Digital
Divide
New electronic charting and data collection systems allow
PHNs to streamline record-keeping and outcomes analysis
By Scott Mace
November 25, 2003
What lessons are public health nurses learning lately when it comes to technology? Although the cost of computers has continued to drop, training and support remain big hurdles in an era of limited budgets.
At the recent American Public Health Association annual meeting in San Francisco, two county public health departments presented advances in collecting and analyzing data required to move health care records from pen and paper to computerized problem-identified and outcome-driven formats. Client outcome data are valuable for policy decisions surrounding health care services in the United States.
For the Marion County Health Department public health offices in Indianapolis, the goal is to move away from paper-based charting. The challenge is twofold: First, nurses must agree upon a standardized vocabulary for classifying client diagnoses, interventions and outcomes. For public health nursing, such vocabulary still is being solidified, according to several nurses who presented research at APHA.
Secondly, financially strapped public health agencies must find resources with which to implement a new client-care vocabulary, purchase supporting software and hardware, as well as train nurses in each of their uses. Health care agencies are being called upon to produce data supporting program area needs and justify their existence and merit.
Patience is a critical watchword. After careful planning and collaboration, one public health nursing information systems' project begun in 1997 just now is coming to fruition.
The MCHD was one agency highlighted at APHA's annual conference. (The incoming APHA president, Virginia Caine, MD, also happens to be the agency director for the MCHD.)
Public health departments spend more and more of their time educating the public on health concerns through home visitation, school encounters, clinic settings and other community events. In Marion County, public health nurses conduct home visits for a variety of reasons such as postpartum/newborn assessments, communicable disease follow-up, chronic disease case management and maternal child-related conditions.
"We wanted to standardize the language used in the charting process, so that it would be clear and concise," said Donna Daulton, RN, a public health nurse with the MCHD.
The MCHD hired a consultant familiar with the Omaha System, which directs and documents nursing diagnoses, interventions and client outcomes. In looking at electronic documentation, the decision was made to use a software package that based its taxonomy on the Omaha System. CareFacts, a software system based in St. Paul, Minn., was selected. Consultants came to the MCHD to provide training for all the public health nurses on the use of the Omaha System and a 19-member nurse Core Training Team to the CareFacts software.
The plan to integrate the electronic medical record into daily practice was met with many challenges that included software/hardware incompatibility, additional nursing responsibilities and nursing shortages. Nurses who had initially been trained on the Omaha System left the health department and the initial Core Training Team of nurses grew smaller.
When the decision was made to again move on the automated record project, the Core Training Team was reactivated to serve as trainers and mentors for the remaining public health nursing staff. The team held four formal four-hour training sessions for about 60 public health nurses. Training sessions allowed staff to learn via structured content presentation, small-group activities and hands-on computer client input. Robert Boehler, a district health worker, was valuable in setting up a Web-based computer tutorial for staff use, said Connie Schneider, RN.
Initially, the training sessions included the use of "pathways," more commonly known as care plans to nurses. Each pathway allowed the nurse to have a minimum set of care activities to follow for each client in a select program area. The ongoing training now is focusing on developing greater use of the Omaha System, allowing staff to document any client problem in the automated CareFacts software.
Staff resistance to the new software has continued following training. "It's the old thing, why rock the boat?" Schneider said. "Some nurses do not want to do away with paper charting. But with practice, you can increase your use of the software when you know what you are doing."
Each public health nurse has entered client record information into CareFacts. They continue to print out their work to include a paper trail in the medical record. The review of the automated client records shows that extraneous narrative charting has decreased, problem-focused care is becoming evident and ease in reading client charts is a reality. However, the majority of public health nurse documentation continues to be paper charting.
With the introduction of HIPAA, patient privacy and accuracy in documentation have become even more important reasons to have a clear and concise way of recording client care. In January, the plan is to move to all-online charting. Staff will be accountable to document services in this format.
The Omaha System promotes additional focus on client outcomes, as it contains a Likert-type rating scale. This feature in the Omaha System parallels the Healthy People 2010 Objectives, a U.S. public health initiative to increase the quality and years of healthy living while eliminating health disparities.
At the County of Los Angeles Department of Health Services, policy-makers needed a more precise way to measure the severity of public health concerns as stipulated in Healthy People 2010. For the first time, software is about to be deployed to drill down into localized areas of the county, using a new Public Health Nurse Assessment Tool. A beta version of the software already was being tested by PHNs in two health districts in October.
"Traditionally, a part of the public health nurse's work has been involved with assisting individuals," said Kathleen Smith, MPH, of CLADHS. "More and more, a bigger part of their work needs to be working with communities and systems at the larger level."
The first phase, implemented in 2001, involved a detailed public health assessment survey, where nurses gathered information about a variety of health concerns across an entire household. From preliminary data analysis, it was possible to determine, for instance, that residents of a particular service planning area identified access to health care as their No.1 concern. "That's going to be very helpful when we're looking to target our effort," Smith said. The software being built could potentially drill down all the way to the census tract level, she said.
The MIS division of CLADHS is writing the software that will allow computers to aggregate and analyze the data being collected via PHN assessment. "Because we're not going the way of a medical model or the Omaha system, and we're looking at it from a public health perspective, we're having to create [the software] ourselves," Smith said.
The remaining barrier for Los Angeles County is funding for full support of the system, as well as additional hardware. If that funding is found, the system could be deployed countywide by next July, Smith said. "Ideally, the assessment tool could be on a tablet [PC] so the nurse could complete it in the field, and, ideally, wirelessly transmit it from the field to a server." But at more than $2,000 each, the cost of providing tablet PCs to 190 district public health nurses remains an obstacle. (In addition, the county has 300 other PHNs who are not district PHNs, but who work with targeted populations.)
"One of our mantras is, there's unlimited good work to be done, so we have to prioritize and focus," Smith said. "We want to have some data to help guide that process."