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Implementing Nursing Informatics

Nurses continue paving the way for the high-speed exchange of healthcare information.

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Healthcare in the 21st century is an exercise in high-speed data exchange, i.e., clinicians at the bedside "co-treat" with the patient's entire care team (past and present) by way of previously entered evaluations, histories and test results.

Gone are the days of written charts, repeated health history questions and telephone wait times to other hospital departments.

Today, nurses rely on computerized platforms with objective, up-to-date information to make informed decisions founded upon evidence-based criteria at their fingertips.

"That's the ultimate goal of nursing informatics-patient safety at the bedside," said Alex Vasserman, RN, CPHIMS, corporate director of clinical informatics at Baptist Health South Florida, a not-for-profit system of hospitals, outpatient facilities and urgent care centers. "The continuum of care is an automated, team-focused approach built on collaboration with the patient at the center."

Benefits at the Bedside

Baptist Health had nurses involved from Day One of its electronic health system's development, building the screens and the workflow to make the platform user-intuitive, said Vasserman.

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When a health system's IT platform is built with nursing in mind, benefits are many and well-varied, said CeCelia Wells, RN, director of nursing for neuroscience and critical care at North Shore University Hospital in Manhasset, NY.

Accurate and instantaneous patient information improves patient safety across the entire hospital system, said Wells. Some key examples:

Medication Profiles. Every patient in the Baptist Health South Florida system receives a barcode for rapid identification and a full patient profile at the nurse's fingertips. Medications are also barcoded.

"We invested a significant amount of money in this safety initiative," said Vasserman, adding that the system automatically verifies that the drug in question has no contraindications and is being administered to the correct patient at the correct dose and frequency. "The wait time for pain medication decreases tremendously" through this approach, said Vasserman, adding that a medication order is instantly shared with multiple departments, eliminating the need for handwritten, phone and in-person communication.

Admission assessments. Automating the admission process saves time while increasing accuracy. All modules are automated, making the transition between departments more efficient, said Vasserman.

Automatic prompts to involve additional disciplines in a patient's care plan is a primary benefit of the intake procedure. As one example, "If a nurse selects that a patient is over 65 and lives alone, that case goes automatically to a social worker for review," said Vasserman.

As part of its in-house electronic medical record system, the University of Pittsburgh Medical Center (UPMC) boasts a robust interoperability solution whereby any patient who has been seen at a UPMC-owned hospital or physician practice will have a full patient profile, including medications administered, allergies, diagnoses and treatments.

"Through our interoperability solution, if a patient comes to the ER, and we've had a prior encounter with that patient at any of our sites, we have key information such as allergies pulled for us immediately," said Marianne McConnell, MN, RN, chief nursing information officer at UPMC. "That can be life-giving information. Our emergency department is one area where we've seen the most immediate gains."

Standardized terminology. Jeffrey Willey, PhD(c), CNS, CLNC, RN, instructor in the nursing department at Salisbury University in Salisbury, MD, cites standardized terminology as a primary benefit to informatics in the nursing realm.

"In medicine, nursing included, we have so many different terms," said Willey, who teaches a clinical informatics to nursing students at Salisbury. "Standardizing the taxonomy of conditions, tests and measures brings everyone to the same level and speaking the same language."

Terminology among Baptist Health South Florida's many departments (ER, OR, laboratory, etc.) have been standardized, and the process of reporting, order entry, patient allergies and medication processing has been completely automated, said Vasserman.

"It's critical that when [nurses] are documenting, they truly understand what the terms mean," said Willey. "Things like lungs clear, no abnormal breath sounds, measures within normal limits -- if a case ever gets to court it's essential that these things were charted consistently and accurately."

"Patient safety and accuracy of information are the primary reasons for a hospital to implement an electronic health system," said Wells, adding that physician orders, lab results, medications and other critical data are easily viewable to nurses at North Shore University Hospital.

Vendor updates. A responsive and customer-driven IT provider will provide periodic updates and staff trainings to reflect system improvements and updated regulatory mechanisms, said Wells, whose department underwent an update of their EMR system last year and will do so again this fall.

"You can't easily take it out of the box and put it in place without considering what those clinical end-users need, what their workflow is, [and] what their business processes are that have to be supported with that system," said McConnell, who acts as an intermediary between her health system's IT vendor and clinical end-users on the nursing floors.

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'Digital Natives'

While older generations of nurses can be hesitant to adopt computerized documentation, younger generations have grown up with computers and take to the electronic health environment as second nature, said Linda D'Antonio, MS, RN, APN, CCRN, CNL, senior faculty associate in the college of nursing at Seton Hall University in South Orange, NJ.

Baccalaureate nursing students at Seton Hall receive undergraduate education on the theories of nursing informatics, master's level students take a specialized review course on the subject, and clinical rotations acquaint student nurses with the hands-on responsibilities of a hospital's specific system.

Even research intensives and capstone projects can focus on this specialization of nursing care.

"They know it like the back of their hand," said D'Antonio, who's been an RN since 1969. The challenge, she said, is to maintain the interpersonal relationships inherent to nursing practice that can get lost in too much technology. "Being an 'older generation' nurse, the personal touch is sometimes not there anymore," she said. "Where you used to have face-to-face communication, you now correspond with a computer system. Personal interaction can suffer."

At Baptist Health South Florida, new hires receive orientation and significant training on the system, which includes a full simulation with a practice case to acquaint them to the specifics of the platform, said Vasserman. But most new hires have already been brought up to speed on the nuances of site-specific informatics through their clinical rotations.

"All our students [at Salisbury University] use the technology at their different clinical sites," added Willey. "It allows them to see the differences and trains them to be adaptable to the specific system they'll be using in their job."

"As other experts have pointed out, today's grads are digital natives," said McConnell. "We older folks are immigrants. Newcomers to nursing are very computer literate, comfortable around technology and need very little training."

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The Final Frontier

While most major hospitals and health systems have been online for some time, the focus will now shift to determining just how these platforms are enhancing care and saving time and money.

"A lot is being written about EHRs-'do they save time, what's the value,'" said McConnell. "That's our challenge now, to demonstrate the value."

Added to the push for objective justification for informatics will be a move toward improved interoperability and a renewed focus on patient involvement.

"The next frontier [will be] the involvement of the patient," said Vasserman. "Physicians and nurses are already on board, we have hospitals investing heavily in technology -- now is the time for the patient to emerge as a primary decision maker."

Tomorrow's informatics systems will be built around open portals allowing the patient to enter their own information, essentially placing them on the same level of the other members of the care team, and giving them an active voice in treatment decisions, Vasserman predicts.

"Technology has become much more involved on the nursing side," said Willey, adding that informatics is set to explode into areas such as electronic ICU (e-ICU) care, e-care, and other telehealth technologies. "Nurses are the ones interfacing with these systems most often. It's critical that they be involved on the ground level and provide the input to make them more nursing-friendly."

Jonathan Bassett is on staff at ADVANCE. Contact: jbassett@advanceweb.com.


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We, at our pediatrician's office, pride ourselves in "customer service" and maintaining an on time schedule. Obviously, in addition to comprehensive medical treatment. However, with EMR, what took one person to accomplish now requires two. There are more line items to complete every time the patient comes to our office.
Another area of concern is that no one should trust or assume that the previous caregiver was accurate in their entry/entries. Every med and every pertinent piece of medical history must be reviewed. I have found ER entries to be inaccurate when the patient returns to our office for an ER follow up. Still some kinks to be worked out!

Susan Bird,  RN,  Physician officeMay 27, 2013
St. John , IN




     

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