"This unfortunate sole…"

Looking back, I can't tell if he was talking about the patient … or reviewing a restaurant!

As the rate of adoption of electronic records continues to climb, have we moved past inaccuracies — such as confusing "sole" (a fish) and "soul" (a person's spirit)? Or does eliminating free-text charting remove the "flavor" from the patient narrative?

Some prefer free-text documentation, thinking that it allows flexibility to describe complex situations and richer semantic meaning. But does free-text really mean freedom? In fact, for clinical nutrition managers, eliminating free-text means less time spent reading misspellings, syntax errors or overlong entries while doing chart reviews. Plus, you can make a stronger case that your department is contributing to quality measures and making diagnoses codes easier to capture for billing. So how can you help your staff free themselves from free-text? 

Integrate, Don't Separate

Integrate your data with the rest of the documentation in the EMR and explore opportunities to use structured input to share your data. Can your documentation be pulled into other clinician's notes? Can the results of the RDN's interventions trigger alerts? Free-text narrative input doesn't lend itself to these uses.

Keep Your Audience in Mind

Other clinicians want to know your assessment. Using the nutrition care process and the mandated clinical terminologies of SNOMED CT and LOINC means that, ultimately, an RDN's analysis will be shared in the transition of care beyond the hospital walls.

Aggregate, Don't Dissipate

Beyond integrating our nutrition care process and terminology with the other health care teams at our facilities and systems, consider the health of populations. Big data requires a statistically significant amount of information, but it can drive evidence-based medicine. Yet, by some estimates, as much as 80 percent of the information remains unstructured.

Create, Don't Be Late

Drive a more thoughtful design of structured data input with your IT department. Some points to consider include:

1. Form-Based Charting
   Forms can include a combination of drop-down lists, checkboxes and free-text narrative boxes. The use of labels and medical record printing enhancements can improve the output.
2. Flowsheet Charting
   These time-stamp data, which helps tell the patient story in real time.
3. Copy and Paste Can Be Controlled and Audited
   If your staff often copies and pastes in free-text, think about why. Is it to describe a multi-factorial complex problem, or to save time?

Free yourself from free-text and enjoy the benefits of what structured data can bring.

There are two parts of my job I really enjoy: learning about new treatments for childhood catastrophic illness and getting more training — I'm always learning something new and improving my skills!

My Introduction to Nutrition Informatics

I became an informatics analyst because I had taken additional training in computer technology, which qualified me for a job as a webmaster and database manager for a managed care company. When the parent hospital system ramped up its staffing to implement a new EHR system with Cerner, because of my bedside RD experience and computer skills, I was hired as a clinical informatics analyst. Most members of our team have had prior clinical experience such as nursing, med tech, pharmacy and — like me — dietetics.

How Informatics Plays a Role in My Day

For me, a typical day is a mix of meeting with clinicians who need new orders, maintaining our orders and order sets (or "power plans"), and helping users who are having computer issues.

For instance, when a physician wants to offer a new treatment protocol for the children of St. Jude, we meet with the team to understand what needs to be built so that all of the orders can be entered electronically. These are some of the considerations: Who will enter the orders? Will charges be dropped appropriately? Do the users need to be notified by email, paging or reports? Do automatic alerts need to fire based on the patient's individual profile?

Maintaining the EHR includes testing new functionality that updates to the Cerner code level afford us. It is fun to see what new functionality might be available to help our users do their work easier. And, it is gratifying to help users with questions about how to use the system and to report issues. Many times, it is just a training question, but sometimes we troubleshoot problems to be resolved.

Getting Involved

I decided to volunteer to work with the Academy's nutrition informatics activities after I took the AMIA/Academy 10×10 class, and saw how much is going on. I have enjoyed using my familiarity with the EHR and interfaces to help the Academy make sure that the Nutrition Care Process and the terms that support them are represented in standards adopted by the Cerners of the world.

Come join the Nutrition Informatics Committee (NIC) and the Interoperability and Standards Committee (ISC)!