E L S E V I E R Computer Methods and Programs in Biomedicine 43 (1994) 261--267

computer methods and procjrams in biomedicine

Information exchange between physicians and nurses

H.J. Tange* , R .P .H.M. S m e e t s

Department of Medical lnformatics, University of Limburg, P.O.B. 616, NL-6200 MD Maastricht. The Netherlands

Abstract

The need for communication between physicians and nurses in clinical practice is undisputed. However, they keep separate patient records. In this article a case study is reported on the needs for, and present state of, information exchange between physicians and nurses. Both groups kept paper patient records. The common information needs that were found were not covered by the formal structure of both records, nor by the exchange of written, structured messages. It is likely that most of their common needs are satisfied beyond the formal structures, particularly in unstructured text and verbal conversation. The advantages and disadvantages of these ways of communication are discussed. As the impact of quality assessment grows, the role of formal communication will enlarge.

Key words: Physician-nurse; Communication; Medical record; Nursing record

1. Introduction

In modern inpatient care physicians and nurses cooperate in a multi-disciplinary team. Their ac- tivities take place simultaneously, so coordination is necessary, In practice the tasks of physicians and nurses are not strictly divided. A nurse may assist the physician during complex medical procedures and may be authorized to perform some medical activities. Therefore, it is expected that physicians and nurses have many information needs in common, and that the information flow between both groups of professionals is large. Nevertheless, they keep their own, separate patient records.

* Corresponding author.

There is a large amount of literature concern- ing at tempts to improve the medical record by computerization. The recent state of the art is described in [1]. The number of information sys- tems designed to support systematic nursing prac- tice is growing [2]. Most of these systems are mono-disciplinary. Only a few are integrated in a hospital information system [3], or will be in the near future. In most integrated hospital informa- tion systems, however, nurses play a role in enter- ing data merely for administrative purposes, sel- dom for their own use. To support their profes- sional activities, physicians and nurses still keep their own, separated records.

The central issue in this article is information exchange between physicians and nurses in in- patient care. A case study was performed to out- line this communication and to explore possible directions for improvements.

0169-2607/94//507.00 © 1994 Elsevier Science Ireland Ltd. All rights reserved. SSDI 0169 2607(93)1497-4

262 H.J. Tange, R.P.H.M. Smeets / Comput. Methods Programs Biomed. 43 (1994) 261 267

2. Method

The study took place at the Department of Hemato-oncology at the University Hospital of Maastricht. At the time of the study there was not an automated information exchange system in place. Three physicians, five nurses and six other professionals were involved, including a hema- tologist, a pathologist, an expert consultant, a radiotherapist, a pharmacist and a dietitian. The investigation was a case study, so the results can- not be generalized, but should be considered as an example. Part of the study was funded by the AIM program of the EU [4].

First, as a theoretical base for our study, we developed a model of information exchange between actors in health care. Second, we studied the need for information exchange by observing discrete patient care activities and by determining the information needs of the different actors by structured interviews. We asked them which data they needed and which level of detail they pre- ferred. Third, we studied the present state of information exchange from several points of view. The medical and nursing records were followed from the moment they leave the archive until the moment they return there. We analysed the struc- ture of documents to locate overlaps between the medical and nursing records. Written information flow between physicians and nurses was studied. Verbal information exchange was also observed, although not in detail. This paper concentrates on the communication between physicians and nurses. Results about other actors in patient care are described in [5].

3. Results

3.1. A model of information exchange Medical decision making is considered as an

iterating process. It starts with actions to gather information about the problem of the patient. This information is interpreted, which leads to hypotheses about diagnosis or prognosis. Based on these conclusions, plans are made and new actions take place. These actions result in (new) diagnostic or therapeutic results, which serve as input for a next iteration. This so called 'hypo-

thetico-deductive cycle' [6] can be transposed to nursing decision making without any restriction.

This classical approach, however, does not recognize the involvement of more than one pro- fessional. To have more than one actor involved, interconnections between different cycles should be possible. Therefore, another type of action must be introduced, resulting in messages. A mes- sage contains an explicit request or response, which may influence the behavior of another ac- tor.

Thus, information exchange between profes- sionals can take place in two ways: by the use of a common database containing the results of diag- nostic and therapeutic actions, or by exchanging messages (Fig. 1). Results and messages may be stored on paper documents or in a computerized database. In our case, a computerized database was not in use for this purpose. Messages can also be verbally transmitted, and not registered at all.

3.2. Di~sion of tasks In our case study we observed a clinical prac-

tice consisting of many kinds of diagnostic or therapeutic actions. We divided these actions into four classes, depending on the actor [5]:

(1) medical actions, focused on the disease of the patient: medical intake, diagnostic and thera- peutic medical actions;

(2) nursing actions, focused on the patient's abil- ity of self support: nursing intake, diagnostic and therapeutic nursing actions;

(3) common actions, involving both medical and nursing personnel: medical therapy, patient/family counselling, patients round and patient discharge; and

(4) actions by others, performed by professionals outside the department: laboratory tests, X- rays, expert consultant advice, etc.

For this study the first three classes were of interest, especially the common actions. Within most common actions there was a formal task division between physician and nurse. In practice this division did not hold. For example: the pre- scription of drugs is a physician's task and the supply of drugs is a nurse's task, unless this supply takes place by intravenous injection. But in cer-

H.J. Tange. R.P.H.M. Smeets / Ce~mpltt. Methods Progroms Biomed. 43 (1994) 261- 267 263

tain circumstances, nurses may be authorized to supply intravenous drugs, or even prescribe light anesthetic drugs.

3.3. Separation of records Most documents circulating at the inpatient

care department were messages; many of them were temporary. Usually the content of the mes- sage (e.g. information about laboratory results) was copied to the medical or nursing record, while the message itself (i.e. information about the communication process) was destroyed. Cer- tain messages, however (e.g. pathology reports and X-ray reports) were added to the medical or nursing record as a whole and thus were not destroyed.

The medical record could be divided into an outpatient part and an inpatient part. We tracked the 'life cycle' of the different patient records with the following result (Fig. 2). A division could be made into three periods.

1. An outpatient period, during which the patient records were stored in the hospital archive, medi- cal and nursing records together in one folder. Only the outpatient record was kept elsewhere, namely in the outpatient clinic.

2. An inpatient period, during which the patient

records were circulating in the clinical depart- ment. Before admission they were gathered by the departmental secretary and divided into a medical record (consisting of inpatient and out- patient records) and a nursing record. An order form (for orders from physician to nurse) was created for each patient. The order forms of all actual patients of the department were kept together in a folder. At the day of the patient's discharge, all their records, together with the order form, were gathered by the departmental secretary.

3. An administration period, during which the patient records from the inpatient period were administered. During this period all documents were kept together in one folder and were sent to various destinations across the hospital: to the Medical Administration Department (for extrac- tion of basic minimal data for government statis- tics), to the physician's secretary (who is an actor other than the departmental secretary), to the physician's office (for the writing of the discharge letter) and back to the physician's secretary again. The physician's secretary then separated the out- patient record from the other two records, and included a copy of the discharge letter to both

I plan

lphysician "N

I observation I-~

;Imessagel //)obse a,'onl /'-"S nu?e l

°ni""on I

Fig. 1. Model of information exchange between physicians and nurses.

264 H.J. Tange. R.P.H.M. Smeets / Comput. Methods Programs Biomed. 43 (1994) 261--267

parts. The outpatient record was sent to the out- patient clinic, while the inpatient record and the nursing record were kept together and sent to the hospital archive. The whole administration period

took 1-4 weeks. If a patient visited the outpatient clinic within this period after discharge, the out- patient record would not be available during the visit, so this would cause a problem.

medical archive outpatient clinic

liP + OPI-I~ departmental administration

nurses ~ ~ _ ~ IINPATIENTCLINICl ~ physician

departmental administration

medical administration

physician's secretary

physician

doctor's secretary

II medical ~ archive outpatient clinic

Fig. 2. Routing of the patient records before, during, and after the inpatient care period. Abbreviations: IP, inpatient record; OP, outpatient record; N, nursing record.

H.J. Tange, R.P.H.M. Smeets / Comput. Methods Programs Biomed. 43 (1994) 261--267 265

3.4. Overlap of data At the hemato-oncology inpatient clinic a total

of 40 different documents was available for the registration of the inpatient care process: 14 for the medical record, 4 for the nursing record, and 1 (the order form) for messages between physi- cians and nurses. The other 21 forms were used for messages to or from professionals outside the department. There were no documents that formed part of both the medical and nursing records.

Most forms were divided into structured sec- tions, varying in detail from a very global entity as 'progress report' to a very specific item as 're- sponsible physician'. A total of 220 sections could be distinguished, 70 of which were part of the medical record, 21 of the nursing record, 4 of the order form and 121 for interdepartmental mes- sages. Only 7 sections could be found in both the medical and nursing records: patient's identifica- tion, responsible physician, medical diagnosis, observation of vital signs, diet prescriptions, med- ication order and drug supply.

3.5. Exchange of information There were three different ways in which infor-

mation was exchanged between physicians and nurses.

also responsible for the administration of written messages that were exchanged between profes- sionals inside and outside the department.

3.6. Information needs To gain insight in the information needs of

physicians and nurses, both groups were pre- sented with a list of structured sections, as we found them on documents at the department. They were asked which information they would need to perform their professional tasks, and which level of detail they preferred. The results are described in [5]. Nurses turned out to be interested in most of the sections of the medical record. In general they preferred a lower level of detail than physicians. Physicians, on the other hand, were not very interested in the content of the nursing record. Most relevant nursing data (vital signs, drugs supply) had already been copied to the medical record. Both nurses and physicians expressed their interest in a piece of information that was neither registered in the medical record nor the nursing record: patient education. This includes the information that has been given to the patient about his disease, treatment and prog- nosis.

4. Discussion

(1) By direct copy, without an additional message. We found that the medical diagnosis was copied from the medical record to the nursing record, and that observations of vital signs and registrations of drug supply were copied from the nursing record to the medical record.

(2) By written message. The only message form that was exchanged between physician and nurse was the order form, containing orders for nursing care and medication orders.

(3) By verbal conversation, which occurred fre- quently. Apart from the daily patient rounds, essentials of the medical and nursing reports, as well as advice and orders, were communi- cated verbally whenever necessary.

A major role in the exchange of information was played by the departmental secretary. She took care of the medical and nursing records before admission and after discharge. She was

In the discussion of the results of this study, one should always keep in mind the following limitations. First, it was a case study in one de- partment of one hospital in one country, so the results should be considered merely as an exam- ple. Second, only the structure of documents was studied, so the actual content of document sec- tions was not analysed. Third, we observed much verbal conversation, but did not analyse the con- tent. Fourth, comparable studies were not found in the literature. Still, some interesting considera- tions can be made.

To achieve a seamless integration of patient care is a key issue in every hospital. This requires intensive cooperation and communication between health care workers. Our study con- firmed that there is an overlap of tasks between physicians and nurses, and that both groups have certain information needs in common. The use of the phrase 'patient record' [1], however, should

266 H.J. Tange, R.P.H.M. Smeets / Comput. Methods Programs Biomed. 43 (1994) 261--267

be considered as the expression of a wish, rather than the description of reality. In our case, the medical and nursing record had only a small overlap in structure, and there was only one document to be used for written messages between both groups.

We did not, however, have the impression that many needs remained unsatisfied. It is likely that two alternative ways of communication play a major role:

(1) The real overlap of medical and nursing records is larger, but this cannot be recognized by their structure. Large parts of both records con- sist of narrative data, which are not structured further. The actual content of narratives was be- yond the scope of our study. A big advantage of using free text is the freedom of expression, which is a vital requirement for the recording of the patient's history, conclusions, etc. [7]. On the other hand, recording free text has serious limitations that influence the quality of information. Narra- tive data are likely to remain 'hidden' for a non- frequent user of the record. Hence, this user will collect and store certain data again, redundantly, which may give rise to inconsistencies in the database. Misunderstandings between health care workers may be a result.

(2) Much of the information exchange goes through verbal conversation between nurses and physicians. The content of this kind of communi- cation was not studied in detail. Verbal communi- cation is less time consuming than the use of written messages; however, it needs the availabil- ity of two parties at the same time. Furthermore, it is straightforward, and often renders an imme- diate response. On the other hand, interprofes- sional communication is a vital component of the health care process, so it should be included in quality assessment procedures [8]. As verbal con- versation is fleeting, it cannot be checked after- wards.

We expect that these relatively informal ways of communication, however satisfactory now, will need to be more formalized in the future.

The use of a comprehensive, integrated patient record instead of separate medical and nursing records, would be a big step forward. However,

certain obstacles have to be taken before an integrated patient record will function well. The patient record has to be available at different locations simultaneously, and its content has to be accessible from different points of view. This cannot be achieved without computerization.

Narratives should be made more transparant for later use. Studies concerning better processing of narrative documents [9], structuring the con- tent of narratives when entering data [10], or by analysing and structuring stored free text [11] are in progress. The need for information at different levels of detail, as the nurses in our study ex- pressed, is an extra complicating factor to take into account, and should be studied.

Furthermore, a greater part of the messages should be stored. In time, as the importance of quality assessment is growing, national govern- ments may even impose a legal requirement to store all relevant messages. The challenge will be how to persuade professionals to register their verbal conversation. Data entry will never be as easy as talking. Although speech recognition may become a proper alternative for routinely written messages, such as radiology reports [12] or for- malized medical knowledge [13], it will be much more difficult to create a lexicon that is suitable for subjective matters like a patient's feelings.

5. Conclusion

Our study confirmed that integrated patient care requires the need for intensive communica- tion between physicians and nurses. The use of formal communication channels, however, did not correspond with this need. It is likely that a major part of communication takes place in a more informal way, either in narratives or by verbal conversation or both. Further study on the con- tent of narratives and spoken communication is recommended. To improve and ensure the quality and effectiveness of interprofessional communi- cation, the integration of medical, nursing and other records, together with the formal storage of all important messages, would be a big step for- ward.

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