By Judith F. Hornback, RN, BSN, MHSA, MAPS
There is no perfect software system. If there were, all hospitals and healthcare organizations would be using that one. As it is, there are several different systems. As chaplains, we use these systems to both inform and be informed. Chaplains don’t get to choose the systems that are used as those decisions are generally made above our pay grade, but we can certainly choose to use these systems to the best of our ability, making sure that our voice is heard and our involvement on the healthcare team is not only appreciated, but also required.
At Franciscan Alliance, our software vendor, Epic Systems Corporation from Verona, WI, was selected because of its electronic health record (EHR) and integration abilities. Allowing patients to be followed throughout the continuum of care in one electronic record system is certainly advantageous, especially in this evolving market of Accountable Care Organizations (ACO) and the impetus to keep people out of the hospital.
Healthcare is on the cutting edge (or is it the bleeding edge) of the electronic health record and there is opportunity for the Pastoral Care Department to be more involved. Unfortunately, pastoral care is not typically invited to the table during planning and sometimes may not be given enough information to be able to offer constructive comments. In addition, pastoral care staff may not have sufficient IT background or experience to be able to offer constructive comments during the analysis, design, and building of these systems, even if invited.
The experiences we have had are probably not unique. The people that build the systems don’t have the practice knowledge and experience of chaplaincy, while the people that practice (chaplains) don’t have the systems’ knowledge and experience. At our multi-hospital system, there was a plan for standardization across all facilities as well as sharing of processes and documentation. We are all familiar with the idiom, “The best-laid plans of mice and men oft go astray” … well, they did. Standardization did not occur and processes/documentation were not shared. Reasons why include lack of one oversight and coordination person/committee for all facilities, lack of operational involvement to a detail level, and reluctance to change.
Integration is achieved because Epic is one large database. From a corporate view, that sounds wonderful. From a detail, staff level, it presents challenges. Usually integration means sharing, however, when you are in essentially five different markets or locations, it really isn’t sharing as much as including. To accurately document patients’ religious affiliations and churches/parishes, for example, all the churches from each area and all denominations need to be added to the database. Originally, in our case, the additions were done by each chaplain. Although there was a specific way to do this, with so many people entering data, we were unable to achieve a standardized format, which led to a lack of control of the process. For instance, do you abbreviate ‘Saint’ or spell it out? Do you use a period or comma? Do you use upper or lower case? Do you add the city for clarity, and if so, with a space, or two spaces, or a dash, or a comma? Each of these factors, though minute, could mean multiple entries for one particular church’s information, and could make a ton of difference in terms of the final data entry that is generated. Initially, it was “all of the above,” which meant having more than 200 entries for one church. After several months, as a way to deal with the duplication of church data, chaplains were no longer allowed to enter this information. Instead, a support log needed to be created, and it could take days for an entry to be made into Epic — long enough that the patient may have been discharged and the record no longer accessible, which means the field is left blank leaving others to speculate if this patient even was seen by a chaplain, and then when admitted the next time, there is no historical information. Churches were initially linked to religion and it took several months to get these fields separated. We are still trying to find a better alternative to gain some control of this challenge or build a process that allows for a more immediate response.
Reports have been another area of challenge. On the day of “go live,” we had no reports or lists, and had to build them as we determined a need. It took at least a few weeks to ensure that we were getting what we needed. Epic is designed as a point-of-care system. This means the system is used to view patient information as well as to document as the patient encounter occurs. That may work for a clinician on one nursing unit, but as chaplains we cover the house. That may be easier for entering vital signs than for building relationships, so a lot of our documentation continues to occur at the end of our shifts. In addition, we need to give a list of patients to our eucharistic ministers for Communion and our priest chaplains that aren’t on staff who do not have a login to the EHR. Although we don’t document daily Communion, the chaplains will document the sacrament of Anointing of the Sick for these priests. We also had to wait several months for a report providing us the information needed on deceased patients for our semi-annual Memorial Service. Within Epic there are “Lists” and there are “Reports.” Lists are easy to create and can be done by each person (i.e., “My List”) or for a group or department (i.e., “Shared List”). Reports are another level and there are two types of reports – Reporting Workbench, to which a few of the chaplains now have access, and then Clarity, which is used by report writers for enterprise reports and statistics.
The level or extent of importance placed by the healthcare team on pastoral care depends upon whether or not, or to what extent, they believe chaplains are part of the healthcare team. Although the spiritual care assessment is documented on its own flow sheet, it is part of the clinical record and visible to the entire team. This is the same information that we documented in our old system, however, we can no longer see who documented that individual flow sheet as we did in the former system. One advantage, however, is that the flow sheet/assessment can easily become a “note” by just clicking a few times, and it will be listed among those of the rest of the care team. In spite of using Epic for over a year now, it remains to be seen as to whether or not our non-chaplain colleagues read those flow sheets/assessments and notes. Just because they are there doesn’t mean they are used, let alone valued. The visibility and physical presence of chaplains, along with taking every opportunity possible to educate the rest of the healthcare team about the work that we do, are still critical and more important than just documenting our work in a patient record. As the shift from inpatient to outpatient becomes more apparent, pastoral care needs to find ways to engage more of that population, and chaplains’ documentation in the health record may need to change. It remains to be seen how inpatient and ambulatory referrals or consults are integrated.
Healthcare systems that have not forgotten about including chaplaincy, even if there are challenges, still need to be applauded. It is always better to make improvements than to start from nothing. One of the biggest challenges we have, however, is financial. Pastoral care is a non-revenue generating department. The value of what we offer to the healthcare team cannot be measured in finite terms, which makes pastoral care, in some cases, more expendable. As doctors and nurses are working hard to maintain IV lines to give medications or are providing wound care, the focus is not always on patients’ feelings, beliefs, or ritual practices, even though many nurses and physicians recognize that as a critical dimension in the holistic healing process.
In evaluating charting and systems, whose expectations are being adopted? Although regulatory and quality organizations recognize holistic care and even base their evaluations upon it, care planning around this is still in infancy stages. Even in an integrated EHR such as Epic, goals, interventions, and outcomes related to physical care still take priority over those regarding relationships and meaning-making. The paradigm shift from “acute care” to “patient site/outpatient/home” or from “come to us” to “we meet you where you are” can only change this in a more positive way. This new care delivery priority is going to need pastoral care even more to help bridge gaps and work within the existing context of community and an interdisciplinary structure.
Judith F. Hornback, a nurse with IT experience, is associate chaplain at Franciscan St. Margaret Health in Dyer/Hammond, IN.