TNA/TONE Health IT
Committee
Mary Beth Mitchell, MSN, RN, BC, CPHIMS
Donna Montgomery, RN-BC, BSN, MBA
© Texas Nurses Association, 2013
Acknowledgement: Contribution by TNA/TONE HIT Committee members TNA = Texas Nurses Association
TONE = Texas Organization of Nurse Executives
For 300,000
Texas Nurses
Optimizing Communication with IT:
Creating the Environment
Conducive to True Progress]
TNA/TONE Health IT Committee
Original Task Force Charge* was to:
• Determine implications of health care informatics for nursing practice and education in Texas
• Include nationally-based Technology Informatics Guiding Education Reform (TIGER) initiative
TIGER Vision: To enable nurses and inter-professional colleagues
to use informatics and emerging technologies to make healthcare
safer, more effective, efficient, patient-centered, timely and equitable
by interweaving evidence and technology seamlessly into practice,
education and research fostering a learning healthcare system.
2
* Based on: TNA (2010). Resolution on Technology Informatics. Texas Nursing, 84(2), 7. Adopted by TNA
House of Delegates on April 24, 2010.
Why Does HIT Matter
Deep in the Heart of
Texas?
Advisory Committee: Practice, Administration, Education and Vendors/Suppliers
Nursing HIT Curriculum Development
CNE for Practicing Nurses
Awareness Campaign Educational Content Dissemination
Environmental Forces:
• Health Care Reform/ARRA
• Advanced Practice Nurse Roles
• EHR Incentives
• IOM/RWJF Report Advancing Health Care
• Informatics Nurse Standards by ANA
Benchmark
Reports
on
Progress
Nursing Leaders
H
IT O
rgs.
T.I.G.E.R
Phase III
Partnership
For 300,000
Texas Nurses
Introduction
HIT Committee Membership
Task Force Members
– Nancy Crider*
– Mary Anne Hanley
– Susan McBride
– Molly McNamara
– Mary Beth Mitchell
– Elizabeth Sjoberg
– Mari Tietze*
Texas Nurses Assoc.
– Ellarene Sanders**
– Joyce Cunningham
– Laura Lerma
Composed of TNA and TONE Members from
practice and academia
Introduction
* = Co-chairs 4
**= Interim Executive Director, TNA
State-wide Priorities for 2013
CNE Programs
3 Advanced
Webinars
1 Face-to-Face
Survey of
Nurses’
Experience
Using their
EHRs*
Packaged Nurse
Informatics
Content
with Support of
Faculty for
Deployment
TIGER III Initiative Content/Collaboration
* Smith et al. (2011). Developing and testing a clinical information system evaluation tool: Prioritizing modifications
through end-user input. Journal of Nursing Administration, 41(6), 252 – 258.
Introduction
Communication/Networking Sub-committee
5
Presentation Objectives
• Discuss strategies for communicating the needs
of the clinician to IT development teams.
• Explain common barriers to good communication
between Nursing and IT
• Explore ways to measure and evaluate the
success of a project through ongoing
communication
6
“Wake Up Call” • Clinician dissatisfaction with EHR documentation
system
• Heuristic Evaluation completed by Harrington, et al., revealed over 300 violations.
• Findings revealed usability issues
• Some were vendor driven
• Other from design and build of the system by the EHR team.
• Increasing amounts of change requests from end user community.
Harrington, L., Porch, L, Acosta, K., Wilkens, K. (2011). Realizing electronic medical
record benefits: An easy to do usability study. Journal of Nursing Administration, 41(7-8),331-335
Sept 2011 EHR User Experience Survey (26 survey items; 6 facilities, 586 nurses)
Source of
Issue
N/A – An
outcome
Policy / design
Infrastructure
Workstation
deployment
Application/
hardware
Survey Item
EHR User Experience Survey
24% of users have a negative overall assessment of the EHR’s impact on their work
EHR Satisfaction Survey of Nursing and
Pharmacist
• Findings of the survey were concerning related to potential unmet needs of nurses
• Review of survey findings by BHCS HIT Subcommittee of Patient Safety Cmte.
• Early finding of assessment indicate significant opportunities for improvement
• The work of nurses is foundational to pt. outcomes, Aiken (2002)
• Focus on finding additional methods and approaches to understand the problems in the EHR that are not satisfying
– Staggers, N. (2012)
– Campbell, E. (2006)
– Zhang, J. (2003)
• Tactics employed;
– Nursing & Pt. Care Informatician roles
– Ethnography and Observations
– Task Analysis
– Data collection and evaluation of improvement
EHR Clinical Documentation Time (excluding medication administration)
* FS = Flowsheet * SN = Structured Note
Shift Assessment took 41-55 min to finish
Multiple elements to common documents (e.g. “education”) add up to significant documentation burden
Streamlining documentation can have a significant impact (e.g. reducing hourly rounding documentation)
Act 3 site (Plano) did not improve over other sites
Use of structured notes
for shift assessment improves efficiency • 17min faster at Garland • 9min faster at Plano • 9min faster at Grapevine
Estimated time (minutes), per 12 hr shift Per occurrence time based on direct observations Assume 5:1 patient to RN ratio
0 10 20 30 40 50 60
IV
GI
GU
Wound/Skin
Pain
Education - Goals/Outcomes
Education - Outcome Record
Plan of Care
Hourly Rounding
Shift Assessment (SN)*
Shift Assessment (FS)*
Minutes
Garland
Plano
Grapevine
* KBMA at Garland combines EHR use for medication administration and documentation * CPP = Comprehensive Patient Profile -Time was for EHR interaction, excluding med administration time (e.g. crushing meds)
Estimated time (minutes), per 12 hr shift Per occurrence time based on direct observations Assume 5:1 patient to RN ratio
KBMA shifted but did NOT reduce overall eMAR time (review and documentation in EHR)
Multiple pt admissions easily put nurses behind in documentation
System freezes (17-39 seconds) observed multiple times each shift
0 10 20 30 40 50 60
Admission CPP*
KBMA (A&D)*
Documentation
Administration*
Verify
Review
Minutes
EHR Use in Medication Administration and Patient Admission
Garland
Plano
Grapevine
0 5 10 15 20 25 30
Login
System Freezing*
Reboot*
Look for Computer*
Minutes
Infrastructure Issues
Garland
Plano
Grapevine
Informatics Framework
Nursing & Pt. Care Informatics Framework-Inputs
Professional
Practice
Principles
Policy, Practice
Guidelines (AACN,
ANA, NACOG, etc.
Clinical Leader
consultation
Quality
Indicators
NDNQI, NQF, AHRQ,
TJC, ISMP, CMS-
numerator/
Denominator-
exclusion/inclusion
Innovation
Other entities examples,
other Allscripts entities
examples, new
functionality,
S2V, development of
prototype
Evidence
Literature
review, Best
Practices and
the expected
clinical
outcomes
Current State
Process
Mid-level
workflow
diagrams
Wisdom of the
User
Principles of
usability, HF,
analysis of themes/
patterns, current
forms or electronic
processes,
Baytracker
Informatics Framework
Nursing & Pt. Care Informatics Framework Workflow
Obj. 1: Clinicians to IT
Communicate in the Hospital
• Barriers to Communication
– Sensitive information- maximum need for privacy and security of information
– Shared environment
– Increased noise levels
– Open access- people coming and going
• Landscape
– Access to information anywhere, anytime
– Increased use of tablets and smartphones
– Better Informed public
• Access to information through apps
• Patient Portals
• Need to communicate
– Between Caregivers
– To Patients
– Families and others
Where we are Headed
• Mobile devices- tablets and smartphones
• Greater use of apps on personal devices
by staff
• Use of portals by patients
– Access to their PHI
– Education
• Increased focus on personal privacy
and security
• Non-traditional communication
– Wireless devices
– Secure messaging
– Social Media
Communication Strategies
Internal Staff to Staff
• Tablets/Smartphones for Nursing
• Secure Messaging
• Wireless Communication
• Social Media
Communications with Patients and Families
• Peek-A-Boo NICU
• Tablets to Patients at
Discharge
• Patient Portal Inpatient
• Integrated Patient Education
Challenges
• Perception that staff are “playing”
• Keeping up with greater expectations and knowledge from patients
and families
• Existing paradigms around texting and messaging
• Need to maintain privacy and security
• Costs and resources
Opportunities
• Enhanced ability to meet patients and families needs.
• Better patient outcomes, increased patient
responsibility for health management
• Faster and more relevant
communication
Communication of IT Needs to Nursing
• What does nursing need to know about IT
• Approximately 80% IT resources in most organizations are committed to maintaining current functionality!
• IT works off project plans, tasks lists, and allocation of resources- usually driven by “tickets”
• Clinicians work from triaging, prioritizing, and managing many things simultaneously
• IT works on one project at a time, and count the hours spent against projected hours for the project.
• Clinicians do not complete a task before moving to the next task
• IT heavily focused on governance to help manage allocation of resources
• IT needs a lot of granularity and detail in explanation to plan and execute.
• Everyone wants to do the right thing for our patients and have good products that produce great outcomes.
How Can Nursing Support IT Communication
• Understanding of their approach- they care about the outcomes as much as nursing, but they have a different perspective.
• They do not always understand how things impact the patient care experience- but they want to.
• Explain things in detail, organize thoughts and plan what is needed for them- get detailed
• Realize they are supporting many projects, and may not know what the priorities are.
• They are basically very proud to be involved in healthcare and feel that supporting nurses is their gift to us- support that!!!
• Some other tactics- have them shadow with a clinician; you shadow with them. Invite them to meetings- go to their meetings.
Networking between Organizations
• Benchmarking with other health systems
– DFW Area
– National
– NI & Clinical Informatics Organizations
• Sharing Successes
– Structures, roles, decision-making & communications
• Lessons Learned
– Communicating & Publishing
– Developing research studies
• Develop Bench Strength
Communication in the Community
• Networking key within and between organizations, nurses,
informaticists, and other disciplines.
• Learn what’s going on in your community
• Share best-practices
• Seek solutions to problems
• Key venues for Communication
– Professional Organizations- HIMSS, ANIA, AONE, etc.
– Most organizations have social media sties, and other ways to
communicate between members.
• Find a couple of others in your community and get started.
Networking in the DFW Area and Beyond
1. LinkedIn site – search on “groups” for DFW Nursing Informatics Community, and join
2. eList for communication of events and information/questions
3. Plan of events – frequent educational/networking sessions
4. TNA pilot blog/email – TNA sponsored blog/twitter/email in development
5. Contact for more information
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References
Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., Silber, J. H. (2002). Hospital
Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction. JAMA,
288(16):1997-1993
Campbell, E., Sitting, D., Ash, J., Guappone, K., & Dykstra, R. (2006). Types of
unintended consequences related to computerized provider order entry. J Am Med
Inform Assoc 13(5),547-556
Harrington, L., Porch, L, Acosta, K., Wilkens, K. (2011). Realizing electronic medical
record benefits: An easy to do usability study. Journal of Nursing Administration, 41(7-8),331-335
HIMSS. Promoting Usability in Health Organizations: Initial Steps and Progress Toward
a Healthcare Usability Maturity Model HIMSS Usability Task Force, HIMSS, 2011.
Montgomery, D., Gugerty, B. (2011). Nursing and Pt. Care Informatics Framework in development
and testing at Baylor Health Care System. Unpublished data.
Stagger, N. (2012). Improving the User Experience for EHRs: How to Begin? Crucial Conversations
about Optimal Design Column. Online Journal of Nursing Informatics, 16, 2 ,1678.
Contacts HIT
Task Force Mari Tietze, PhD, RN-BC, FHIMSS
Texas Woman’s University
College of Nursing
Nancy Crider, DrPH, RN, NEA-BC
University of Texas
School of Public Health
Co-chairs
Imagination is more important than knowledge
-- Albert Einstein