SELECT caregivers.label, icustays.first_careunit, COUNT (*) as chart_count
FROM chartevents
INNER JOIN caregivers ON chartevents.cgid = caregivers.cgid
INNER JOIN icustays ON chartevents.icustay_id = icustays.icustay_id
WHERE caregivers.label = 'RN'
GROUP BY icustays.first_careunit
LIMIT 500Analysis Report Three - Information Systems and Healthcare Provider Interactions
Executive Summary
The core findings that I discovered from this weeks assigned readings is that the transition from paper-based medical records to Electronic Health Record systems represents one of the most significant operational shifts in modern healthcare (mcalearney2015journey?). Despite federal mandates through the meaningful use program and substantial financial incentives , EHR adoptions has been met with a lot of different mixed opinions (mcalearney2015journey?). Research has shown that while the EHR systems do offer benefits in information access and care coordination, the burdens placed on front-line caregivers, nurses specifically, that remain underestimated and under addressed throughout ICU units in particular (rathert2019seven?). MIMIC-III does reinforce the reality that registered nurses account for an overwhelming majority of clinical documentation activity, which logs over 600,000 chart entries compared to just the 570 for physicians (as shown in my Visualization #2) (silow2012using?). EHR implementation strategies that fail to center the nursing workforce are strategies built to fail, in my opinion.
Introduction
The Federal Government’s Meaningful Use initiative, established through the Health Information Technology for Economic and Clinical Health Act, created powerful financial incentives to drive EHR adoption across American healthcare institutions (menachemi2011benefits?). Replacing paper charts with integrated digital systems should improve care coordination, reduce medical errors, and give providors faster access to critical patient information (menachemi2011benefits?). In practice though, the experience has been more complicated. Research examining physician and nurse experiences with EHRs seven years after the Meaningful Use implementation found that the challenges outnumbered benefits in provider accounts, as well as an increased workload, horrible training sessions that were not applied from the trainees, and lack of standardization (menachemi2011benefits?). There was a seperate study that was attempted framing the EHR adoption through the lens of Kubler-Ross’s stagtes of grief and found that providers often experienced the entire transition as a form of loss of autonomy, workflow familiarity, and direct patient engagement (mcalearney2015journey?). Based by what I read, the readings establish that the human side of EHR implementation is not a side concern, it is the central challenge facing healthcare organizations today.
The Healthcare Context
Modern Healthcare Organizations are navigating a tension between the promise of digital health infrastructure and the reality of the caregivers expected to use it. Despite federal mandates through the Meaningful Use program and substantial financial incentives, EHR adoption has produced mixed results (mcalearney2015journey?). Providers consistently have reported that increased documentation demands, lack of standardization across systems, and insufficient training have created as problems as its solved (mcalearney2015journey?). There is now a sudden sense of a ‘silent-culture’ in healthcare facilities, where front line staff develop informal workarounds rather than escalating system problems, making it nearly impossible for organizations to identify and correct failures before they affect patient comes (mcalearney2015journey?). Nurses today, carry the heaviest burdens of the effects from the transition. RN’s chart events at a rate 1,000 times more than most other frontline healthcare workers.
Data Visualizations
Visualization One
ggplot(data = myquery2,
aes(x = first_careunit, y = chart_count)) +
geom_col() +
labs(title = "RN Chart Event Volume by ICU Care Unit",
x = "Care Unit",
y = "Total Chart Entries")
EXPLANATION OF VISUALIZATION ONE: I created this visualization to examine how RN workload is used across ICU care units by counting chart events per unit. The CAREGIVERS table is joined with CHARTEVENTS and ICUSTAYS to try and connect the provider identity with patient location and clinical activity. For most healthcare organizations, the data above can be directly actionable, there are constant units showing disproportionately high charting volume which can point to certain inefficiencies like under-staffing or complex patient issues that administrators need to address. EHR systems can make a workload analysis like this possible in real time, which gives managers the visual that is needed to make much smarter staffing decisions.
Visualization Two
SELECT caregivers.label, COUNT (*) as chart_COUNT
FROM chartevents
INNER JOIN caregivers ON chartevents.cgid = caregivers.cgid
WHERE caregivers.label IN ('RN', 'MD', 'Resident')
GROUP BY caregivers.label
LIMIT 500ggplot(data = myquery5,
aes(x = label, y = chart_COUNT, fill = label)) +
geom_col() +
scale_y_log10() +
labs(title = "Chart Event Volume by Caregiver Type",
x = "Caregiver Type",
y = "Total Chart Entries",
fill = "Caregiver Type")
EXPLANATION FOR VISUALIZATION #2: I created this visualization to show the direct findings of navigating EHR implementation. RN’s are responsible for an overwhelming majority of clinical documentation. Almost over 1,000 times more chart entries than physicians in this data-set. I used joined the CAREGIVERS table with CHARTEVENTS using the shared cgid field to count the total number of chart entries recorded by each caregiver type. The query also uses COUNT, with GROUP BY on caregivers.label which is the same core concept that we all had learned this week throughout the readings and practice modules. I added a log scale to the visualization to make both bars readable, since the MD only had 570 compared to the 613,570 entries for RN.
Without data visibility into who is actually doing the charting organizations risk designing EHR adoption strategies that can overlook their most impacted employees, leading to burnout, resistance, and much worse patient outcomes.
Recommendations for Industry
My recommendations for the healthcare industry, is that organizations have to treat the EHR implementation as an ongoing people management challenge, not just a one-time technology installation. The data presented above from my visualizations makes it clear that nursing staff carry the overwhelming majority of clinical documentation. To me, this means that the training programs, workflow redesigns, or system upgrades does not center around the nursing experience and is miscalculating resources from the start. Organizations need to build continuous, role-specific training programs, establish formal channels for front line staff to raise system concerns without any fear of retaliation. Most importantly, I think that administrators should leverage the data visibility that EHR systems provide, through all kinds of structured queries like the ones I demonstrated above. I believe this will monitor the workload distribution across units in real time and make proactive staffing decisions before burnout becomes further turnover.
References
(rathert2019seven?), title={Seven years after Meaningful Use: Physicians’ and nurses’ experiences with electronic health records}, author={Rathert, Cheryl and Porter, Tracy H and Mittler, Jessica N and Fleig-Palmer, Michelle}, journal={Health care management review}, volume={44}, number={1}, pages={30–40}, year={2019}, publisher={LWW} }
(mcalearney2015journey?), title={The journey through grief: insights from a qualitative study of electronic health record implementation}, author={McAlearney, Ann Scheck and Hefner, Jennifer L and Sieck, Cynthia J and Huerta, Timothy R}, journal={Health services research}, volume={50}, number={2}, pages={462–488}, year={2015}, publisher={Wiley Online Library} }
(silow2012using?), title={Using electronic health records to improve quality and efficiency: the experiences of leading hospitals}, author={Silow-Carroll, Sharon and Edwards, Jennifer N and Rodin, Diana}, journal={Issue Brief (Commonw Fund)}, volume={17}, number={1}, pages={40}, year={2012} }
(menachemi2011benefits?), title={Benefits and drawbacks of electronic health record systems}, author={Menachemi, Nir and Collum, Taleah H}, journal={Risk management and healthcare policy}, pages={47–55}, year={2011}, publisher={Taylor & Francis} }