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 )
        - 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