# Presentation: 172645

## Electronic health records and nursing

- Applications to nursing care
- Anne Sales, PhD RN
- Faculty of Nursing
- University of Alberta,
- Edmonton, Alberta

## 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

## Overview

- Background comments
- Inpatient setting
- Applications of EHR in inpatient nursing care
- Possible future directions

## 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

## 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

## Role of EHR in interacting with nursing care

- Documentation
- Includes care documentation as well as workload
- Prompting
- Force functions
- Decision support

## 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

## 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

## 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

## 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

## 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

## 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

## 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

## The VA Nursing Outcomes Database (VANOD)

- Contact person:  Bonnie Collins (_[bonnie.collins@va.gov](mailto: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

## 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?

## 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

## 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

## 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

## 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

## 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