Nurse leaders are impacted on multiple fronts by a changing healthcare landscape. Healthcare reform and economic stimulus legislation are rapidly advancing, along with targeted information technology (IT) regulations that incentivize the adoption of electronic health records (EHRs) to improve the well-being of Americans. Nurses understand that meaningful use of health IT, when combined with best practice and evidence-based care, can improve health and healthcare for all Americans. To achieve our nation's healthcare reform goals, we must tap into sources of patient care technologies and information management competence to ensure that our investment in health IT is leveraged effectively over the next five years.
Transforming health through meaningful use of data will require a phased approach. Ensuring that the right clinical data are captured in the right format at the point of care is the first step. Nurses are instrumental in identifying and standardizing key data elements necessary for this foundational component. The wide variety of nursing documentation forms, processes, and workflows used across hospitals and health systems today adds further complexity. Standardizing clinical workflow and the related documentation components in advance of EHR systems implementation will go far to ensure success. Nurse leaders must work with frontline staff to develop standardized care pathways, define order sets, and select terminologies that accurately and consistently describe the essential work of nurses.1
Improving the ability of EHR systems to capture and enable sharing of clinical data will support more rigorous and robust quality measurement and improvement. Nurses want to trust that their investment of time and effort to assess and document patient information will be returned to them through the systems they use in the form of analysis for optimal decision making. Nurse leaders want to leverage the impact of EHR system implementation to achieve more effective care processes. These advancements will go far toward improving health outcomes and reducing duplication of effort, thus streamlining workflow and reducing cost.
Starting at the top: Executive support
Senior IT executives increasingly understand that IT can have a positive impact on healthcare delivery, according to the 21st Annual HIMSS Leadership Survey.2 In fact, improving patient care was the number one key business objective identified by the 398 survey respondents. Slightly more than one third of respondents indicated that IT could improve clinical and quality outcomes, and one quarter said that IT can reduce medical errors and improve patient safety. Survey results also suggest that clinicians play a critical role in leveraging IT to enable these advancements through their participation in systems evaluations, by acting as project champions, and by performing systems training for clinicians.
These insights come as no surprise. Nurses interface with every aspect of assessing and communicating patient care needs, from admission through post-discharge across all healthcare settings. In their role as the “central hub” of information, nurses have significant responsibility for the quality and safety of patient care. When information systems are implemented in any healthcare setting, nurses must be involved in decision making about the usefulness, efficiency, and satisfaction with these systems to ensure continuity of patient care.3
Successful IT adoption and innovation hinge on leadership that understands the importance of creating an EHR that follows the patient with a commitment to providing patient safety and quality. A recent example of this type of leadership team is found at MultiCare Health System, an integrated not-for-profit organization in Tacoma, Washington. Led by President and CEO Diane Cecchettini, RN, MultiCare Health System was awarded the 2009 Nicholas E. Davies Award of Excellence for implementation of MultiCare Connect, an enterprise-wide EHR with the goal of “one patient, one record.”4
The project's patient care goals were:
- Patient safety – do no harm
- Access – know the patient's story
- Accuracy – create effective communication among care givers
- Efficiency – eliminate steps that don't add value
- Financial performance – reduce the patient's length of stay
- Adoption – innovate to deliver the ideal patient experience.
The impact on safety that was realized as a result of MultiCare Connect is shown by the following statistics:
- 13% decrease in adverse drug reactions within 2.5 months of implementing computerized provider order entry (CPOE); 75% of orders are entered directly by physicians
- 24% reduction from the time a STAT med is ordered to the time it's verified by pharmacy
- 30% reduction in laboratory order turnaround time
- 50% reduction in imaging order turnaround time.
Clearly the EHR implementation at MultiCare was owned, championed, and actively supported by organizational and clinical leadership. As noted in the organization's Davies application, “System implementations are often seen as IT projects, but without the engagement of the clinical end-users and their leaders, success cannot be realized.”4
End-user acceptance: Staff usage
As primary clinical end-users, nurses constitute the largest single group of U.S. healthcare professionals—nearly 3.1 million individuals. In their front-line roles, nurses profoundly impact care quality and effectiveness, and thus must be adequately supported in their knowledge work by EHR systems. Nurses are also leaders in the effective use of IT through policy initiatives, terminology, standards development, research, education, systems design, and selection.
According to recent testimony presented by the Alliance for Nursing Informatics to the Institute of Medicine on the future of nursing, nurses must be supported by a healthcare environment that adequately enables their knowledge-based work as:
- leaders in the effective design and use of EHR systems
- integrators of patient information
- full partners in decision making
- care coordinators across disciplines
- experts to improve quality, safety, efficiency and reduce health disparities
- advocates for engaging patients and families
- contributors to standardize EHR infrastructure
- researchers on safe patient care
- educators for preparing the workforce.3
Informatics nurses play a role in applying informatics competencies while partnering with their colleagues to leverage IT to improve patient safety, quality, and efficiency of care delivery. This partnership is integral to achieving a vision that will require a nationwide effort to adopt and implement EHR systems in a meaningful way. The future of nursing relies on this transformation, and on the important role of nurses in achieving this digital revolution.
Results of recent research show that nurses want technology solutions that improve their workflow and eliminate and/or reduce non-valued use of their documentation time, such as with duplicate entry into multiple systems.5 They want systems that eliminate the wait time for information, for physician and team member communication, and for supplies. As a top priority nurses want to reduce the amount of time and the number of steps it takes to manage medications. Ideally, they want devices that are integrated, voice activated, handheld, use biometrics, provide translation, are portable, are wireless, auto populate, and are “smart.” These types of devices are increasingly used in the consumer space, so why aren't they also readily available for nurses who manage the health and safety of patients?
At the IOM's Robert Wood Johnson Forum on the Future of Nursing, Dr. Pamela Cipriano made four specific suggestions regarding technology:
- Include nursing workflow as a focus of healthcare information technology funding to ensure that systems and devices will enable nurses to be more efficient and produce safer care.
- Advocate for nurses to be included in technology design and evaluation to enhance rapid adoption.
- Ensure that nurses are seen as meaningful users of technology.
- Support nurses in moving high-technology care into the hospital setting of the future—the home and community.6
Achieving the healthcare reform goals of widespread EHR adoption and “meaningful use” will require that efficiency and usability are addressed. Usability is often misunderstood as being the same as user satisfaction, which is an oversimplification. The key usability principles related to EHR systems are multifaceted, and include simplicity, naturalness, consistency, minimizing cognitive load, efficient interactions, forgiveness and feedback, effective use of language, effective information presentation, and preservation of context.7 Usability evaluation should be incorporated into the planning for EHR systems implementation and include a process for measuring efficiency and effectiveness, including patient safety.
According to a recent study funded by the Agency for Healthcare Research and Quality (AHRQ), best practices and standards for design, testing, and monitoring of the usability of EHR products aren't readily available.8 Study recommendations encourage formal usability testing early in design and development.
Return on investment: Smart systems, safe care
What are some of the innovative technologies that can be leveraged for nursing? One example is a closed loop medication delivery system. This workflow would begin with CPOE, which triggers alerts and reminders to ensure the correct medication is ordered. The pharmacy management system would then verify the medication order, providing a double check for patient allergies, contraindications or duplicate orders. The clinician can view the orders on a handheld device or the EHR and retrieve the medication from an automating dispensing cabinet. Ideally all medications are bar coded in a unit dose package (or the infusion pump fluids), which allows the clinician to scan the patient ID band and then the medication to verify the 5 rights of medication administration. Finally, the electronic documentation of the scanned drugs can be confirmed in the EHR via the electronic medication administration record (eMAR).
The nursing market for EHR systems continues to advance. According to the HIMSS Analytics™ Database, nursing applications with the highest expected purchase rate for hospitals over the next 24 months are nursing documentation and eMAR.9
The future of nursing hinges on patient safety, change management, quality improvement, and usability of systems as evidenced by quality outcomes, enhanced workflow, and user acceptance. These areas highlight the role of nurse leaders in the adoption of health IT and innovation to deliver higher quality care and demonstrate outcomes within our rapidly changing reality.