Electronic health records and nursing

1
Electronic health records and nursing

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

2
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 VAs EHR
• Describe future opportunities

3
Overview

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

4
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

5
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

6
Role of EHR in interacting with nursing care

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

7
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

8
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

9
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

10
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

11
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

12
Clinical reminders

• Specific software within VHAs 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

13
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

14
The VA Nursing Outcomes Database (VANOD)

• Contact person Bonnie Collins
  (bonnie.collins_at_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

15
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?

16
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

17
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

18
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

19
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

20
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