Before Advocate Good Samaritan Hospital in Downers Grove, IL decided to implement an electronic medical record (EMR), a lot of thought went into the transformation that would take place, how staff would adapt to the new online documentation and where would the future take the facility. Research had shown an EMR improves quality and patient safety, reduces errors, increases efficiency, reduces redundancy in documentation and enhances communication.
Twenty years ago, nurses' training did not include preparation for today's technologically advanced world. Nurses went to work knowing exactly how to take care of patients and document the care provided on paper. A five-step process was followed: assessment, nursing diagnosis, planning, implementation/intervention and evaluation. Paper documentation would change occasionally as new regulations occurred but overall the workflow was unchanged.
Although the five-step nursing process is still used today, technology has launched rapid changes that impact nursing workflow. Enter the clinical nurse informaticist, whose focus is to facilitate the adoption of new technologies to enhance safety, quality of care and patient outcomes while at the same time protecting and retaining the nursing process.
Vehicle for Improvement
Advocate Healthcare implemented its vision of being a leader in clinical outcomes with three key tactics: clinical technology, clinical performance and patient safety. Clinical initiatives are achieved by implementation of best practices, education, tools and other improvement efforts to achieve excellence. The EMR is used as a vehicle to improve outcomes by integrating all clinical results, orders and online documentation. While paper documentation is still used, it will eventually become a thing of the past.
In 2003, hospital leaders began planning for the launch of an enterprise EMR. The facility already had laboratory and radiology systems but no system integration. Drawing from the experiences of other hospitals, a review of best practices and an understanding of the importance of nursing leadership, a director of nursing was selected to oversee the project. This nurse leader was charged with converting the hospital to an EMR while also maintaining and improving nursing and other clinical processes.
How the transformation would take place, how nurses and other staff would adapt and where it would take the hospital were common concerns.
Although the EMR was initially considered a project, it soon became obvious that having a nurse who specialized in informatics at the table for many hospital projects was necessary. Whether it was redesign of a nursing unit, hardwiring documentation to support initiatives such as core measures or to support nursing/ancillary/physician workflow, clinical informatics became a key component of the hospital's infrastructure. From that initial project evolved the hospital's clinical informatics department, which now includes five nurses and one analyst. With a strong shared governance nursing program that demands evidence-based practices, the department has become an integral part of the hospital's workforce.
Protecting the Nursing Process
The American Nurses Association in 2008 published the Nursing Informatics Scope & Standards of Practice ,which defines nursing informatics as a specialty integrating "nursing science, computer science and information science to manage and communicate data, information, knowledge and wisdom in nursing practice." Nursing informatics facilitates the integration of data, information, knowledge, and wisdom to support patients, nurses and other providers in their decision-making in all roles and settings. This support is accomplished through the use of information structures, information processes and information technology (American Nurses Association. (2008). Nursing informatics: Scope and standards of practice. Silver Springs, MD: Author).
So how can a clinical informatics department protect the nursing process when technology is advancing so quickly? Key stakeholder participation is essential. As initiatives are launched, changes in the physical plant of the hospital are considered, or when technology is purchased a nursing informaticist must be at the table. While information technology specialists are essential, decisions made purely from a technical perspective have led to bumps in the road. These include computers on wheels so heavy the smaller nurse can't move them and computer screens so small the average-aged nurse can't read them.
Nursing needs to guide work redesigns and technology decisions so documentation remains true to practice.
For example, an EMR is heavily influenced by regulatory guidelines, such as the Joint Commission's National Patient Safety Goal 2E, which requires a standard approach to handoff communication. To not only meet this requirement but also to improve patient safety overall, nurses across Advocate Health Care designed, tested and implemented an electronic tool directly from their EMR. Based on front-line feedback, multiple cycles of improvement have since been made to the EMR to enhance communication and patient safety. For example, nursing workflow was improved with the addition of reminders to their task list to administer influenza and pneumonia vaccinations.
Aligning With the Future
Clinical informatics nurses and other clinical team members can utilize the EMR as a vehicle to improve outcomes, place orders, integrate all clinical results, provide safety alerts and do online documentation. Nurse leaders have a duty to develop and communicate a vision of how the nursing process can and will be enhanced by technology.
Nurses continue to play an important role to improve quality and safety outcomes. Regulatory changes, advances in nursing and other clinical practice can be enhanced by the use of technology when combined with nursing input in design, testing and implementation.
Our clinical informatics department plays an essential role in defining and implementing strategies to support the delivery of quality patient care and enhance nursing practice. The focus is to enhance nursing practice through the use of technology, maximizing nursing productivity and improving the work environment infrastructure, all while remaining true to the nursing process.
The challenges and goals get tougher every year; meeting them requires continual learning and a focus on innovation. Technology and nursing need to be in alignment with the future of healthcare moving forward to ensure safety, positive outcomes and patient satisfaction. Nurses need to commit to being at the forefront of technology and innovation because it will continue to be a part of their future.
Marlene Bober is director of clinical informatics and Jan Boonstra is manager of clinical informatics at Advocate Good Samaritan Hospital, Downers Grove, IL.