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
25
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