPs in this survey indicated that they felt confident in documenting their patient care in the EHR about 55% of the time. As EHRs are rapidly implemented in the ambulatory care setting with monetary incentives for meaningful use over the next 5 years, NPs must continue their education to become familiar with their EHR's ability to document the full scope of their practice. NPs must also advocate for mechanisms within their EHR product to access SNL through reference terminologies such as SNOMED-CT.
The large response of 703 ambulatory care NPs from every region of the United States out of a sample size of 1997 resulted in a greater than 99% confidence level that the findings can be generalized to AANP ambulatory care NPs. Attitudes of NPs who are not members of the AANP are unknown. In the rapidly changing field of EHR technology, additional studies will be needed to assess the progress of NP attitudes toward documentation of nursing and the use of SNL in EHRs to reflect that care. Continuing research is needed to study best practices that include SNL in daily documentation of care as well as retrieval of data to report outcomes.
Implications for NP practice
This study provides insight into the perceptions of ambulatory care NPs toward inclusion of nursing care in their documentation. Because NP practice is a blend of medical as well as nursing care, NPs will need a system of SNL as well as medical language that can be documented and retrieved as discrete data in an electronic format to fully describe NP care. NPs have not embraced the current recognized SNLs. This may stem from unfamiliarity with the languages due to lack of formal instruction in their nursing education programs as well as perceived lack of ability of the current languages to reflect their practice. Efforts to identify the appropriate terminologies to reflect ambulatory care NP practice and educate NPs on their use in electronic records are needed.
The policy barrier of lack of reimbursement for nursing documentation can be overcome if NPs can show evidence-based care that contributes to improved patient outcomes with their unique practice. With the use of SNL to reflect the nursing portion of NP practice alongside the standardized medical coding currently incorporated in EHRs, NPs have the tools to retrieve the data needed in an electronic format. NPs must be knowledgeable in the field of informatics and advocate for products that can fully reflect their practice. Until discrete data in the form of SNL are available and utilized, the impact of the NP's care will be unidentifiable for outcomes reporting and therefore invisible.
This study revealed that most NPs value the medical and nursing portions of their practice but identified that most do not currently use and are not familiar with SNL as a vehicle to document their nursing care in patient records. Although over 63% of the NP respondents stated that they currently use an EHR in their practice and over half are confident in using the EHR to document patient care, the barriers to using SNL in the EHR are multifactorial and complex. The barriers include lack of reimbursement for nursing documentation, lack of time to document, lack of availability of SNL in electronic records, and a belief by some that SNL is not important or appropriate to document NP practice. Until these barriers are addressed and discrete data in the form of SNL is available and utilized in the EHR, the impact of the NP's care will be unidentifiable for reporting outcomes. Identifying and informing the NP on these barriers will equip the NP to participate in selection and development of EHR products that address the ability to document and report the full scope of their practice using both medical and nursing standardized language.
We appreciate the support of the expert panel who reviewed the survey including Kathy Dontje, PhD, FNP-BC; Joanne Pohl, PhD, ANP-BC; and Marisa Wilson, DNSc, MHSc, RN-BC. We also appreciate the help from the AANP research staff as well as all the AANP members who participated in the survey. Special thanks to Alan J. Conrad, MD, Sandra Gruenberg, Steven Gruenberg, Elizabeth Davis, Kathy Kirch, Mary Ellen Snow, Sue Ennis, Harold Conrad, Jackie Conrad, Mark Barnett, and Suzette Asiala in assisting with the research as well as Michelle Harris, PhD in reviewing the manuscript.
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