HIMSS: Nursing's critical role in EHR success

NEW ORLEANS—Robert Wood Johnson University Hospital, in New Brunswick, N.J., survived a failed EMR implementation effort before it could experience a successful one, according to Nicole Martinez, BSN, RN, director of nursing informatics, who spoke during the Healthcare Information Management and Systems Society annual convention.

The hospital’s leadership was evenly divided about the EMR implementation. “There was no middle ground,” said Martinez. “That created a problem when we were trying to create workgroups.” There also was a lack of support from all levels of nursing leadership. “They spent no time or resources educating middle management” who really run the hospital, she said. The ICU nurses had no information until the day of go live. The ICU nurses happen to be the group with the most nursing experience but the least exposure to technology, Martinez said.

Nurse educators from the ICUs were the primary stakeholders at all design sessions—not doctors and nurses. The educators were excited about the new tool but “they’re not the ones at the bedside.” Testing was done by med/surg nurses already familiar with the system. The med/surg nurses tested ICU flow sheets, which went well “because they didn’t know what they were clicking on.”

The effort failed. The hospital experienced a change in 75 percent of its leadership over three years. The new leadership put strong effort into explaining to staff the importance of the initiative by sharing their vision of the future, Martinez said.

To ensure success the second time, the hospital established structural empowerment through the formation of a Sunrise Clinical Manager (SCM) End User Council. This group was different, she said, because it included representatives from every nursing unit with a subcommittee for ICU.

The executive power to approve all decisions related to the EMR was delegated to the bedside nurse through this forum.

Meanwhile, physician leadership formally abdicated executive power decisions to the SCM end user group. “The physicians supported the nursing staff so much they said ‘whatever works for you is more important than what works for me.’ They realized that if the ICU nurses can’t practice, document and look at information in a way that supports their practice, it’s only going to hurt them.” That thinking created a very different environment in the ICU, she said. “For physicians to truly collaborate with nursing, the nurses now cared about the physician struggle. It’s a two-way street.”

The organization developed a mission statement and everyone agreed to share everything. The nurses refuse to miss meetings, Martinez said. “They are totally invested.” Hospital leadership gave them one rule: We will build it exactly as you want it with one caveat; you must use the existing EMR, but we will create whatever you want within that structure. We can’t buy a different system.

Staff also accepted the responsibility to take “homework” back from meetings to their peers, obtain feedback and report back to the team.

The hospital fostered structural empowerment through communications including an end user webpage on the hospital intranet. The meeting minutes are sorted by date including images. There also is an internet mailbox communication system anyone can post to and nursing leadership must address within 72 hours.

Staff collaborated with their physician colleagues to identify the best practices for their documentation. Key physician stakeholders were identified as champions. They reviewed the nurses’ decisions and suggested revisions; however, the final decision was with the nurses.

Staff stakeholders identified processes and workflows to enhance their practice. These include automated clinical decision support mechanisms and enhanced workflows for vaccines, medication reconciliation and timely documentation. “From a physician perspective, that has greatly improved the accuracy of information when they’re trying to look for it.”

Meanwhile, over the last five years participation in the hospital’s nursing satisfaction survey improved by more than 40 percent and job satisfaction scores improved 17 percent. Compliance for medication reconciliation has been above 90 percent for the four years since the electronic medication reconciliation has been in place. Also, “we have not had a peripheral IV infiltration in three years. Our pressure ulcer rate decreased by 66 percent. We’ve been able to maintain and make big changes in nursing practices based on how we utilize the EMR.”