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The reality of documentation, health information exchanges

Raso, Rosanne MS, RN, NEA-BC

doi: 10.1097/01.NUMA.0000407589.27717.4f
Department: Leadership Q&A

Senior Vice President of Patient Care Services and Chief Nursing Officer, Lutheran Medical Center, Brooklyn, N.Y.

Q Regulatory bodies have gotten out of control with all the requirements of nursing documentation. Is any group taking a stand against them?

It does seem that the regulations for nursing documentation become more detailed every year. It can be frustrating to sort through national, federal, state, specialty, and accreditation requirements, constantly implementing revised documentation expectations. Time studies of nursing work show up to 34% of the shift being spent on documentation, and many feel it takes precious time away from direct patient care.

Cheryl Hoying, president of the American Organization of Nurse Executives (AONE), recently wrote about the impact of regulations and legislation on nursing.1 She reminds us that the intent of the rules is to improve quality and safety and to think of it as doing the right thing for patients. Documentation is “proof” and critical in the coordination of care. With that perspective, could a stand against “excessive” documentation be seen as a stand against quality care?



In review of several professional nursing organizations' websites, there are clear legislative priorities, however, they usually aren't regarding documentation reform. They're more likely about improved access to healthcare, workforce issues, scope of practice, role of nursing, emergency preparedness, and other related topics. AONE does have a Regulatory Monitoring Committee, which monitors and responds to regulatory issues such as those from The Joint Commission or the Medicare Conditions of Participation. Often regulatory agencies allow a comment period before enacting changes or new rules; The Joint Commission regularly seeks opinions.

It isn't only groups or professional organizations that can take a stand; it takes all of us to make a difference. If you feel strongly, you should make your individual opinion known either directly to the agency or to your professional organization.

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1. Hoying C. Focus on the impact of regulations and legislation on nursing. Voice of Nursing Leadership. July 2011.

Q Is a health information exchange (HIE) going to become a reality?

An HIE coordinates health data exchange between disparate systems and interested stakeholders, for example, between hospitals and private physician's offices or among different healthcare organizations across the country. Government funding and standards for HIEs were established under the Health Information Technology for Economic and Clinical Health Act as part of the American Recovery and Reinvestment Act of 2009.

HIEs can be at a national, state, regional, or local level. They're intended to improve patient-care quality through shared access to electronic health information data. Other potential advantages of HIEs include public health benefits from data access and decreased costs due to reduced duplication and administrative efficiencies.

HIEs are driven by providers, hospitals, employers, payers, public health agencies, and private stakeholders, especially now that government funding is available. There are big concerns among our IT and chief information officer colleagues surrounding HIEs, including sustainability when government funding is gone, standardization of data and how they're collected, and privacy/security issues. Participation is voluntary. There's no defined model from a legal, security, IT, organizational, or other perspective. Maybe someday there will be a single, meaningful patient health record database that can generate enough revenue to sustain itself. Access to patient data through a secure information exchange remains a desirable goal.

Copyright © 2011 Wolters Kluwer Health, Inc. All rights reserved.