Nurses as Power Users: The Role of Nursing Informatics in Health IT is Growing
When it comes to clinical informatics, nurses bring a lot to the conversation. In the course of their daily work, they’re immersion users of technology, collectors of crucial data and firsthand observers of health IT’s effect on patients. They provide much of the information necessary to improve patient care, show regulatory compliance and propel research.
One of the top trends for 2010 will be the involvement of nursing professionals in system analysis, design, selection, implementation and optimization of information technology,” says Joyce Sensmeier, MS, RN-BC, vice president of informatics at the Healthcare Information and Management Systems Society (HIMSS). According to the 2009 HIMSS Informatics Nurse Impact Survey, the benefit of these nursing professionals to health IT is that they have an impact on patient safety, workflow and user/clinician acceptance within their organizations.
A landmark 2008 Robert Wood Johnson Foundation report, titled “Nursing Time and Motion Study,” showed just how important workflow optimization has become. Researchers surveyed how medical/surgical nurses in 36 hospitals spent their time, and revealed that less than 20 percent of nurses’ time is spent in patient care activities. Even more startling: The study found that only 7 percent of nurses’ time is spent in patient assessment and observation.
“Truly transforming the hospital-patient care environment to improve the delivery of safe, high-quality, patient-centered care would be a paradigm shift. The task now is to test solutions to create a more-effective work environment that seamlessly supports clinicians in the direct care of patients,” the study’s authors concluded.
Stepping up
Nurse informaticists are stepping up to test those solutions. “This generation is so computer-literate, they’re looking for more opportunity to use computers, simulation, any type of electronic device, not less,” says Dorothy Jones, RN, EdD, director of the Yvonne L. Munn Center of Nursing Research at Massachusetts General Hospital, and professor at the Boston College William F. Connell School of Nursing. Jones says she sees students in her classes “transitioning into nursing from other careers, and bringing their knowledge of information systems with them to nursing.”
“More nurses are actively participating in health IT use and format decisions, particularly in the clinical area around electronic documentation,” says Jones. Within the Partners Health Care System the parent company of Massachusetts General Hospital, for example, “nursing is well represented on a committee that discusses acute care documentation (ACD). The group has been meeting for several years to revamp the EHR system for nursing, medicine and allied health providers,” Jones says. “This work has supported a deep dive around communicating assessment data, interventions and outcomes, use of standardized language within information systems, discussions around coding and [determining costs for] services, and looking at the data recorded in electronic records to increase evidence for practice.”
“Nursing as a discipline has the knowledge about the patient experience that differs from other disciplines. Communicating this information about patients and their response to an illness can be helped by the use of standardized nursing language. For nurses to be visible within the era of the patient’s electronic record requires academic preparation of nurses—not only in terms of using equipment and knowing how and what to document. Using standardized nursing languages to reflect the collaborative as well as the unique perspective nurses provides new opportunities for national and international research to improve care.” (See sidebar, page 6.)
“The more you get this data in an electronic version, the more you can see the relationship between the elements of caregiving within the practice environment and care outcomes, staffing ratios and retention, data on national quality indicators and safety,” says Jones.
Early warnings
“Data are fine, but data in trend tells an amazing story,” says Lee Ann Hanna, PhD, RN, CPHQ, FNAHQ, director of education at Centennial Medical Center, a 649-bed tertiary facility in Nashville, Tenn., who helped research, implement and hone a MEWS (modified early warning score) tool in her facility.
MEWS is a medical algorithm that assigns a score to a patient’s physiological values (vital signs, oxygen saturation and neurological status). As the score increases, patients may have clinical deterioration, “which means that we need to take a second look,” says Hanna. As a nurse documents vital signs in Centennial’s Meditech EMR, the MEWS tool automatically calculates a patient’s score: “Either it’s OK,” if the score is below five or has not increased by two, “or it will stop them and flag the score along with the last six scores [if available], for review,” Hanna says.
The MEWS tool has streamlined the workload in the ER by alerting staff to patients whose condition is trending worse, says Hanna.
Centennial decided on the MEWS tool in 2006. “We piloted it for two months in several med/surg areas,” says Hanna. The results of the pilot tests showed Centennial needed to revamp the MEWS scale to make it work with the patients Hanna and her group were most likely to see, she says. The group decided to add a value for oxygen saturation measured by pulse oximetry (SpO2) to the MEWS tool.
“We’re tertiary care, so we measure [SpO2] on most of our patients. We added that and assigned values,” says Hanna. When the team reviewed the patients included in the original sample, but with SpO2 values included in the MEWS score, they found a significant difference between the admission and Rapid Response Team MEWS scores. The hospital’s Rapid Response Team and informatics staff members then developed automated alerts and reports based on this information.
“Over the years, it’s morphed again,” based on feedback from nurses, to include a warning when blood pressure is high, Hanna says, and the current—fourth—version also includes a value for sepsis screening.
The MEWS tool isn’t a substitute for clinical judgment and isn’t a predictor of critical illness, but it has identified patients in danger of spiraling into life-threatening situations, says Hanna. “When people hear about it, they realize the value.”
| Speaking the Same Language | ||
Standardized Diagnosis Terminology Would Allow Communication Among Providers at Every Level
Leave nursing language out of the EMR conversation, and you risk a breakdown in communication. “Clinicians in general need a common language that can support clinical documentation in the EMR, so you can perform data analysis,” says Gail M. Zielinski, MS, RN, director of Clinical Transformation/Clinical Excellence at Ascension Health in St. Louis, Mo. “Wherever possible, the one key thing we want to see is a single patient problem list,” Zielinski says. “Nursing practice has very unique documentation needs: We coordinate care 24 hours a day for patients. We use a holistic approach, incorporating medical and nursing observations into assessments, interventions and outcomes.” “Ascension Health will continue to evaluate what will be useful in measurement and in practice. As an example, through the use of the Outcomes Measurement Database, we are able to compare patients and see if their outcomes are better than expected, which is why it’s important for us to have consistency in the terminology and the data collected,” Zielinski says. The North American Nursing Diagnosis Association-International (NANDA-I) generated the first standardized nursing classification on nursing diagnosis in 1973, says Dorothy Jones, RN, EdD, director of the Yvonne L. Munn Center of Nursing Research at Massachusetts General Hospital, and professor at the Boston College William F. Connell School of Nursing. This was followed by development of Nursing Intervention Classification (NIC) and The Nursing Outcomes Classification (NOC), by nurse researchers at the Center for Nursing Classification at the University of Iowa. “Today, there are several other classification systems approved by the American Nurses Association for use in clinical documentation,” she says. NANDA-I, NIC and NOC are widely used in the United States, says Jones. The International Classification of Nursing Phenomena (ICNP), developed by the International Council of Nursing (ICN), is used globally and incorporates many of the nursing concepts found in NANDA’s classifications. Vendors such as SNOMED have integrated and mapped reference nursing language taxonomies into a reference terminology to allow wide use of existing systems. “When one system classifies a phenomena as ‘ineffective pain management’ and another group labels the phenomena ‘pain’ or ‘discomfort,’ SNOMED will allow systems to talk with one another and report the problem in a unified way,” says Jones. “A current challenge is around the translation of the standardized languages across groups and cultures. A nursing diagnosis described in the NANDA-I classification as ‘failure to thrive’ may have meaning for a nurse in the USA, but little or no meaning in another country,” says Jones. “We’re are currently working on these issues and trying to develop a standardized language with a content that has a common core to everybody and also tolerate unique differences across groups and cultures.” Hospital Corporation of America advocates use of yet another language, Clinical Care Classification (CCC), says Kelly Aldrich, MS, RN, CCRN, Nurse Informatics Specialist at HCA. CCC differs from NANDA in that CCC codes actual nursing interventions, teaching and outcomes, “allowing for the plan of care to be executed in a codifiable way, capturing the essence of care,” Aldrich says. In addition, CCC taxonomy is within SNOMED-CT. “We’re trying to quantify and qualify the essence of care, and that’s what the CCC can do,” she says. “The language is initially complex, but once you immerse yourself in [CCC], it makes a lot of sense to nurses because it doesn’t change their language. It’s non-physician terminology. We have been stretching it beyond nursing,” to respiratory therapies, pharmacy and other clinical documentation areas, Aldrich says. |
Giving time back to clinicians
As a former open-heart surgery recovery nurse, nursing supervisor, neuro-trauma ICU nurse and interim CNO, among other roles, “I bring bedside representation … to be able to talk with CNOs, bedside nurses, project management and IT professionals,” says Kelly Aldrich, MS, RN, CCRN, nurse informatics specialist at Hospital Corporation of America (HCA), based in Nashville, which manages 162 hospitals in 23 states. Working in corporate-level nursing informatics, “our job is to help the end-users, people who are at the bedside caring for these people, so we’re allowing them to spend more time with patients by automating things in their environments.”
HCA has worked with Meditech for more than 19 years, Aldrich says, and is now moving toward a paperless environment. HCA will be alpha-testing a new platform of evidence-based documentation along with a coded standard taxonomy. “We’re also mapping physician care orders to nursing interventions,” Aldrich says.
A separate project will automate vital signs captured from the bedside into the core Meditech app, for non-critical-care environments. “We partnered with IT and defined [a request for information], and found four vendors that met our technical [requirements]. Each came to our corporate campus and gave a presentation to 160 nurses.” The nurses evaluated each vendor’s product usability, functionality and ease of use, and told Aldrich’s team what they would actually use if it were put into their environments. “We had our nurses come forth and their voices are being heard … and hands-down, the nurses chose one vendor,” she says.
The company plans to pilot test the application in the fourth quarter of 2010. “In addition to time savings for our nursing staff, communication of vital signs will be more timely,” says Aldrich.
Putting tech to the test
Getting clinicians to meet and agree on the features in an EMR—and then getting vendors to install those features—is no small feat. But these are some of the tasks that Gail M. Zielinski, MS, RN, director of Clinical Transformation/Clinical Excellence at Ascension Health, based in St. Louis, Mo., has helped to accomplish. Ascension, the nation’s largest nonprofit, faith-based health system, has more than 500 locations in 19 states and the District of Columbia.
Since 2006, Zielinski has used her background in cardiac nursing and managing an acute medical unit, along with informatics experience, to provide system-level nursing informatics leadership for Ascension Health on clinical/technology projects. “Many of these projects involve EMR platforms—Ascension Health facilities use Cerner, McKesson, Eclipsys, Meditech, Siemens and Epic—and other technology vendor partners [such as] Hill Rom [and] Hospira. The various EMRs were in place at our Health Ministries prior to joining Ascension Health, and integration between records is a big part of the job,” says Zielinski.
“I’m a collaborative partner with senior managers, local health ministry leaders, the C-suite—CNOs, CMIOs, regional CIOs, and my most frequent interactions are with nursing transformation leaders at each one of our sites. Through partnerships with them, I serve as an informatics resource,” says Zielinksi.
“Early on at Ascension, I organized a summit of about 100 nurses, physicians, pharmacists, system technologists and allied health professionals to review existing clinical documentation for one of their EMR platforms, and worked toward redesigning it. The project brought together two of [Ascension Health’s] early adopters using clinical documentation, plus others who hadn’t started on that journey. The focus was to share experiences of adopters, with clinical documentation: their approach in developing the clinical documentation and their philosophy of why they did what they did,” she says.
“This project demonstrated a shift in local culture with the EMR, by sharing and seeing the benefits of what other people had done. Our Health Ministries recognize the benefits of collaboration and that everyone doesn’t always necessarily have the answer but someone else might.”
“We’re working toward providing technology that supports documentation and the workflow of the clinician, [with] the use of Hill-Rom (beds and devices for call systems) and Cerner. We’ve tested the interoperability of ICU technology such as physiological monitors to capture data and seamlessly transfer the data using a Bedside Monitoring Device Interface (BMDI) to the EMR,” she says. “[It was] the first time these two vendors came together to work on a solution that resulted in efficiencies in documentation … Nursing and the technology team worked to help vendors understand what the needs were and what was needed locally.”
“We were able to prove that you could have an interface [that enabled] data coming from the patient’s bedside to be sent to the EMR and populate that electronic record, and the nurse would have the opportunity to verify that that information was correct, then it would get posted to the EMR,” says Zielinski. “Now they’re seeing the value of working together and we’re able to benefit because of the efficiencies in clinical workflow and documentation.”
With the ongoing national conversation around meaningful use and the work that organizations such as the National eHealth Collaborative, Health IT Standards and Protocols Committee, and others are doing, Aldrich says “the word is getting out—people are recognizing nursing informatics as a field that can bring value to the organization.”