Crisis Documentation Strategies to Reduce Burden of Documentation During the Pandemic: Texas' Pilot to Generate Consensus.

The coronavirus disease 2019 (COVID-19) pandemic highlighted challenges and opportunities in our healthcare systems. Prior to COVID-19, clinicians have noted an unsustainable burden of documentation that must be addressed.[1] The COVID-19 pandemic has significantly compounded this identified issue with electronic health records (EHRs) that has created distress, dissatisfaction, and an overall impact on joy in work.[2,3] Healthcare organizations attempting to reduce the burden of documentation during periods of “surge” of COVID-19 patients were met with acceptance by many nurses but also had some nurses express concern about changing the documentation during crisis.[4] Nurses found themselves trying to balance providing care during peak census periods while upholding professional standards of care, including nursing documentation. Surge capacity can be defined as “the ratio of patients to medical beds, staff, and consumable resources.”[5]

Early in the pandemic, nursing leadership in Texas convened to determine how to support nurses during this time. The following is a brief report on a Texas pilot project to reduce EHR documentation burden throughout the pandemic. The purpose of this project was to generate a statewide consensus as to what might constitute reduced EHR crisis documentation and define a definition of surge that would trigger the use of the crisis documentation.

BACKGROUND

In early 2020 when the COVID-19 was first identified in the United States,[6] and cases began to surge in the state of New York, the Texas Nurses Association (TNA), and Texas Organization of Nurse Leaders (TONL) Health Information Technology (HIT) committee convened statewide nursing informatics leaders. The TNA-TONL committee, founded jointly in 2010, queried the informatics nursing leadership community to determine what the HIT committee members could do to help hospitals prepare for potential COVID-19 surge. The community of informatics leaders in Texas had identified the standard operating procedure (SOP) for crisis documentation developed by Sengstack and Hughart[7] as a draft for Vanderbilt University Medical Center. Recognizing the potential for large volume and high-acuity patients with COVID-19 likely to impact Texas hospital bed capacity, they requested an initiative to identify consensus about how nursing documentation burden could be reduced. Vanderbilt's draft SOP had identified nursing documentation for inpatient, ambulatory, and emergency department admissions and data fields for consideration for reducing documentation. However, there was no nationwide consensus on what fields should be eliminated, particularly in light of regulatory documentation requirements.[8]

As a result, a consensus-generating tool was developed to capture data from Texas hospitals on what the specific healthcare systems and independent hospitals planned to adopt methods to create EHR crisis documentation strategies. Several of the hospitals and systems had already started to build test environments in their EHRs. The purpose of this project was to generate consensus in Texas as to what might constitute crisis documentation in an EHR build and what definition of surge would trigger the use of the crisis documentation. Specifically, the project in Texas was initiated so that findings could be used to: (1) examine how nursing EHR documentation was reduced during peak times in the COVID-19 crisis; (2) describe nursing EHR documentation reduction during peak times in the COVID-19 crisis; and (3) promote the development of a statewide standard/policy for nursing EHR documentation reduction in times of crisis.

TEXAS NURSES ASSOCIATION–TEXAS ORGANIZATION OF NURSE LEADERS HEALTH INFORMATION TECHNOLOGY COMMITTEE HISTORY

In 2009, shortly after the Health Information Technology and Economic Heath Improvement Act passed,[9] the TNA and TONL jointly convened an HIT Task Force. The Task Force was composed of TNA and TONL members representing practice and academia and was directed to build on the work of the nationally based Technology Informatics Guiding Education Reform initiative.[10] The Technology Informatics Guiding Education Reform initiative was launched in 2004 by a number of stakeholders to establish a shared vision for supporting information technology–enabled nursing practice and education that would provide safer and higher-quality care. For the past 11 years, the TNA-TONL Task Force has met its charge to determine implications of healthcare informatics for nursing practice and education in Texas and in creating an annual report for action.

TEXAS PILOT INITIATED TO ADDRESS BURDEN OF DOCUMENTATION DURING COVID-19 PANDEMIC

As soon as the World Health Organization declaration of pandemic was made in March 2020,[11] the cascade of initial recommendations, guidelines, and presentations commenced, supported by the American Nursing Informatics Association and the American Academy of Nursing Informatics and Technology Expert Panel. The goal of the joint effort was to identify and disseminate resources that nursing leadership and the informatics community could share to address the COVID19 pandemic.[4,12] A common theme identified throughout the emerging challenges was the need to address documentation burden in the time of crisis.[7,8,13-17]

Various academic centers, healthcare systems, and regulatory agencies joined the discussion. The group's objective was to identify the minimum documentation requirements of nursing staff to adhere to regulatory requirements and continue with excellent patient care. Attempting to achieve this objective occurred while adapting the healthcare environment to the COVID-19 pandemic.

Important considerations during the COVID-19 pandemic were the influence of regulatory rules. Investigation into the regulatory agencies started the process for many healthcare organizations, as they set the rules for what constituted required documentation during normal times and set the initial definition of facilities reaching surge capacity or surge. In the early months (June 2020), the Centers for Disease Control and Prevention started offering an application, COVID-19Surge, to help facilities calculate surge and offer strategies and guidance to those who would need it.[6] Later, depending on the state, it would be defined as having greater than 15% of the facility bed capacity full of COVID-19 patients.[18]

As the recommendations progressed through April and May 2020, structured guidance began to take shape in the literature and professional nursing organizations, including the American Nurses Association, American Nursing Informatics Association, and the American Medical Informatics Association. A search of the literature supported the Texas pilot and TNA-TONL HIT committee recommendations for nursing leadership across Texas to initiate changes to nursing documentation during crisis. Furthermore, regulatory agencies, such as the Joint Commission, Centers for Medicare & Medicaid Services, and the Texas Board of Nursing, began to communicate what was considered minimum documentation requirements. This discovery led to several institutions and vendor organizations who extrapolated this information into what could be used as policy or guidance for their own workflows and staff (eg, Vanderbilt, Henry Ford, and Texas Tech). From these expert nursing leaders and informaticists, the content of the Texas pilot study was developed. The community of nursing informatics leaders, supported by the TNA-TONL HIT committee, had developed a tool to capture information from their respective Texas hospitals on the status of plans to implement or on details on what they had implemented for decreasing nursing documentation within the EHR due to surges of COVID-19 patient volumes. The new data capture tool was used to poll participants as to their individual healthcare systems' demographics and their respective healthcare system's response to changes, if any, to nursing documentation in the inpatient, outpatient, or emergency department settings.

The survey was sent to select individuals that were either chief nursing officers or informatics nursing leadership. Many organizations worked jointly with informatics and nursing leadership to complete the survey. The institutions were instructed to convene informatics nursing leadership knowledgeable about previous, current, and future builds in the EHRs specifically related to nursing documentation. Our pilot findings suggested that initial screening, initial assessment, plan of care, and discharge documentation are key areas where Texas institutions identified ways to decrease nursing documentation burden. The subject matter experts across Texas determined that a cutoff point of 50% or greater of the respondents having updated their build to accommodate an EHR reduced documentation strategy would constitute consensus (noted by respondents as build complete deployed, build complete–not deployed, and build modified or other were included in the total percentage). Similar findings were noted for outpatient admissions and emergency departments (findings available upon request). The pilot work in Texas helped identify ways to improve the tool to capture valid and reliable data to inform national crisis documentation strategies. Subsequently, the pilot will be developed into a full research protocol beginning with rounds of Delphi[19] recruiting national subject matter experts to examine the updated online data capture tool.

PROPOSED NATIONAL STUDY SUPPORTED BY THE ALLIANCE FOR NURSING INFORMATICS

The Alliance for Nursing Informatics (ANI), a collaborator and supporter of many national and state nursing organizations, addresses how technology can impact nurses' issues and opportunities in all areas of practice.[20] The ANI has been supportive of the ongoing work of COVID disaster documentation in helping align the work of these organizations and supporting their efforts at a state and national level. ANI helps communicate these efforts to the nurses of their various member organizations and encourage dialogue of these organizations around COVID-19 through their member representatives. This Texas pilot study, although limited in scope, sets the stage for a nationwide study. This project has national implications for addressing safe patient care during crisis and has implication for longer-term strategies to reduce documentation burden with specifications on precisely which areas can be decreased without patient safety compromise. ANI and their member organizations will play a dominant role in bringing about national consensus. The national consensus will inform policy and regulations related to necessary nursing documentation during times of crisis.