A workforce study of rheumatology in the U.S. was conducted recently and it was revealed that the high demand for rheumatology services will cause a shortage of rheumatologists in the next several decades. A group of American researchers administered a nationwide survey of midlevel providers such as nurses and physician assistants (PAs) and found that they can alleviate the projected workforce shortage. The questions on demographics, level of practice, responsibilities, training, independence, use of objective outcome measures, drug prescribing, and knowledge and use of treat-to-target (TTT) strategies were included in the survey.
From the 174 responses, the researchers found three-quarters had less than or equal to 10 years of experience and around 53 percent received formal training in rheumatology care. The top three practice responsibilities of almost all respondents were providing patient education, adjusting medication doses and performing physical examinations. If two-thirds of respondents said they have their own panel of patients, majority of respondents were comfortable in diagnosing rheumatoid arthritis (RA) and had prescribed disease-modifying antirheumatic drug (DMARD). While three-quarters said they are using disease activity measures for RA, 56 percent reported their practices used TTT strategies. Since majority of respondents reported they had considerable expertise and adopted relevant strategies in their practice, the researchers suggest that midlevel providers may be able to help reduce workforce shortage.
Midlevel providers in rheumatology care should also ensure that their record keeping is going well for improved RA treatment and care. Electronic Health Records (EHRs) provide them with a number of advantages. The major benefits are:
- Ability to set up alerts that can trigger certain tasks that might be overlooked. For example, some providers may accidentally leave the clinician chart sections that are not frequently used blank without drawing a line or writing ‘NA’. This may be considered as lack of proper documentation if there is a malpractice allegation. This problem can be solved by setting up alerts that insist clinicians complete the charts to close them.
- Data within EHR can be used to measure multiple quality indicators for patients having RA such as the proportion of patients who were prescribed a DMARD, whether the patients have undergone appropriate laboratory testing prior to therapy, whether the patients were monitored for drug toxicity at the time of treatment and patient adherence to DMARD use.
- Electronic prescribing (e-prescribing) is possible only with EHRs, which transfers prescriptions from paper order pads to an integrated electronic system that allows nurses, pharmacists, and other clinicians to access the full treatment plan, medication history, allergies, drug benefit coverage, and other pertinent information of patients at the point of care quickly using a computer or handheld device.
However, many nurse practitioners complain that clinical documentation is taking a long time with EHRs as there are endless loggings in and out, slow and cumbersome systems due to system failures, increased mandatory documentation and duplicate entries. They also struggle with the need to page through unnecessary screens and face difficulty finding where to chart something. Due to this, they are losing a good amount of time that should be dedicated to patients. Copying and pasting data within EHR is a good idea to save time. However, while the clinician copies and pastes data hastily to save time, there is more chance to perpetuate errors in the chart which will reflect on the entire digital record system and badly affect e-prescribing. Another complaint is that many practitioners find that EHRs require them to chart not only what they did, but what they didn’t do as well. Narrative description is also not possible with pre-defined templates and boxes.
A practical approach for nurse practitioners is to seek the support of transcriptionists to transcribe their dictations to produce a comprehensive and complete chart with reduced errors and populate the details into the digital record system using discrete transcription technology. This will save the time and effort of midlevel practitioners and at the same time improve the quality of treatment and care.