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 VAs
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
What nurses do in each setting can be highly
variable
Outpatient care
Ambulatory surgery
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
Risk assessment
Ensuring right person, right dose, right timing, etc.
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
Clinical reminders
Templates
Decision support?
Care management/workload capture
Electronic Kardex
Whiteboards
Staffing matrices
Order entry
Nurses have dual role
But not everything that happens for a patient depends on
orders
Order input
Order processing/fulfillment
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
Progress notes
Vital signs and other data recording
Currently not standardized across the system
May be difficult to standardize adequately
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 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
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)
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, multidisciplinary health record capable of
capturing data at very frequent
intervals (e.g. q minute) incorporating
n-way real time dialog functions, multidisciplinary decision support, and fullscale 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
