Nursing Information Systems: Integrating for Better Care
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| Physician Assistants Patricia Geraghty, RPAC, and Dan Bannen, RPAC, view a patient’s EMR at Winthrop University Hospital, in Mineola, N.Y. |
Nurse informaticists are playing a more critical role in the integration of various clinical applications, including clinical/nursing documentation and clinical information systems, CPOE, EMR and EHRs, according to the Health Information and Management Systems Society (HIMSS) annual Nursing Informatics Workforce Survey (see sidebar, below).
On the same page
Utilizing a CPOE system (Siemens), the 590-bed Winthrop University Hospital in Mineola, N.Y., is moving toward 100 percent electronic documentation in part because of an integrated informatics effort. The structure of the informatics department is unique in that the academic medical center combines nursing informatics with other informaticists to create one clinical informatics department."We have pharmacy, nursing, physician informaticists and non-physician informaticists all working side by side," says Winthrop CMIO Maureen Gaffney, RN.
"We need to have individualization of health IT systems as providers at a certain level since people work differently," says Gaffney. "We needed a system to match our workflow because we can't have systems dictating what we do; otherwise patient safety is at risk and we don't optimize the value of having technology to support quality of care and patient safety.
"The power of automation took us to the next level. The nursing staff and providers got to understand each other's workflows and were on the same page for what we were trying to work for and speak the same language. CPOE broke down the silos."
Before automation, medication interpretation differed among nurses, pharmacists and physicians, Gaffney says. For example, an order to give antibiotics three times a day might mean something different to a physician than a nurse. For a provider, "three times a day" for an antibiotic could mean the patient would get the first dose soon, whereas a nurse might interpret "three times a day" as 8 a.m., 2 p.m. and 8 p.m. Automating the process "forces us to be on the same page with regard to interpretation of orders," says Gaffney.
The language difference regarding medication frequencies was a revelation for Winthrop, according to Gaffney. "My advice, from the beginning of switching to an automated system, is you need to know workflows across the organization since there's a lot of variation of workflow processes from practitioner to practitioner, unit to unit," she says.
Using the automated system, the patient harm associated with medication variances decreased 6 percent—to less than 1 percent—from 2006 to 2009, Gaffney reports. In addition, inappropriate ordering of proton pump inhibitors decreased by 55 percent and telephone/verbal orders decreased 14 percent—to less than 1 percent for each—in the same time frame.
"This is an opportunity to get everyone discussing the right way to agree upon a job and get the staff to respect each other's workflow and how it will streamline their job," she says.
Centralized and integrated
A closed-loop medication process is being used at Nemours, a pediatric health system based in Wilmington, Del., with clinics in Florida, New Jersey and Pennsylvania. Nemours switched to an EMR (Epic) system specifically for clinical integration, especially among nursing staff, says Connie Trusko, MSN, RN, Director of Nemours Health Informatics. Using a medication distribution system (Picis), nurses document vital signs in the EMR and validate and accept medications.| Systems Integration Tops Nurse Informaticists’ Wish Lists | |||
The results of the web-based survey of 660 nursing informaticists in December 2010 and January 2011 show that “nurse informaticists play a critical role in the implementation of various clinical applications, including clinical/nursing documentation and clinical information systems, CPOE and EMR/EHRs,” according to HIMSS. Fifteen percent of respondents received on-the-job informatics training and 56 percent reported having a post-graduate degree. This represents an increase from 52 percent in 2007. The 2011 data also reveal that 35 percent of respondents hold a master’s degree in nursing, 1 percent have a PhD in nursing and 24 percent holding a master’s degree in a field other than nursing. “It’s worth noting that the 2011 respondents have less clinical experience than their 2007 and 2004 counterparts, but they have had more experience as nurse informaticists,” the report stated. About 39 percent in the 2011 survey have been in this position for 10 years or more, compared to one-third in 2007 and one-quarter in 2004, suggesting an increase in the length of career as the discipline continues to mature. 2011 respondents were most likely to report that their primary job responsibility is systems implementation (57 percent), including preparing users, training and providing support. Second on the list was systems development, at 53 percent. An equal percentage of respondents in 2004, 2007 and 2011 surveys do not have individuals reporting to them (approximately 60 percent). Not surprisingly, lack of systems integration/interoperability was mentioned most frequently as a top barrier to respondents doing their job. This corroborates other studies, which cite integration and interoperability as a perennial headache for CMIOs as well. |
When the platform was rolled out across the enterprise in 2009 and data began flowing across state lines to Pennsylvania, New Jersey and Florida, Nemours began to see care improvements almost immediately, Trusko says. For example, when a Nemours patient from Florida was in a severe car accident while visiting friends in Delaware, "the EMR enabled the nurse to review the patient's medication record and allergies and provided knowledge that this patient had a severe chronic disease. This information was very helpful because a caregiver wasn't present to give any clinical information," says Trusko.
There also are some safeguards to the e-prescribing process, says Milov. A nurse cannot prescribe medications unless he or she has entered the patient's weight. "Because medications for children are closely related to the patient's weight, it is imperative that the weight is entered into the system to prevent adverse drug events," he says.
Documented EMR outpatient medication reconciliation at Nemours jumped from about 35 percent in January 2007 to just shy of 90 percent in July 2010 for percentages of visits with medication reconciliation. The rate of prescription in unapproved outpatient prescription abbreviations also has decreased through smart checks in the EMR, Milov adds.
Closing the loop
These days, the only handwritten documents at Lehigh Valley Health Network (LVHN), in Allentown, Pa., are physicians' daily progress notes. LVHN has implemented a fully closed-loop medication management system, beginning with a computerized provider order entry (CPOE) system in 2001, with barcode technology added in 2003 and electronic documentation in 2005—on a single platform (GE Healthcare), says Donald Levick, MD, MBA, medical director of clinical informatics at LVHN.Developing the system was a collaborative team-based approach to design, testing, training, implementation and support. Nursing and ancillary departments remain involved in the continued refinement of the systems. "It is critical for our success that both leadership and the personnel at the front lines contribute to our improvement efforts," says Levick.
"From the nursing perspective, we work continuously with several of our committees, such as Nursing Practice Council and Clinical Documentation Committee within patient care services, to improve the technical as well as process aspects of system use," says Janice Wilson, RN, MS, manager of nursing IS at LVHN. "We also are integrally involved in work of quality initiatives and our many system leadership teams."
LVHN is pretty consistent with the rest of the nation in their features and functions they would like to see improved: interoperability and clinical decision support, Wilson says. "I can never have enough tools to improve the bedside clinicians' care of the patient."