Clinical data from nursing flow sheets is critical intel for health systems increasingly leveraging data analytics and artificial intelligence to predict or improve outcomes.
However, what makes flow sheets so useful for data abstraction and analysis is also what adds to nurses’ growing documentation burden, as nurses must click through and enter meticulous information on vital signs, assessments and more, shift after shift.
This tension emerged during a Sept. 17 panel at Becker’s Health IT + Revenue Cycle Conference in Chicago, when an attendee asked the three chief nursing information officers speaking: Should the industry move away from flow sheets?
The consensus: not so fast. Instead, the CNIOs advocated for first revisiting what is entered into flow sheets and how.
The leaders traced the challenge back to the industry’s transition to EHRs, when health systems reproduced paper forms on screens rather than reconsidering them.
“We just took those trifolds and put them in the software,” said Donna Woelfel, MSN, RN, chief nursing informatics officer for the Northern California region at Oakland, Calif.-based Kaiser Permanente.
She suggested health systems first audit what information is included on a flow sheet and where they can ease documentation burden on nurses. Organizations should start by establishing the salient data elements that must be in the record, then identify what else is being captured for purposes such as revenue cycle and quality, and only then decide how any of it gets collected, according to Ms. Woelfel.
“Does the admission flow sheet need to be 150 lines long, and if it does, which element of that does nursing working top of license need to complete and what other elements of it can be done some other automated way?” she said.
Meg Atkins, MSN, RN, chief nursing information officer at Newport News, Va.-based Riverside Health System, pushed the same idea further, arguing systems should question whether nurses need to be the collection mechanism for discrete data.
“I’m not saying we should get away from documenting data in discrete ways, but how do we get it into the record more easily for nursing?” Ms. Atkins said.
She offered an example: A nurse may not need to click a box documenting that a patient was turned every two hours if a sensor in the bed or an AI overlay in the room can detect the turn and file it automatically.
Melissa Beckwith, BSN, RN, chief nursing informatics officer at Marietta, Ga.-based Wellstar Health System, also noted how easily flow sheet rows can expand over time. They are added one regulatory requirement, quality initiative or state mandate at a time, by different people, at different moments, with no corresponding mechanism for subtraction. As a result, duplicative charting accumulates, with the industry “dying a death of a thousand paper cuts,” she said.
Her proposed fix is a national standard for what nurses document.
“If we could come together collectively and make some kind of national standard, I think that that would be a great thing,” Ms. Beckwith said, noting many organizations are held to the same Joint Commission standards.
Ms. Beckwith suggested AI could help audit what organizations actually document against the standards they are held to and surface what is required, what is redundant and what is missing.
Beyond the flow sheet itself, Ms. Atkins called ambient documentation a potential game changer, though both she and Ms. Beckwith said it’s a bigger culture lift for nurses than for physicians.
Ambient AI has gained traction among physicians in part because dictation already mirrors how they practice, Ms. Beckwith said. Nurses are not trained to narrate care aloud, and nursing schools are not teaching it, making adoption as much a culture change as a technology rollout. Ms. Atkins said nursing narrated care more consistently a decade or two ago than it does today, and that Riverside is doing pre-work now on how to bring the practice back and embed it in nursing workflows.
“Is this an opportunity to completely transform the way that nurses deliver care? I think it is,” she said. “Whether or not we as an industry will take that opportunity is to be determined.”
