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)

Contact person: Bonnie Collins (bonnie.collins@va.gov)

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