By Ted Stucka, PhD
When I was in school I had a professor who said, “Except for Surgery, the primary modality of treatment in hospitals is through pharmacological intervention. It is up to everyone in health care to make both as safe as possible.”
I never forgot that simple statement and its meaning. It’s up to all of us to make drug therapy as safe as possible. We all know that medication errors compromise patient confidence and increase hospital costs but now, with the evolution of electronic health records, we have a new tool in our arsenal to try to make drug therapy as safe as possible. One could even say that medication safety is the most important part of EHR.
A closed loop system for medication ordering, dispensing and administering allows us to look at this process in a systems oriented approach. We define, develop procedures, monitor and define success. With a collaborative, multidisciplinary approach we can now look at, understand, and help resolve drug-related problems. EHR data and the ease in which we can gather information allows us to develop a system wide approach to enable improved monitoring of patients and specific medication associated with medication errors. The use of closed loop systems for medication use and distribution can help us minimize patient risks at each step of the delivery system.
Errors that happen at all levels of experience are multifactorial, ranging from lack of knowledge, sub-standard performance, mental lapses, or system failures. EHR’s allow us to monitor mistakes, alter and monitor the changes made to our procedures. We can set-up Rules based monitoring to ensure patient safety is not compromised by intervening at the moment when errors occur. We can remind prescribers of renal or hepatic issues at the point of order entry. We can have dosing checked when the drugs are verified. We can have allergy information appear at every stage of the loop making the complete a reason before the drug is ordered, verified and then every time the drug is administered. Systems that allow the user to define and develop their own warnings where they feel a need is an added bonus. Remember that your institution is unique with your own personalities and issues. Custom warnings made with a rules based engine help you define what your institution needs for improved patient care.
So when looking at your EHR system make sure you begin to utilize the information gathered and available to make sure your medication management system has the policies and procedures needed to make patient safety the primary goal of your institution. Use a collaborative approach to monitor your success or failures and be willing to change the behavior of the root causes of errors.
While EHR software has been touted as the savior of many things I submit that the case for improved patient safety is the most important. While it may not prevent human error, it can be used to ameliorate a great majority of errors making the patient that much safer.
By Penny Casebolt RN, MSN, MHA
In 2012 the American Hospital Association published a progress report on the implementation of EHRs in the United States. At that time it was estimated only about 17% of RNs were using a complete EHR system in their workplace. I was amazed at this statistic until I recognized the key word “Complete”. Certainly a higher percentage of nurses use some component of an EHR but much fewer have access to a full or comprehensive product. Although this percentage is undeniably growing with the rush to meet ARRA requirements this current statistic is at the heart of many of the issues nurses have with moving to an EHR. With the complexity of the nursing process there is a need to better understand the various components of the nursing work-flow that integrate into a comprehensive delivery of patient care. Simply put, nurses provide complete care and need a product that supports this.
Brokel and Harrison (2009) identify the most frequent activities of nursing as assessment, documentation and communication. The research places assessment as the most time-intensive activity at 18.1% of the nurses’ day with documentation at 9.9% and communication at 11.8%. This is almost 40% of one shift devoted to these three activities. Clearly for any EHR to be functional for the nurse the EHR must offer strong components in these areas. As any nurse will tell you, these three activities go hand in hand: I assess, I document, and I communicate. Without an integrated product that enhances the ability to coordinate all three activities the EHR has the potential to create additional work and frustration for nurse users. The barriers to nursing adoption are well documented and include concerns about work-flow disruption and diminished time with patient care. One of the reasons I believe a partially implemented EHR can be so disruptive to the nursing process is the underlying issue with existing inefficient work-flow. The movement from paper to EHR often uncovers redundant and outdated work flows. Without nursing involvement in the EHR implementation project these work-flow challenges would not be pre-identified and only surface as an “EHR issue” when in fact it was just a poor process.
Fortunately both nursing leadership and EHR developers are listening to concerns voiced and actively pursuing methods to improve the movement from a technical point of view to a practical one in terms of clinical use of the EHR product. One key to positive adoption and sustainable use is the increasing role of the informatics nurse. Healthcare organizations and EHR vendors are both realizing the value of employing individuals with the clinical understanding of how the system will work. Informatics nurses can help identify work-flow processes and any potential disruptions. A comprehensive EHR can provide the nurse with powerful tools that enhance the documentation and coordination of care and with a well thought out implementation plan can bring positive results. One hospital study reports 75% of nurses report the EHR had improved the quality of documentation and 76% believed there was improvement in patient safety and quality of care (Moody, Slocumb, Berg & Jackson, 2004). Having nursing intimately involved in development and implementation can only help ensure the EHR meets the goal of ARRA and brings meaningful use of a comprehensive EHR into every nurse’s workday.
Brokel, J.M., Harrison, M.I. (2009). Redesigning care processes using an electronic health record: a system’s experience. Jt Comm J Qual Patient Saf. 35(2): 82-92
Moody, L., Slocumb, E., Berg, B. & Jackson, D. (2004) Electronic health records documentation in nursing; nurses’ perceptions, attitudes, and preferences. Computer Inform Nurs. 22(6):337-344
By Penny Casebolt RN, MSN, MHA
A key component of my daily work is focused on integrating the ARRA stage 2 meaningful use criteria into practical bedside applications. Nursing has always taken exception to the introduction of non-value added work into clinical care and many fear that meeting meaningful use criteria is just another thing that will fall on the backs of the nursing staff and I cannot say this fear is unfounded. As a result, I believe that there is a tremendous responsibility on the part of EHR vendors to ensure that their products not only provide the means to meet meaningful use requirements, but that they do so in a way that provides a practical and functional clinical application. There is no doubt every nurse will be an integral part of the expansion into the electronic collection of meaningful data and its use in point of care clinical decision making and I encourage every nurse to become familiar with the purpose behind meaningful use implementation. These criteria are defined in a document named Meaningful Use Matrix, which was developed by the Health IT Policy Committee within the National Coordinator for Health and Human Services and is available at the website below http://www.healthit.gov/policy-researchers-implementers/meaningful-use.
Reciting the exact criteria is not the essential aspect in understanding meaningful use, but rather it is recognizing the health policy priorities inherent within these criteria. Proceeding in three phases implementation, data capture and sharing and advanced clinical processes with decision support meaningful use requirements target five key policy priorities. The meaningful use objectives center on improving quality and reducing disparities, engaging patients and families, enhancing care coordination, targeting public health, and ensuring privacy. To be successful, these strategies require collection of clinical information at the point of care and the ability to share this information across the entire continuum of care. If meaningful use objectives are successfully implemented these strategies have the potential to improve health outcomes in our country.
Establishing a patient’s medication history is one example of a process to be enhanced under MU requirements. Every nurse has met the patient who takes the pink pill but doesn’t know the medication name or dose. Even more dangerous are situations of medications prescribed but not taken or reported, as well as medications taken at home but changed during hospitalization. The opportunity for the nurse and provider to access medication history data from outside sources and track changes in home medications throughout the patient stay will facilitate true medication reconciliation at discharge and enhance the ability to provide clear patient education on discharge medications.
The role of electronic clinical documentation systems will also expand in the future. It is the meaningful data collected by these systems that will give meaningful use the ability to transform care. In her column for The American Nurse, Karen Daley (2011) made valuable comments on what the EHR should mean for the nurse. The need to move beyond the capture of the patient’s physiological data such as vital signs to capturing “descriptors about the patient and their responses to illness, disease, and treatment, and their wants or needs for optimal health and quality life. That is what nursing does.”
Evidence-based care has been rooted in nursing practice for some time. Meaningful use objectives and the EHR functionality required to meet them will only strengthen the nursing process by providing consistent evidence-based order sets, pathways, and processes all available at the bedside. I believe that if a strong collaboration continues between EHR developers and clinical care providers then achieving meaningful use will be an enhancement to the delivery of nursing care rather than a burden.
Daley, K. (2011). Making HIT meaningful for nursing and patients. The American Nurse. http://www.thearmericannurse.org/index/php/2011/08/01
By Penny Casebolt RN, MSN, MHA
I recently had lunch with a nursing colleague that I had not seen for a number of years. Our conversation ran through a myriad of topics but soon settled on our professional work. My friend is a nursing leader at a hospital just beginning the process of implementing a full EHR. Given my professional work as a clinical informatics nurse for Meta Healthcare IT Solutions I was fascinated by her litany of concerns about the impeding transition. Her lamentations included the following:
- The average age of my nurses is 52- how am I going to get them to embrace charting at the bedside and working without a paper medical record?
- How is anyone going to know what a doctor has ordered?
- This is just going to be one more thing that interferes with a nurse relating to the patient-” I mean who wants to talk to someone with their face in a computer?”
Having worked in the field of clinical informatics for a while I admitted that these were concerns I have heard countless times. Being long time colleagues I felt comfortable challenging the validity of her remarks. Do nurses really fear the use of an EHR as much as implementation teams report? How do nurses feel post-implementation? Does using bedside documentation really dehumanize the patient/nurse relationship? In this blog I will share my personal thoughts on these issues with subsequent blogs providing research on current perceptions from nurses on health information technology and EHR utilization.
I graduated from nursing school in 1977. In my decades of practice I have witnessed the introduction of technology into the bedside delivery of care at a tremendous pace. These changes have transformed how care is delivered in profoundly significant ways. Pharmacy and laboratory services seem to have integrated technology quickly into their processes. Where would bedside nurses be if pharmacy still relied on a paper process for filling orders? How would a nurse handle not being able to do bedside testing of blood glucose or arterial blood gases? Nurses adopt and enhance tools into the care delivery process all the time. In my view every technological advance brought into the bedside has given the nurse an additional tool to better care for the patient. An electronic health record is just one more tool for the nurse to use and with the mandate of meaningful use requirements it has the potential to impact patient outcomes dramatically. In an article by Huryk (2010) it is noted successful implementation requires nurses to believe the benefit of daily use of the EHR will influence patient outcomes. The author provides additional insight on the role of meaningful use on nurse adoption of EHR, current data on nursing attitudes and common detractors, as well as the need to increase the role of nurses in systems design. These topics will be focus of my next few blogs.
One last note, during the lunch with my 62 year old nursing colleague, she received several text messages from her daughter including video of her grandson placing soccer. She used her IPad to check availability for our next outing and pulled up her Facebook page to show pictures of her husband’s latest project. Although there are times smartphones and devices can hinder a personal interaction, in this instance the connection between two friends was enhanced. Why, because my friend used the technology in a meaningful way to enhance our experience. As nurses we should embrace the technology at our fingertips and engage in applying the technology bedside in a relevant manner. In the end it will make all the difference.
Huryk, LA. (2010). Factors influencing nurses ‘attitudes towards healthcare information technology. Journal of Nursing Management. DOI: 10.1111/j.1365-2834.2010.01084.x
By Penny Casebolt RN, MSN, MHA
Travel during the last week of February can be risky with the likelihood if airline delays and cancellations. I recently experienced this truth while traveling to a small hospital in Nebraska. The plan was to arrive a day early and explore an area I had never visited. The reality was two days stuck in the Denver Airport. With a connection from Denver to a small regional airport I found myself stranded with local residents on their way home. Upon arrival to my final destination I was struck by the beauty of the land and hospitality of the people. With a goal of providing an on-site evaluation of EHR readiness and work-flow review for a local Critical Access Hospital (CAH) I was thrilled to see the level of excitement and involvement displayed by staff throughout the organization.
In an earlier posting I commented on the importance of staff involvement in achieving a successful EHR selection and implementation. I have worked at various sized organizations throughout my career but never one as small as this critical access hospital. With a large community responsibility and limited resources a CAH has unique barriers to EHR selection and implementation.
This particular site lacked full time pharmacy and IT support and clinical leaders wore multiple hats to provide consistent organizational support. The inability to staff at full time levels for these key positions is not unusual for small rural hospitals. However what this site demonstrated was the ability to see through the barriers and see the real solutions that an EHR can offer the organization. In meeting with the staff, key elements were highlighted as critical to success for their organization. With a given expectation that every EHR should provide the basics of eMAR, CPOE and Clinical Documentation the staff was interested in how the system could enhance the current workflow and improve patient care. The areas identified were focusing on communication, education, mulit-department functionality, and personalization of product. I found that with limited email capability in many small organizations that secure staff communications were a challenge and the opportunity to send patient and non-patient related emails within the EHR product is a very useful feature.
Ultimately though, education is the key to successfully integrating an EHR into the daily workings of a hospital. This site was well prepared with questions not only on initial training and go-live support but the need for on-going services. An expectation of printed as well as on-line tutorials is reasonable expectation from any vendor. A delicate matter for sites and vendors is the topic of personalization of product. As a small facility this site had developed processes that worked and had a course set for their future. And while understanding products requires a degree of standardization, there was a desire for the opportunity to personalize the product to fit the unique organizational workflow inherent in a small facility. Asking the vendor questions around custom design capabilities and enhancement request process is an important and often overlooked aspect in EHR selection. Most importantly, it is imperative that all key players are represented in the EHR selection and process.
My site visit to the CAH in Nebraska was an adventure and also an excellent learning opportunity for me. I was excited to experience the energy and degree of preparedness of the staff. Through full-leadership support and transparency of process this small facility is leveraging barriers into a well-organized and thoughtful selection of an EHR.