Electronic health records and nursing

1. Electronic health records and nursing Applications to nursing care Anne Sales, PhD RN Faculty of Nursing University of Alberta, Edmonton, Alberta

2. Objectives • Develop a common understanding of the challenges in developing an EHR optimized for inpatient nursing care • Discuss the needs of inpatient nursing • Situate needs within the context of VA’s EHR • Describe future opportunities

3. Overview • Background comments • Inpatient setting • Applications of EHR in inpatient nursing care • Possible future directions

4. A couple of important notes • Nurses cross all settings in health care • Inpatient intensive, acute, and sub-acute care • Long term care • Ambulatory care • Outpatient care • Ambulatory surgery • What nurses do in each setting can be highly variable • Focus here on inpatient acute care nursing • But generally, what nurses do has not been the focus of information systems • Nursing care is often perceived as invisible

5. What do nurses do? • Surveillance function • Delivery system for therapeutics • Medications • Procedures or treatments such as wound or tracheostomy care • Important component of safety in delivering therapeutics • Ensuring right person, right dose, right timing, etc. • Risk assessment • Falls, pressure ulcers, social support, other possibly preventable adverse events • Care planning and intervention to minimize risk • Education and advocacy

6. Role of EHR in interacting with nursing care • Documentation • Includes care documentation as well as workload • Prompting • Force functions • Decision support

7. The acute inpatient setting • Probably best understood setting in terms of nursing care and what nurses do • High patient acuity • From critically to seriously ill • High dependency for meeting basic needs • Breathing, moving, hydration, nutrition, toileting, pain control, anxiety/stress • High intensity of care activities • Very dynamic • High levels of activity • Time sensitivity

8. Components of an EHR potentially applicable to inpatient nursing • Order entry • Medication delivery: Bar-coded medication administration (BCMA) • Documentation • Templates • Clinical reminders • Decision support? • Care management/workload capture • Electronic Kardex • Whiteboards • Staffing matrices

9. Order entry • Nurses have dual role • Order input • Order processing/fulfillment • But not everything that happens for a patient depends on orders • Role of the nursing care plan • Nursing assessment, diagnosis, and planning • These elements do not appear in order entry • At core, order entry is a communication device • Usually interdisciplinary • One-way, not two-way • Strong legal component • Enforces hierarchy in health care delivery

10. Medication administration • VHA uses bar-coded medication administration (BCMA) • Early adopter • Little evidence • Rapid implementation with extensive period of “working out the bugs” after implementation • Primary objective safety principle • Ensure right person, right med, right dose, right timing • Little focus on workload, work flow, human factors concerns– Patterson and colleagues • Major issues of work-arounds which may lead to heightened concerns about patient safety

11. Documentation • Initial assessment • Currently not standardized across the system • May be difficult to standardize adequately • Progress notes • Vital signs and other data recording • Specific issues related to intensive care where physiologic data capture is of extreme importance • Variation in degree to which there is electronic capture of physiologic data in ICU • Integration with the rest of the EHR • Issues of data encoding • Accidents, incidents, and near misses– adverse events • Proliferation of databases • Redundancies and lack of integration

12. Clinical reminders • Specific software within VHA’s EHR architecture • Permits data encoding • Has reporting functions • Uses logic statements that can be used to identify populations or sub-groups of patients • Potential for some degree of decision support • Offers documentation support

13. Care management/Workload capture • Of extreme importance to nurses and nurse managers • How many patients of what acuity are being cared for by how many and what kinds of nurses when and where? • Currently very difficult to assess using current tools in the EHR • Tools under development • Electronic Kardex • Electronic whiteboards • Staffing matrices

14. The VA Nursing Outcomes Database (VANOD) • Contact person: Bonnie Collins (bonnie.collins@va.gov) • Began as a pilot in 2003 with 12 sites selected by stratified random sampling • Covers: • Inputs (staffing and skill mix) • Patient outcomes (falls, pressure ulcer prevalence, satisfaction) • Nurse outcomes (musculo-skeletal injury, job satisfaction) • Currently in roll-out with about 60 of 130 hospitals included • Functions using data extraction from existing databases coupled with survey data and biannual pressure ulcer prevalence survey • Trade-offs between data validity and quality and efficiency/feasibility • Reporting function using web-based reports generated through ProClarity– predefined and user-defined reporting function

15. Other research • Ask Ken Hammond and Charlene Weir to comment briefly about their current work in this area • Other comments or discussion about ongoing work?

16. Where is research happening outside VA? • Several nurse informaticists are working with proprietary companies like Cerner to develop inpatient-nursing focused applications • Very difficult to track this activity • Proprietary nature • Even academic presentations are highly guarded in what they present

17. What are the challenges, and why is this so hard? • Heterogeneity of nursing practice makes it very difficult to develop applications that are broadly useful • Lack of education in most nursing programs means that practitioners are often not very adept at manipulating systems • Systems are non-standard and vary widely from place to place • Even when nurses learn a system and how to manipulate it, their knowledge is often very specific and non-transferable • Nursing work is very broad– ranges from very task-specific to very cognitive • Difficult to create applications that will deal with this breadth as well as the necessary depth • Requires considerable flexibility in the applications– not commonly found in most consumer-level applications

18. Summary • The current VHA EHR is optimized and designed for outpatient, ambulatory care • Design and functionality not optimized for inpatient acute care • Currently only partially addresses the needs inpatient nurses have for information technology • Much of current functionality is quite fragile

19. A potential vision of the future • Fully integrated, multi-functional, multi-disciplinary health record capable of capturing data at very frequent intervals (e.g. q minute) incorporating n-way real time dialog functions, multi-disciplinary decision support, and full-scale acuity adjusted workload and care management capture with full data archiving and retrieval capacity

20. And the reality… • IT development takes real resources • Financial • Human • Intellectual • There are multiple competing priorities and political considerations • But to date there are no over-arching frameworks for priority setting • Patient safety, cost and efficiency issue, ethical and moral consideration are all possible approaches and criteria which may lead to competing priorities