Electronic Charting

[Mar010891]

I have a concern/question.

I have been a RN for 3 years. The first hospital I worked at used electronic charting. The hospital I work at now uses paper, BUT we are transitioning to EPIC in October (yay!)

We have been told for months there will be ONLY electronic charting and the doctors will put in their own orders, but the nurses still have the ability to input telephone/verbal orders if needed.

We have been informed as of today we will be keeping blank physician order forms on the units even with the Epic Charting System. The unit secretary will transcribe their paper orders and input them in EPIC if on the RARE (sarcasm) occasion the physician writes out orders. Hence, we will still have to signed off on orders in the chart AND the computer.

My concern/question is doesn't this defeat the purpose of electronic charting? There was suppose to be no more paper. I also believe if we do not get rid of paper now, the culture of the hospital will never change.

Thanks guys!

[roser13, ASN, RN]

I believe your suspicion is correct. 4 years into Epic, we are still accepting paper orders & H&P's. I've almost accepted that the culture will never change.

I understood when the older docs balked at learning a new system in their last years before retirement, but some of the younger docs just flat out refuse to assimilate. Really blows my mind how we accommodate them.

[NotMyProblem MSN, ASN, BSN, MSN, LPN, RN]

Old habits die hard. There are some doctors who are just plain resistant to change. Until the powers that be are able to win them over, the paper orders remain. We went through this exact same thing; it took a minute, but we are completely computerized now.

[RNperdiem, RN]

Depends on the hospital. I work where residents do most of the ordering. They are young, familiar with technology, and employees of the hospital. An academic teaching hospital can get that level of compliance from doctors. Maybe smaller private hospitals might cater to doctor preference more.

[HouTx, BSN, MSN, EdD]

CPOM (computerized physician order management) adoption is one of the important criteria that is being measured as part of the "meaningful use". ... For non-USA folks, this is a Federal initiative that provides monetary incentives for adoption of healthcare documentation technology & penalties for non-adoption. The CPOM goals are indicated in terms of the percentage of physician orders that are physician-entered directly into the electronic system - NOT transcribed from paper. Facilities in my organization are hovering at ~ 80% right now, but it's been a struggle.

So - failure to implement CPOM will incur significant $ penalties. If they're just now at this point, OP's facility is really behind the curve and probably unable to meet the time deadlines. Allowing physicians to opt-out of CPOM & continue to use paper forms is a losing proposition, because they are notoriously resistant to any sort of change, especially one that has an effect upon their own work habits.

A logical outgrowth of CPOM is elimination of verbal/phone orders... because in the mature EHR systems, physicians can access the electronic system from pretty much any place that they can use a phone. In many instances, they don't even have to touch a keyboard since speech-to-text systems have been implemented for them.

[Mar010891]

I KNOW!!! I thought the regulations were clear when it said ELECTRONIC charting. I wish the hospital would get fined for paper charting. The older doctors who don't want to use a new system should retire early. Change is inevitable. It is really frustrating that they complained enough to where we will keep blank paper order forms for them. It's obnoxious.

[quazar]

Depends on the hospital. I work where residents do most of the ordering. They are young, familiar with technology, and employees of the hospital. An academic teaching hospital can get that level of compliance from doctors. Maybe smaller private hospitals might cater to doctor preference more.

Yes, this. I can speak from first hand experience in both environments, and this hits the nail on the head, in my opinion. In smaller hospitals, or even in large hospitals without residents or a teaching hospital environment, this is exactly how it has been for me.

[nrsang97, BSN, RN]

You still need paper copies of stuff, they do have down time.

[Wrench Party]

We have the opposite problem- everyone is so well trained to electronic charting! The providers about damn near had a meltdown when Epic went down for 4 hours on a Saturday night for its 2016 update and had to write out paper orders. If the order wasn't absolutely necessary, it wasn't happening.

[FurBabyMom, MSN, RN]

We've been on Epic at my institution for a few years. It's far more efficient than our old system - we used 4-5 systems depending on where in the hospital. Our ED was on one system, the procedure areas another (and our system had not really been updated since it was purchased 20 years prior), floor and ICU nursing was on one system, results and physician orders on two other systems. We had a lot of paper when we switched - many H&Ps for procedures, as well as all specimen requisitions / order sheets were on paper. All blood product order forms were paper and had to be filled out by staff nurses (or physicians depending on the situation).

We have very little on paper anymore. Consent forms, ticket to ride forms, sticker sheets, the sheets that are sent from lab with blood products, and printed records from outside hospitals (if patients are transferred to us). Report handoff sheets (floor/ICU to OR and OR to PACU or OR/PACU to floor/ICU), count worksheets, etc - none of which are part of medical records anyways. We also - our emergency blood release forms (for "emergency release" and for "massive transfusion") are small papers that just require patient information and an MD signature.

All orders are entered electronically, mostly by physicians or NPs/PAs. RNs, respiratory therapists and radiation technologists are allowed to enter verbal/phone orders too. Most nurses in our facility don't use this outside of emergency situations. In my environment, we enter a fair amount of verbal orders - ICU placement, changing bed placement orders, wound vacs, prepare RBCs, specimen orders, all kinds of stuff. It's impractical for surgeons to break scrub and put in their own orders in those situations. All of those orders go for the MD to sign off with us. Some of our orders - for certain medications, have to be entered by an attending physician. We can only use paper forms if the system is down, but we had a CPOE system before Epic so that wasn't actually a change.

In fact, we had a utility failure somewhat recently. It was the first time we faced needing paper forms since transitioning to Epic. We still do most of our code documentation on paper and enter it into the code flowsheet in Epic after the dust settles. Somehow, we only had about 10 minutes without Epic (longer without other tools / resources but that's another story). We were just like "Um...where *are* downtime forms now kept?" Because now we're only on paper when something crazy happens or when planned upgrades happen (and then only emergent cases are running). In my environment, prior to Epic, about once a week, I'd be charting on paper because the old system would crash and it would be back up but be unreliable for several hours.

[Qing]

I worked at a hospital that uses electronic charting but there was still the papers for the physician orders. So the way I understand it is there are doctors that still use the paper to write orders. Many now are adjusting to using electronic charting, but if the goal was to be paperless- then yes it really defeats the purpose. I doubt though that papers for physicians to write orders will go away anytime soon. So we still have the responsibility to check the patient's chart to not miss any orders that may have been written. However, I dont think we can completely rely on the electronic charting because we had the computers crash on us and we had to go back to paper charting or wait until the system was back online to chart. I still think a balance of electronic and paper is needed, but have no idea how they will achieve that.

[psu_213, BSN, RN]

One hospital in our system was going to 100% computer charting 5 or so years ago, including CPOE. Basically all the cardiologists--even ones in competing groups--all banded together and refused to go to CPOE. Given the $$ these physicians brought to the hospital, the hospital caved, and 100% computer charting did not happen.

The hospital at which I work now is suppose to be all electronic. However, some older physicians will not put in their orders. They will either log in, but have the NP/PA put in orders so that their percentages don't look to bad, or, if their APPs are not available, they will go to a nurse and give verbal orders. These doctors are not questioned by the medical administration of the hospital, so they are allowed to get away with these practices.