STORIES FROM THE FIELD: Implementing an Electronic Health Record


Inpatient and outpatient clinical nutrition staff at a large academic medical center had been using their facility’s electronic health record (EHR) for more than 10 years. Registered dietitian nutritionists (RDNs) were not included in initial EHR design; instead they were reassured that the design team would take nutrition care into account. The nutrition manager at the time was not aware of the im- portance of provider input into EHR design and told staff they would “get used to things” over time. Inpatient and outpatient RDNs used the same documentation format for their notes.


The design team determined (without conducting a workflow analysis, due to “time and money con- straints”) that RDNs should document using “flowsheets” that included mainly structured data entry. RDNs were told that data entered into the flowsheet would “flow” into an appropriately formatted nu- trition progress note that could be easily read by other providers. The rationale given to clinical nu- trition staff was that nursing preferred to use flowsheets, and nursing leaders determined that other allied health professionals should also use flowsheets to document care.


Shortly after the new system was implemented, RDN staff realized documentation was problematic for several reasons:


» Although the patient’s height and weight were entered by the RDN at the beginning of documentation, this information did not flow to calculations of BMI or estimated nutrition


requirements, thus requiring double data entry.


» RDNs were required to check off a series of data points for all patients. Radio buttons and check boxes were constructed using inpatient workflow and were not always applicable to each


patient.


» RDNs were required to check boxes that documented exactly which educational handouts were given to patients. This flowed to the preformatted nutrition note. There was no plan to analyze


these data, leading to unnecessary work for the RDN and a cluttered final note. While inpatient RDNs simply ignored this requirement, outpatient RDNs were required to document handouts provided. To date, none of these data have been used for analytics purposes.


» Data collection for nutrition focused physical examination was difficult to complete and was found in two different areas using two different formats. Information on oral examination was


not included.


» The electronic Nutrition Care Process Terminology (eNCPT) was included but used drop-down menus that listed each diagnosis, etiology, and sign or symptom, leading to very long drop-


down menus. This information was evaluated, and it revealed that busy RDNs tended to select the most convenient diagnosis instead of actually diagnosing the nutrition problem. In addition, only one diagnosis was allowed, so when a patient had more than one nutrition diagnosis, the RDN had to manually enter each as free text. Because this took more time, RDNs noted that many nutrition diagnoses were not documented.


It was thought that these problems may be due the following circumstances:


» Although much of nursing documentation works well as structured data entry fields, it is not known whether nutrition data works well as structured data.


» There are substantial differences between nursing and dietetics workflows.


» The flowsheet and nutrition note did not take RDNs’ workflow into account, leading to several cognitive breaks during the documentation process when RDNs had to switch between using the flowsheet and entering free text. Each cognitive break interrupted the RDNs’ thought process and required them to refocus, thus risking loss of time and clinical information.


The nutrition manager requested a formal workflow analysis for both inpatient and outpatient clin- ical nutrition settings. This resulted in separate documentation formats for each area of practice. Drop-down menus for nutrition diagnoses were streamlined and allowed for documentation of more than one nutrition diagnosis. The requirement for checking boxes for handouts was removed.


CHAPTER 14: Nutrition Informatics


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