One patient, one record Professor Dame June Clark Professor of Community Nursing University of Wales...

One patient, one record

Professor Dame June Clark

Professor of Community Nursing

University of Wales Swansea

Informing Healthcare Informing Nursing

Tuesday 16th November 2004

Aim: To identify…...

Implications of Informing Healthcare for nurses

Implications of the Single Electronic Health Record for nurses

What nurses have to do Next steps

Implications of Informing Healthcare for nurses

Informing Healthcare is not just about the ICT elements of

Improving Health in Wales. It has a fundamental role in facilitating the

whole range of structural and process changes that are required to deliver a modern NHS in Wales

IHC para 3.23

Informing Healthcare is a strategy to support change. It is not a technology strategy. Simply

purchasing new ICT facilities will not solve our problems. We need to

integrate new technology with a strategy that addresses new ways of working, the requirement for new skills and behaviours for staff and patients and clarify about how new

information will be used

The implementation of Informing Healthcare will involve significant changes for the workforce, both in

developing new skills and in finding new ways of working. The exploitation of high quality

information is likely to become more central to clinical culture and

to consultations with patientsChapter 7: Summary

The modernisation of information systems is necessary, but it will not bring benefits unless it is properly integrated with changes to current working practices across the whole health economy, which must be led by health professionals themselves

IHC para 9.2

The most commonly cited cause of technology related project failure is failure to prepare the ground in an organisation before implementing

the change process and introducing new technology

IHC para 5.30

Implications for nurses: Core messages

The status quo is not an option, but nurses must own the change and believe in what they are doing

IHC involves radical changes in our ways of working, and in some of our traditional ideas about nursing

Technology is not the whole story: a computer is just a sophisticated pen -you still have to decide what to write

Changes to traditional ideas about nursing

2 ways of looking at nursing: nursing as “doing” nursing as “deciding, then doing”

core of professional practice is clinical decision making

“No man’s decision is better than his information” (Paul Getty)

So nurses have to be able to….. Get information Appraise it Use it in their practice (evidence based practice) Transmit it to others (documentation)

This changes our whole approach to documentation

Update use of the nursing process

From Assessment Planning Implementation Evaluation

To Assessment Diagnosis Outcome

identification Planning Implementation Evaluation

In short a new approach to record keeping is needed in Wales because

the current system is simply no longer appropriate to support

current and developing models of healthcare and inconsistent with a commitment to high quality and

responsive patient care.IHC para 6.5

Implications for nurses of the Single Electronic Health Record

Single Integrated Electronic Health Record

A structured set of information about an individual’s health and care status and encounters across all healthcare sectors and settings

Accessible from a wide variety of locations Organised to support continuing efficient quality care across

the complete patient journey Protected by secure access to ensure that access is on a “need”

basis Added to by both health professionals and patients themselves A replacement for existing paper records, including use as a

medico-legal document

The electronic patient record

“Health professionals will need to reach agreement on the structure, terminology, communications and access standards necessary”

Better Information Better Health para 44

Implications for nursing The status quo is not an option Requires radically changed approach to

nursing documentation Opportunity to make make nursing

visible: to demonstrate the difference that nurses make

Accelerates what we should have been doing anyway

How electronic records differ from paper records

Only put in what someone wants out clinical care aggregated data

No more long narratives Collect once, use many times for multiple

purposes You can’t computerise chaos

Requirements for electronic patient records

Agreed data set Architecture that enables concepts to be

located and linked Standardised terminologies that include

concepts used by patients, doctors, nurses, other health professionals, drugs, equipment, etc

Supports data entry, retrieval and analysis of data

Dispelling some myths

Standardising nursing documentation is not standardising nursing practice

Standardised terminology is not new - we do it already

We already use different language for different purposes

Standardised terminology

“There are thousands of LEGO elements and knowing their proper names helps you to organise and use them more efficiently. When you create a naming system for something to help you stay organised, you are creating a nomenclature. Learn the LEGO nomenclature and build on!”

We use different languages for different purposes

Informal Formal

Clinical Clinical Local National Planning

care record audit statistics

(Adapted from Hoy 1995)

Standardisation is necessary to:

Communicate with other people (Humpty Dumpty)

Aggregate data Compare like with like Save time

Structure is necessary to: Ensure all the elements are there (all

disciplines): what’s wrong (diagnosis) what to do about it (intervention) did it work (outcome)

Link the elements

Know where to look to get them out

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Intervention

Problem/Diagnosis Outcome

The Interaction of Diagnoses, Interventions and Outcomes

So, what do we have to do?

Recognise that nursing is decision making, and therefore the significance of nursing documentation

Update the use of the nursing process to include nursing diagnosis

Get information management (IM) skills Get basic IT skills

Next steps

Review existing (paper) documentation Learn to use the the language

(SNOMED-CT) Get access to computers Get basic IT skills

Help is at hand

Informing Healthcare (Stakeholder engagement programme)

ECDL All-Wales e-health group for nurses

Which kind are you?

Those who make things happen Those who watch things happening Those who wake up too late and wonder

what has happened