The transition to a Point of Care (POC) IT model is a key goal of “Meaningful Use” guidelines, as well as basis of safe CPOE and optimal EHR benefits. Minimally, critical patient assessment data collected by nurses, such as Allergies, Height/Weight, I & O and Vital Signs including values from medical devices, should be captured at the POC in near real-time.
However, the benefits of POC and real-time charting often aren’t immediately obvious to those with roots in paper-based models. The extent of culture change and complexity of automating POC nursing processes are rarely appreciated by IT personnel.
“POC data” are used by diverse on-site and community-based MDs and clinicians to support a variety of care delivery, disease management, infection prevention and discharge planning processes. Physicians consider POC data with Laboratory and Radiology information in clinical decision making, including determination and management of patients’ diagnoses, treatment protocols and medication regimens.
POC data transcribed on paper for later (or much later) computer entry replicates the paper process, although data are eventually entered into the EHR. Data collected but not charted are not available to MDs performing CPOE, who may be off the nursing unit, off site or at home. Use of aged data can result in delayed or inappropriate interventions and, worst case, introduce harm if inappropriate treatments are initiated based on out-of-date information. With CPOE, MDs are more reliant on the EHR for accurate and timely decision support data.
In our opinion, the transition to a Point of Care charting model will not occur as a byproduct of EHR implementation. A sustainable POC model forces dramatic culture and process changes requiring staunch clinician leadership with strong IT collaboration and support.
