Nursing and EHRs: The ‘Value Is There’

Involving nurses in EHR implementation is a must, says Theresa Jasset, MSM, RN, program director for perioperative nursing informatics at Brigham & Women’s Hospital in Boston. “Nurses understand workflow better than anyone. It’s their work you’re trying to document and chart.”

Nurses also interact with so many other disciplines, from surgery and case management to nutrition and physical therapy, that they understand all other workflows. “Other users only touch on a small portion of the overall system, but nursing touches on all of it,” she says.

Incorporating nurses within EHR implementation teams is improving, Jasset says. “As systems become more advanced, you need the end user there. The value is there.”

The gold standard

Jasset has used the super user model incorporating nurses in IT implementation. That works well, she says, because nurses are natural teachers and coaches. And, because healthcare is so time-sensitive, there isn’t time to slow down a schedule. “There is very little margin to slow down patient flow.” Jasset has pulled nurses off of patient care and given them advanced training so they are comfortable and can troubleshoot the system. It’s expensive because the nurses are being paid to work on the IT system, not provide patient care, but to Jasset, the model is “the gold standard.” The short-term pain, she says, is worth the long-term gain.

Jasset recalls turning on a new system in 43 operating rooms one Wednesday morning. There was almost one super user for each nurse. “It was a little chaotic for the first 24 hours,” she says but by Friday, the super users were bored. By the fifth day, they had a five to one nurse to super user ratio.

Nurses also serve as a valuable go-between, “reporting little glitches we didn’t see,” Jasset reports about one IT implementation. But their expertise is valuable early in the build process as well. “They can tell you what’s practical.” As projects move forward, they get involved in heavy duty testing.

Take two

Robert Wood Johnson University Hospital, in New Brunswick, N.J., survived a failed EMR implementation effort before it experienced a successful one, according to Nicole Martinez, BSN, RN, director of nursing informatics, who shared her experience during the Healthcare Information Management and Systems Society annual meeting.

The hospital’s leadership was evenly divided about the EMR implementation. “There was no middle ground,” says Martinez. “That created a problem when we were trying to create workgroups.” There also was a lack of support from all levels of nursing leadership. “They spent no time or resources educating middle management” who really run the hospital, she says. The ICU nurses had no information until the day of go live. The ICU nurses happen to be the group with the most nursing experience, but the least exposure to technology, Martinez says.

Nurse educators from the ICUs were the primary stakeholders at all design sessions—not doctors and nurses. The educators were excited about the new tool but “they’re not the ones at the bedside.” Testing was done by med/surg nurses already familiar with the system. Those nurses also tested ICU flow sheets, which they said went well, but not being ICU nurses, “they didn’t know what they were clicking on.”

The effort failed. The hospital then experienced a change in 75 percent of its leadership over three years. The new leadership put strong effort into explaining to staff the importance of the initiative by sharing their vision of the future, Martinez says.

To ensure success the second time around, the hospital established structural empowerment through the formation of a Sunrise Clinical Manager (SCM) End User Council. This group was different, she says, because it included representatives from every nursing unit with a subcommittee for ICU.

The executive power to approve all decisions related to the EMR was delegated to the bedside nurse through this forum.

Physicians abdicate

Meanwhile, physician leadership formally abdicated executive power decisions to the SCM end user group. “The physicians supported the nursing staff so much they said ‘whatever works for you is more important than what works for me.’ They realized that if the ICU nurses can’t practice, document and look at information in a way that supports their practice, it’s only going to hurt [the physicians].” That thinking created a very different environment in the ICU, she says. “For physicians to truly collaborate with nursing, the nurses now cared about the physician struggle. It’s a two-way street.”

The organization developed a mission statement and everyone agreed to share everything. The nurses refuse to miss meetings, Martinez says. “They are totally invested.” Hospital leadership gave them one rule: We will build it exactly as you want it with one caveat; you must use the existing EMR, but we will create whatever you want within that structure. We can’t buy a different system.”

Staff also accepted the responsibility to take “homework” back from meetings to their peers, obtain feedback and report back to the team.

The hospital fostered structural empowerment through communications including an end-user webpage on the hospital intranet. The meeting minutes are sorted by date including images of handouts and other information so they can see exactly what was shared. There also is an internet mailbox communication system anyone can post to and nursing leadership must address within 72 hours.

Staff collaborated with their physician colleagues to identify the best practices for their documentation. Key physician stakeholders were identified as champions. They reviewed the nurses’ decisions and suggested revisions; however, the final decision was with the nurses.

Staff stakeholders identified processes and workflows to enhance their practice. These include automated clinical decision support mechanisms and enhanced workflows for vaccines, medication reconciliation and timely documentation. “From a physician perspective, that has greatly improved the accuracy of information when they’re trying to look for it,” Martinez says.

Meanwhile, over the last five years participation in the hospital’s nursing satisfaction survey improved by more than 40 percent and job satisfaction scores improved 17 percent. Compliance for medication reconciliation has been above 90 percent for the four years since the electronic medication reconciliation has been in place. Also, “we have not had a peripheral IV infiltration in three years and our pressure ulcer rate decreased by 66 percent. We’ve been able to maintain and make big changes in nursing practices based on how we utilize the EMR.”

The numbers are impressive and further support the integral role nurses play in workflow and EMR implementation, evolution and innovation.

Expanding informatics education

The TIGER Initiative [Technology Informatics Guiding Education Reform] was formed in 2004 to bring together nursing stakeholders to develop a shared vision, strategies and specific actions for improving nursing practice, education, and the delivery of patient care through the use of health IT. In 2006, the TIGER Initiative convened a summit of nursing stakeholders to develop, publish and commit to carrying out the action steps defined within this plan.

“Evidence and Informatics Transforming Nursing: 3-Year Action Steps toward a 10-Year Vision” raised awareness and launched a movement to increasing nurses’ informatics skills. While younger nurses have grown up with social media and online banking and so they pick up EHRs more quickly, IT “is harder for older nurses who grew up in the paper world,” says Theresa Jasset, MSM, RN, program director for perioperative nursing informatics at Brigham & Women’s Hospital in Boston.

But, once nurses learn basic IT skills, “it becomes second nature.” The TIGER initiative is aimed at getting health IT into curricula earlier. “We’ve come a long way in the last decade—out of need and necessity.” Whether nurse, doctor or physical therapist, the end user must be at the table. “Who better to build a physical therapy model than physical therapists?” Jasset says.

Learning from each other is an important element of informatics education, she adds. “Lessons learned are so valuable.” When people understand both the limits of the system as well as the potential, and they are installed right, “you really build nice clinical decision support tools, increase efficiency and have reliable data easily accessible and shared.”