BONUS CONTENT FROM LPN2009

Deep impact: Informatics and nursing
By Joyce Sensmeier, RN,BC, MS, CPHIMS, FHIMSS

It’s exciting to realize that many hospitals and health systems are currently purchasing and implementing information systems that can positively impact patient care delivery. Currently, 56% of U.S. hospitals have some level of electronic medical record application installed to support care delivery.¹ However, it’s essential that nurses guide these projects to ensure that their work is supported, not compromised.

Healthcare has been slow to take advantage of the benefits that computerization can bring, and most hospitals still do much of their record keeping on paper. The technology awakening creates an opportunity for nurse informaticists to take the lead in bridging the gap between information technology (IT) and patient care to move healthcare into the digital age.

Where we’re at
Nursing informatics was recently ranked by Yahoo Education as one of the 10 Great Careers You’ve Probably Never Heard Of.² The American Nurses Association identified nursing informatics as a specialty in 2001. And U.S. News & World Report recently listed health informatics specialists as number one in ahead-of-the-curve careers.³ While more than 8,000 nurses are practicing as nurse informaticists, many more are needed to achieve widespread adoption of the electronic health record (EHR).

A recent study found that the health IT industry needs at least 40,000 additional professionals to move toward a paperless system.⁴ To reach this goal, much work is needed to educate both nurses and faculty in informatics competencies so that technology can be embraced as a tool in everyday practice. The TIGER (Technology Informatics Guiding Education Reform) Initiative is making strides to promote this education. TIGER started out as a grassroots effort to engage all stakeholders in a common vision of ideal EHR-enabled nursing practice, and today more than 120 diverse organizations have joined the effort. Hundreds of nurses have volunteered their expertise to work on the nine collaborative TIGER teams, each focused on a key topic and led by industry experts. The goal of the collaborative teams is to share their findings and recommendations with all practicing nurses and nursing students through targeted outreach activities with summary reports to be published this fall.⁵

There are many opportunities to take advantage of technology to improve the efficiency of nursing care. Nurses from 36 medical-surgical units recently participated in a time and motion study to assess how nurses spend their time. Study results showed that changes in technology, work processes, and unit organization and design were areas of potential improvement in the use of nurses' time and the safe delivery of patient care.⁶ Proposed improvements included creating closed-loop medication administration systems, wireless networks, handheld and ear devices for the delivery of patient information, and systems that track the physical location of a medical provider. These ideas bring forward a vision of nurses and other caregivers working in an environment seamlessly supported by technology that’s pervasive rather than invasive. Involving nurses in this transformation is critical to its success.

Challenges to overcome
The opportunities may be plentiful, but challenges still exist. Only 39% of the chief information officers (CIOs) responding to the 19th Annual Healthcare Information and Management Systems Society Leadership Survey identified clinical application support as an IT staffing need.⁷ Another 20% specified the need for clinical informaticists, and only one-quarter of the CIOs identified process/workflow design as an area for staffing support. Although clinical information systems were identified as one of the most important applications for the next 2 years, financial support for IT continues to be a barrier according to 26% of respondents.

Can patient care be improved with IT? Over three-quarters of respondents to a recent Vantage Point survey on IT and clinical workflow indicated that quality of care would benefit as a result of the presence of IT that assists clinicians in carrying out their day-to-day job.⁸ Eighty percent of respondents noted that nurses at their organization are involved in how technology should be integrated into the nursing workflow. However, nearly 40% of the respondents indicated that the technology that’s currently available doesn't fit into workflow.⁸ A survey published in The New England Journal of Medicine found that physicians who use the EHR say overwhelmingly that such records have helped improve the quality and timeliness of care. But fewer than one in five of the nation’s physicians has started using such records.⁹ Of the more than 2,600 physicians who participated in the survey, 82% of those using EHR said the technology improved the quality of clinical decisions, and 86% said it helped in avoiding medication errors.¹⁰

Where we’re headed
So how can informatics positively impact nursing practice? The ultimate goal is to use technology to bring critical information to the point of care to increase efficiency and make healthcare safer and more effective.¹¹ This goal requires implementation of an interconnected EHR system across hospitals, healthcare systems, and regions. The need for interoperability exists across all settings of care, including ambulatory care, and ultimately reaching into the home.

Nurses are working as leaders in several national initiatives to lay the groundwork for this nationwide health information network using standardization and technical specifications. The Healthcare Information Technology Standards Panel is selecting standards and developing interoperability specifications based on priority use cases and promoting the adoption of these standards.¹² The Certification Commission for Healthcare Information Technology is developing criteria for interoperability and certifying EHR systems.¹³ More specifically, IT solutions such as bar-code systems for medication management are being used by healthcare providers to reduce the risk of error. Results of a study published in the journal Pediatrics showed that medical errors harm one out of 15 children who are hospitalized. Aggressive measures, including technology-based solutions such as closed-loop medication administration, are needed to combat this shocking statistic.¹⁴

The National League for Nursing (NLN) recently published a position statement calling on faculty, deans, and administrators to require that all nursing students graduate with knowledge and skills in each of three critical areas: computer literacy, information literacy, and informatics. One impetus for this statement was a 2006 NLN survey, which revealed that only 60% of nursing programs had a computer literacy requirement and 40% had an information literacy requirement. Less than 60% of survey respondents said that informatics was integrated into the curriculum and experience with information systems was provided during clinical experiences.¹⁵

Given the shortage of trained, experienced informatics nurses and the limited number of schools that include informatics competencies in their curriculum, how can we better embrace technology to improve nursing practice?

• Seek nursing input. Nurses should be involved in every IT decision that impacts their workflow. IT champions should be recruited from nursing staff members to act as a resource and model for colleagues during system implementations. Organizations should engage nurse informaticists to be leaders for the design, selection, and implementation of information systems that impact patient care.
• Invest in training. Nurses need consistent training to feel comfortable with the use of IT in their everyday practice. Onsite trainers are needed who can be an available resource to reassure nurses that patient care won't be compromised by the intrusion of a new system. Chief nursing officers should pursue continuing education in informatics competencies and partner with their nurse informaticist colleagues to lead IT-based projects. Nurse educators should embrace informatics competencies and ensure that they're incorporated into curricula.
• Promote IT excellence. Look to other organizations that have achieved improved outcomes through the use of technology. Learn from nurses at organizations that have achieved awards of excellence like the Davies Award to better understand how they successfully moved from paper-based systems to electronic processes.¹⁶ Keep in mind that IT should enable quality improvement by capturing data as a byproduct of the care process, and leverage every opportunity to do so.
• Build toward an EHR. Consider selecting systems in a staged approach so that you can build the foundation for a fully paperless EHR.¹⁷ Start with the basics, including ancillary systems such as laboratory, radiology, and pharmacy. Build a clinical data repository that can collect data from such systems and subsequently provide it at the point of care. Add clinical documentation and clinical decision support to elicit information from data that can further enhance nursing knowledge. After these foundational systems are in place, add computer-based order entry and closed-loop medication administration to better address quality and safety issues. By using a staged approach you'll be well positioned for success to achieve IT-enabled clinical transformation.

References
1. Garets D, Davis M. Electronic medical records vs. electronic health records: Yes, there is a difference. HIMSS Analytics White Paper. Available at: http://www.himssanalytics.org/docs/WP_EMR_EHR.pdf.
2. Santina J. 10 great careers you've probably never heard of. Yahoo Education. Available at: http://education.yahoo.net/degrees/articles/featured_10_great_careers_you_never_heard.html.
3. Nemko M. Ahead of the curve: Health informatics specialist. U.S. News & World Report. December 19, 2007. Available at: http://www.usnews.com/articles/business/best-careers/2007/12/19/ahead-of-the-curve-health-informatics-specialist.html.
4. iHealthBeat. Hazy definitions for health informatics field compound issues in work force development. Available at: http://www.ihealthbeat.org/Special-Reports.aspx?start=31.
5. The TIGER Initiative. TIGER Initiative: An update. Available at: https://www.tigersummit.com.
6. Hendrich A, Chow M, Skierczynski BA, Lu Z. A 36-hospital time and motion study: How do medical-surgical nurses spend their time? The Permanente Journal. 2008;12(3):25–34.
7. Healthcare Information and Management Systems Society. 19th Annual 2008 HIMSS Leadership Survey. Available at: http://www.himss.org/2008Survey/DOCS/19thAnnualLeadershipSurveyFINAL.pdf.
8. Healthcare Information and Management Systems Society. HIMSS Vantage Point. IT & clinical workflow. Available at: http://www.himss.org/content/files/vantagepoint/pdf/VantagePoint_200802.pdf.
9. Lohr S. Most doctors aren't using electronic health records. The New York Times. June 19, 2008 Available at: http://www.nytimes.com/2008/06/19/technology/19patient.html.
10. Blumenthal D, DesRoches C, Donelan K, et al. Health information technology in the United States, 2008: Where we stand. Available at: http://www.rwjf.org/qualityequality/product.jsp?id=31831.
11. National Quality Forum. Wired for quality: The intersection of health IT and healthcare quality. Available at: http://www.qualityforum.org/news/Issuebriefsandnewsletters/ibhitMar08.pdf.
12. Healthcare Information Technology Standards Panel. Quality Interoperability Specification. Available at: http://www.hitsp.org .
13. Certification Commission for Healthcare Information Technology. New CCHIT Certified 08 Materials. Available at: http://www.cchit.org.
14. Monegain B. Medical errors threaten one in 15 hospitalized children. Healthcare IT News. April 7, 2008.
15. National League for Nursing. Position statement. Preparing the next generation of nurses to practice in a technology-rich environment: An informatics agenda. Available at: http://www.nln.org/aboutnln/PositionStatements/informatics_052808.pdf.
16. Healthcare Information and Management Systems Society. HIMSS Davies Awards program: What's new? Available at: http://www.himss.org/ASP/daviesAward.asp.
17. Information and Management Systems Society. HIMSS Analytics. EMR adoption model. Available at: http://www.himssanalytics.org/hc_providers/emr_adoption.asp.

Source: Men in Nursing. May 2009.