Nursing Central to Health IT Success

When it comes to the continuous care and feeding required of health IT—upgrades, new apps, bar code medication administration and so much more—“nurses are ready to make that happen,” says Carol Bickford, PhD, RN-BC, CPHIMS, senior policy fellow in the American Nurses Association's (ANA) department of nursing programs.

The association is working on the second edition of the nursing informatics scope and standards of practice which modifies the definition and revises the scope of practice statement, Bickford says. ANA also is participating in federal initiatives and working to make sure that informatics content and competencies are included in nursing educational programs.

IT competency required

Mary Beth Mitchell, MSN, RN, BC, CPHIMS, chief nursing informatics officer for Texas Health Resources (THR) in Arlington, can attest to that demand. “In this day and age, every nurse has to have a certain level of informatics competencies and understanding of technology.”

THR was recognized by the Healthcare Information & Management Systems Society last year with a Davies Award which recognizes excellence in the use of health IT so the organization is no stranger to using technology to increase efficiency.

Once the EHR was implemented at 13 Texas Health hospitals in late 2010, a team of nurses representing each of the hospitals as well as nurse IT analysts analyzed the EHR for functionality and user acceptance.

The Nurse Champions, as the team named themselves, simplified patient admission history records. By lowering the content requirements from 286 separate entries to 150, they reduced the average time of completion from 45 minutes to 20 minutes. “The nurses were committed to fine-tuning the EHR to meet the needs of all nurses to improve patient care,” she says.

THR’s medical error reduction effort and modified early warning system (MEWS) are two more examples that showed the organization’s focus on collaboration and getting value out of technology, used to make the organization’s case for the Davies award. Both initiatives have a big nursing component, allowing them to take action as soon as possible. Alerts “get the smarts to the EHR and are really what I think provides us the best results,” says Mitchell. “Nurses rely heavily on clinical decision support tools.” The MEWS uses predictive CDS to drive a lot of nursing care.

Involved from the start

But before nurses can take advantage of such tools, they have to help with the initial design of the EHR, says Mitchell. “All EHRs need to be designed after taking the end-user clinicians’ perspective into consideration.” When THR began planning for its EHR implementation, they transitioned nurses into builders of the EHR. “They brought their frontline clinical knowledge to decisions about how the EHR was going to work.” In fact, about one-quarter of THR’s IT staff dedicated to the EHR build, optimization and maintenance are nurses or other clinicians.

Nurses from all 14 hospitals were involved in every aspect of the EHR design which took about 18 months. “The good part is that when you can show that those nurses’ input was really valued, then you get much higher adoption,” she says.

Bickford agrees with that strategy. Nurses must “be right there at the very beginning when concepts are being created.” That they haven’t has been the problem and systems have been generated to focus on payment for services rather than the services themselves. “Many of the concepts important to nurses, doctors and pharmacists have not been incorporated well within these systems.” 

IT is not front and center for a nurse—“it’s more of a tool for doing the work we do,” says Nancy Hanrahan, PhD, RN, CS, FAAN, associate professor of nursing at the University of Pennsylvania School of Nursing in Philadelphia. IT systems are typically imposed upon nurses  who are then expected to utilize systems they were not involved in developing. EHRs become “big traps that complicate their work lives. Nurses want tools that help them do their jobs without getting in the way of communicating with or caring for patients.”

In her experience, however, Hanrahan says nurses have been the backbone of a lot of EHR developments. “To develop a really good IT system you have to know which variables are important to collect. Many nurses are involved in defining those variables and how those variables can be used for quality improvement and measure outcomes that are pertinent to patients and providers and systems.”

Collaboration, new skillsets

Hanrahan helped Penn launch its Health Technology Lab three years ago to offer nurses an interdisciplinary experience of designing innovative solutions to problems commonly experienced by nurses when delivering their patient care. "Nurses intuitively know ways to use technology to advance communication with patients, fill gaps in care and make our work more efficient." Using simulation in assist in teaching and learning new skills is a technological advancement that is growing in use. Simulation labs allow for interdisciplinary encounters “so we can build team practice competencies" and remediate the siloed educational experience.

Hanrahan teaches an innovation and health technology course that brings together nurses and computer scientists, engineers and more. The nurse defines the problem and a group of technology experts, technology experts and other key content experts develop a solution.

One project is an app, called Next, designed to enhance the decision-making of women around their perinatal period. The tool helps women and their providers make decisions about contraception after birth and increase continuity of care. “It’s a powerful tool. Nurses are getting involved in developing these kinds of solutions more and more.” Hanrahan finds it exciting to be part of the process that brings together diverse groups of students, researchers and developers. “Where would they meet otherwise? Bringing them together is what is so powerful. Together we create better ways to deliver care to our patients.”

Nurses have always had the advantage of being a face-to-face provider, so “we know where the glitches are,” says Hanrahan. But, the profession needs to learn more about how to design solutions. “Designing a solution is another skillset.” The ability to collaborate with students in many other disciplines provides a language around design of solutions which can only improve the possibilities of better healthcare and better processes of care and communication.”

Another Penn faculty member, Kathryn H. Bowles, PhD, RN, the van Ameringen Chair in Nursing Excellence, is doing research on how to identify patients at the highest risk of readmission and who will have the most needs following a hospitalization. Bowles, says Hanrahan, paired with a group of students from Penn’s Wharton School of Business to develop technology that can be built into hospital information systems.

The team also is working on ways to alert home health services about an upcoming discharge so they can begin the process and make sure patients are seen at home as soon as possible. “Think how practical it is to plan that a nurse arrive at the patient’s home the day they return from the hospital.”
Role in patient safety

Nurses can play a critical role as the healthcare system deals with the impact health IT has on patient safety. “When you put in IT, it can mitigate errors but also can increase errors because technology is different from the old manual system,” says Joyce Sensmeier, MS, RN-BC, CPHIMS, vice president of informatics for HIMSS.

“Systems can act in ways you don’t anticipate.” To manage that risk, a nurse or nurse informaticist should be involved in the configuration, evaluation and testing of electronic tools, she says. And with more sophisticated tools such as clinical decision support, “nurses need to make sure systems are basing decisions on sound evidence.”A nursing background and focus on research and evidence makes nurses “much more able to anticipate potential risks.”

Sensmeier sees technology and innovation becoming interwoven with nurses involved in mobile and care coordination across multiple episodes of care. “Wherever the patient is you’ll find the nurse as a champion.” The nursing informaticist role has matured as a specialty since its inception in the 1990s so they are “ready to be part of innovative changes. They are involved in pilots and leadership roles and having those conversations. It’s great to see the advancement of the specialty.”

Much more to come

Hanrahan has conducted research on how gaming affects people with mental health problems. The primary intervention has always been medication but “that’s a mixed bag because the medication also causes people a lot of problems.” Antipsychotic drugs can cause diabetes and metabolic syndrome. So, she has studied whether gaming methodology can help those with mental illness learn better coping and living skills. And, can gaming slow the aging process and associated conditions such as dementia? Do games cause people to be more violent? She is working with a doctoral student to better understand how humans respond to games. “That’s an example of how nursing is branching out to use technology as a way to dig in deeper to solve health problems.”

Going forward, Hanrahan sees nurses involved in developing “at the fore of how we can use technology to better communicate with patients in the between their contact with us. That’s really where nurses are moving but it’s still a pretty brand new avenue and venue for nurses to take on.”

“Continuity of care is an area of high interest for nurses,” she adds. Opportunities for nurses to contribute to improved communication, improved process for care delivery and education are emerging. “These solutions use technology that we’ve not had before. The more nurses are involved, the more we’ll see advancements in the usefulness of technology. The power of technology is really coming to the fore.”

Nurse informaticist field doubles

According to the 2014 Nursing Workforce Survey, the nursing informatics field has doubled since 2011, with 70 percent of respondents noting that informatics makes up a significant part of their employment.

“This year’s survey showed a marked growth across the field of nursing informatics, as well as a deeper understanding and recognition of informatics as a nursing specialty,” says Joyce Sensmeier, MS, RN-BC, CPHIMS, vice president of informatics for HIMSS.

Some 43 percent of more than 1,000 nurses responding to the poll have a master’s or doctorate in nursing, while 20 percent have some bedside clinical experience to round out their academic achievements. “In the beginning of nurse informaticist as a profession or specialty, nurses were pulled off units and asked to help with implementation. We just got information and education wherever and whenever we could.” Today, nurses are taking advantage of educational programs and building on their past training to become more IT and informatics focused. “The typical nurse informaticist is more likely to have a graduate degree, probably with an informatics component. That’s a big change in the last decade.”

“System optimization/utilization was a new option in the 2014 survey and selected by 39 percent of respondents, suggesting that we may be moving beyond simply implementing systems and towards leveraging their value,” Sensmeier says.

In the past, nursing informaticists have been focused on implementation, selection, evaluation, design and configuration of EHR systems. “Now that EHR systems are installed, we’re looking at how to optimize to get more benefit out.”

For example, we can see varying patient outcomes based on different nursing interventions, she says. “We can really look at systems that have been implemented and make them better and look at standardizing them. We’re getting more efficient in terms of workflow and systems are more usable so users have an easier time getting out data more efficiently.”

Nursing association voices IT concerns

There are major problems in patient care today that are largely unreported by the major media but have a huge impact on patient care--both quality of care and access to care, according to a new campaign from National Nurses United (NNU), a national association of 185,000 nurses that was established in 2009.

The organization is concerned about the proliferation of medical technology that “increasingly puts patients at risk in large part by ignoring their individual condition,” according to Charles Idelson, communications director.

NNU goes on to say that bedside computers that diagnose and dictate treatment for patients, based on generic population trends not the health status or care needs of that individual patient, increasingly supplant the professional assessment and judgment of experienced nurses and doctors exposing patients to misdiagnosis, mistreatment and life-threatening mistakes.

EHR systems often fail, leaving doctors and nurses in the dark without access to medical histories or medical orders, the organization claims. They also cite a report from the Office of the Inspector General for the Health and Human Services Department that found widespread flaws in the heavily promoted systems. Telemedicine and robotics marketed as improved care deprive patients of individualized care so essential to the therapeutic process central to healing, NNU says.

“I think we will see some changes over time when there is a critical volume of nurses engaged in this force,” says Nancy Hanrahan, PhD, RN, CS, of the University of Pennsylvania School of Nursing in Philadelphia. Nurses can operate with a design solution model of thinking and collaborate to accomplish better healthcare systems.

“I’m not really all that interested in the conversation about technology hurting nurses. What I’ve seen is just blowing my mind.”