Submitted by Maree Ferguson, PhD, RD. This is a summary of the paper "Comparison of Paper Versus Electronic Medical Record, Incorporating the International Dietetic and Nutrition Terminology, on Efficiency and Effectiveness of Dietetic Practice in Hemodialysis Patients," which was recently accepted for publication by the Journal of the Academy of Nutrition and Dietetics.
Written by Megan Rossi, Katrina Campbell, and Maree Ferguson, Nutrition and Dietetics Dept, Princess Alexandra Hospital, Brisbane, Australia, this study compares the efficiency and effectiveness of electronic and paper medical records for documenting the Nutrition Care Process (NCP) and the International Dietetics and Nutrition Terminology (IDNT) in hemodialysis patients.
Maintenance hemodialysis patients with a dialysis vintage of more than 3 months, who were 18 years of age or older and who provided consent, were eligible for inclusion in the study. A convenience sample of 56 patients was followed for 12 months. During the first 6 months, patients received the usual standard of care, with documentation via a manual paper-based system.
Nutrition reviews by a qualified renal dietitian were scheduled based on patients’ needs after baseline assessment and on a referral basis from nursing and medical staff throughout months 1 to 6. In the following 6-month period (months 7 to 12), nutrition care was documented by an electronic system.
An electronic system was developed to incorporate the following components:
- Automated calculation and alerts for anthropometry and dietary data
- Download of monthly biochemistry
- IDNT checkboxes with prompts
- Graphical tracking of patient data over time
The dietitian reviewed patients in the electronic study phase based on changes in assessment variables, such as weight loss or adverse changes in biochemical data.
Workload efficiency and resolution of IDNT diagnosis codes were the main outcome measures. Data also were collected on the Patient Generated-Subjective Global Assessment tool (PG-SGA) and quality of life (QOL) (EQ-5D); data not described here.
Compared to paper-based documentation of the NCP, this study demonstrated that an electronic system improved the efficiency of total time spent by the dietitian by 13 minutes per consultation. A greater number of nutritional diagnoses also were resolved using the electronic system, compared to the paper-based documentation
The implementation of an electronic vs paper-based medical record system resulted in improvements in patient outcomes and significant improvements in the efficiency of implementing the NCP and IDNT. This has substantial potential for cost savings and improving patient outcomes. This study supports the implementation of an electronic system to maximize the efficiency and effectiveness of dietetic care.