It has always been recommended that charting take place as near to the care event as practical, with the key word being practical. In reality, clinicians and nurses often stay after shifts to do their charting because entry is not seamless during patient care.
"Real-time data enables staff and organisations to work more efficiently and productively and, in turn, results in improved care for patients, who can move through the care pathway in a timely fashion. The use of electronic devices must become a routine part of healthcare to make the best use of increasingly limited resources.” - Glenister, H, COO of The Learning Clinic, Nursing Times, 2015
The more time that passes between the health event and the data entry, the more likely the data input will be generic rather than detailed and the greater the chance for error from the physician or via incorrect hand-off communications. Delayed data entry impacts patient outcomes and creates unnecessary administrative overhead.
The Benefits of Real-Time Data Entry
Real-time data entry has been shown to improve patient care, particularly the identification of patients who may be deteriorating, to free up more direct-care time for nurses and clinicians and to help hospitals better deploy staff and resources.
According to a study published in Nursing Times, the availability of up-to-date data can help nurses and clinicians spot patterns in data that indicate a patient is deteriorating or may have an infection. While these data points may now automatically feed into the EHR, the value of observational data from nurses and doctors is no less vital in providing care.
Real-time electronic recording of all clinical data, including observations and assessments and actions taken, improves the care process, gives an overall picture of patients for staff deployments, and provides a clear data trail during investigations of incidents and complaints. Real time documentation and order entry during rounding can also help speed up timely care and minimize future interruptions later in the day.
We could go on. The benefits of real-time data entry are well known. Unfortunately, in many hospitals, real-time charting has been unrealistic.
The Challenges to Real-Time Data Entry
Logistical and design issues in many EHR systems, siloed healthcare systems and a lack of devices are often cited as the biggest barriers to real-time charting. Some hospitals may have mobile workstations, but such workstations may only be available to clinicians, require logging in and logging out, or cause so many delays in real-time patient engagement that they are soon dropped.
"One nurse believes that since going live, EHRs have added 3 hours to a 12-hour shift. The extra time that EHRs take has many origins — endless logging in and out; paging through unnecessary screens; duplicate entries; trying to find where to chart something; slow, cumbersome systems; and increased mandatory documentation.” - Laura A. Stokowski, RN, MS, Electronic Nursing Documentation: Charting New Territory
In order to create an EMR that is accurate, actionable and timely, the care team must be supported with tools that allow for simplified real-time charting.
How Telmediq Supports Real-Time Data Entry
Healthcare IT integration is very difficult and costly to accomplish in today's large hospital systems. Telmediq has developed a number of off the shelf ‘plugins’ that allow information to flow freely between disparate IT, clinical, and telecom systems, including the EMR / EHR. The result is a cohesive, integrated communication platform that ensures that the right care gets delivered to the right patient at the right time.
With such integrations, the Telmediq Healthcare Communication Hub becomes a natural tool to support real-time charting. We support real-time charting with:
- Intelligent field mapping to reduce duplicate data entry requirements
- Voice-to-text capability to improve the patient experience and speed up data entry
- Easy and elegant interface
- No need to switch between apps, since all information is available on a single clinical platform
- Easy transfer of PCM notes to clinical notes to support rapid documentation
- Record chat threads in text format or PDF attachment (to include images) to the EMR, either manually or based on automated rules to help reduce manual and redundant documentation and improve the audit trail for compliance requirements
- Real-time access to lab results & orders to support decision making and real-time charting
- Immediate delivery of critical abnormal test & lab results to the clinician. In accordance with Joint Commission requirements, the date/time and recipient of a critical lab result message (both delivery and read status) are auto-recorded to the EMR
When real-time data entry is combined with seamless care co-ordination, the entire care team can work seamlessly to improve patient outcomes. Contact us to set up your demo today.