As we noted in Week 1, healthcare delivery is growing more complex, leading to more demands upon nurses. Consider the examples below.
- An increasingly global society, which introduces healthcare problems not previously common to the United States
- Advances in technology and drug therapies that enable us to keep sicker patients alive
- Increased demands to use EBP to improve care and patient outcomes
- Rapid turnover in knowledge
- Expanding roles
- Shorter patient stays
This complexity moves proficiency with technology and informatics skills from recommended to imperative in today’s healthcare delivery system. Technology extends our capabilities to care for patients and provides access to information and knowledge beyond our individual abilities to “know.”
Technology also creates new information and knowledge needs and changes the way that we work. It can be an enabler or an obstacle, depending upon one’s attitudes and skill sets. We will look at some of these tools and technologies here—namely, electronic health records (EHRs) and patient-care technologies—that are at our disposal now or promise to be available in the near future.
Electronic Health Records (EHRs)
EHR or EMR (electronic medical records) are used interchangeably as a generic term to refer to an electronic version of a record of a single treatment episode, or the information system in which it resides. The term has evolved to refer to a comprehensive, birth-to-death record of all health information and treatment encounters for an individual—something that has yet to be realized in a healthcare delivery system that still, in 2016, remains highly fragmented with separate records at hospitals, clinics, urgent-care centers, public-health offices, long-term care facilities, subacute care, and doctors’ offices.
The realization of a birth-to-death record promises many benefits, not the least of which is improved access to information, continuity, and quality of care. Both Presidents George W. Bush and Barack Obama called for the establishment of an EHR for every American as a means to improve care across the life continuum and to help transform healthcare delivery. The target date of 2014 for that goal will not be met, although progress has been made.
Electronic record systems are built around large databases that allow input, storage, and retrieval of specific data for use in a meaningful way that can support other functions, such as decision support, results reporting, and order entry. Clinical documentation and clinical messaging are other basic functions. Use and reuse of data relies upon the collection of structured data that follows a format that supports manipulation.
Historically, automation started with a limited number of functions, such as patient registration; then, it expanded to include clinical systems, which grew to share laboratory, pharmacy, and radiology information. Clinical documentation began with simple elements, such as vital signs and intake and output, before the incorporation of “nurses’ notes” and progress notes.
Order entry first automated a paper process in which physicians wrote orders on paper charts for transcription into the computer by clerks and nurses—a process subject to errors until it was replaced by computerized provider order entry, or CPOE, a system in which providers enter their own orders. Realizing the benefits associated with the EHR requires structure provided through standardized languages and health-information exchange (HIE). As we discussed in Week 3, standardized languages support clinical decision support, research, communication, and information sharing.
Have you ever wondered why a field on a computer screen only accepts certain characters or a limited number of characters? This is an example of screen design to force entry of structured data. Another example is providing predetermined choices rather than allowing users to enter free text. Can you see advantages or disadvantages with this approach? What might these be?
How Do EHRs Support the Information Needs of Nurses?
EHRs collect, store, and permit retrieval of clinical information in a legible format,often while supporting views customizable by each user. Additional support for direct-care providers can be seen with clinical alerts, decision support, and the integration of evidence-based guidelines for care. EHRs can also incorporate links to resource materials and databases that allow users to quickly and seamlessly view information about the patient’s condition without exiting the EHR (Cimino, Jing, & Del Fiol, 2012). The bulk of users rely upon clinical data needed for the direct provision and documentation of care, but what other information might EHRs provide?
The creation and use of structured fields support legal, accreditation, reimbursement demands, the collection of core criteria for Meaningful Use, and disease and procedure code information,some of which can be tied to specific patients, while other data such as that collected for Meaningful Use is stripped of patient identifiers. Some of you use reports generated from your clinical systems and EHRs, either on demand, monthly, or on an annual basis using various criteria such as MRSA status, payer status, or a number of other criteria. While these reports can be very useful, they are not always easy to obtain or available when timely decisionmaking is needed.
Healthcare delivery Reflection
Can you think of information that you would find useful in a report that is not currently available to you? Is it information collected by your electronic record system? If not, could you see a way that it might be collected and made available? What is this information, and how could it better support your work and the care that you provide? How might you determine if you could access this information?
The healthcare sector is just beginning to realize the potential value of the large pools of de-identified data at its disposal. This aggregate data, also known as secondary or big data, can be used to improve care, discover patterns, reduce costs, support research, and identify and respond to consumer preferences. The process of tapping this data is known by many names—analytics, data mining, knowledge discovery in data bases, or business intelligence. The end result is that the analysis provided can support better and timelier decision making, decrease risks, and discover valuable insights as long as appropriate tools are used. Harper (2013) suggested improved staffing models based upon patient information as one potential application for nurses.
Can you think of some other ways that secondary data can support nurses?
Good use of secondary data requires (Mantalvo, 2013)
- good data quality;
- leaders who recognize and are willing to support the use of secondary data;
- appropriate technical infrastructure;
- a culture that supports secondary data use and informed decision making; and
- value to the data.
Another requirement for good use of secondary data is that it be available in a manner that is meaningful to those who need it and in a timely fashion to support informed decisions. Enter dashboards. Dashboards are a decision-support tool that graphically represents data in a manner that is easily understood. Dashboards can be adopted for clinical displays as well as use in the executive suite.
More potentially valuable information exists in an unstructured format in narrative clinical documents. This resource may be available in the near future with the adoption of a technical information exchange standard (Harper, 2013).
Patient-Care Information Technology: Nursing Informatics
Technology and the informatics skills required to support patient care is growing exponentially, and it would seem that its applications are limited only by one’s imagination. Applications range from the relatively “low tech” to extremely complicated. Consider some of the following examples already in use that serve to save labor and supply information that supports care and documentation. Consider where informatics skills might be used in each instance:
- Monitoring technology. Digital monitors measure vital signs, heart rate and rhythm, and other parameters and can directly input those values into the patient’s electronic record. The addition of video and audio makes it possible to monitor patients at another location, whether that may be their home or at another facility.
- Positive patient identification. Several technologies support identification of the correct patient and retrieve the associated record for further action, whether that is a lab draw, medication administration, or patient registration for a treatment episode. These technologies include barcodes, radio frequency identification (RFID) chips on patient identification bands, and biometric scans that use a unique trait such as fingerprint, palm print, retinal scan, or facial recognition to confirm identity.
- RFID technology tracks physical location of patients, staff, or equipment, making it quick and easy to determine location.
- Barcode or RFID medication administration. These systems provide positive patient identification and assurance, and documentation of correct medication, route, dose, and time. Detailed information on staff usage and compliance with established policies is available.
- Smart technology. This is integrated technology that saves time and work, and improves patient outcomes. Examples include intravenous infusion pumps that exchange information with pharmacy systems and barcode or RFID medication administration systems allowing infusion programming information to be sent directly to the pump at the bedside when the nurse scans the medication, thereby eliminating programming errors. A growing number of facilities have smart rooms, which incorporate RFID recognition of employee badges, announcing their name and role to patients as they enter rooms.
- Voice recognition. Voice recognition allows staff to interface with the information system at the point of care and provides patients with hands-free access to the phone, Internet, bed controls, or television controls.
- Mobile healthcare. A growing number of individuals use their smartphones as well as their computers for healthcare information and to manage their health, reporting glucose levels, suicidal ideation, weights, and VS, to name a few applications. Social media provides a means to announce services, provide support, and even conduct research.
- Telehealth applications. Telehealth applications are increasingly popular as a means to manage chronic conditions, such as mental health issues and heart failure.
- Wearable monitors. While your first thought might be the Holter monitor used to collect detailed information on cardiac rhythms, there are many more options! Some technologies are embedded in clothing and work with cell-phone technology.
- Robots are used in pharmacies to dispense medications, in surgery to facilitate procedures, and within facilities to deliver supplies and medications, freeing staff to complete other tasks.
Can you think of some additional ways that secondary data collected from patient-care technologies might be used?
There are many other applications to support nurses in their work including, but not limited to,
- voice-recognition technology for nursing documentation;
- office productivity applications; and
- web-based systems for education.
Implications for the Master’s-Prepared Nurse Roles that Require Informatics Knowledge, Leadership, and Skills
As leaders in healthcare, master’s-prepared nurses need to
- recognize the power of information and knowledge;
- ensure the integrity of data collected through providing education and oversight of colleagues and subordinates;
- create a culture that values data integrity;
- work with administrators to provide the infrastructure needed to maximize both primary and secondary data collected from EHRs, patient-care technologies, and other healthcare systems;
- articulate what data and information is needed to support nursing and patient care;
- learn more about the use of analytics and business-intelligence tools;
- think outside of the box for new, potentially useful data streams; and
- participate in the design and use of dashboards for better decision making.
Armed with appropriate knowledge and skills, the master’s-prepared nurse will play an active role in transforming healthcare delivery.
Technology changes the way that we work, extending our capabilities to care for patients and improving our access to information and knowledge.
EHRs facilitate the collection, storage, and retrieval of clinical information and provide a rich source of secondary data that can be used to improve healthcare and build nursing knowledge.
Structured data facilitates data use and reuse, although the adoption of additional data standards may soon be used to unlock the data, information, and knowledge found in unstructured data.
The application of large-scale analysis of aggregate data, known as analytics, data mining, knowledge discovery in data bases, or business intelligence is now being used to support data-driven decisions in healthcare.
Harper, E. M. (2013). The economic value of healthcare data. Nursing Administrator Quarterly, 37(2), 105–108. doi: 10.1097/NAQ.0b013e318286db0d
Mantalvo, I. (2013). How smart are your data? Nursing Management, 44(6), 23–24. doi: 10.1097/01.NUMA.0000430412.80830.e6
McGonigle, D. & Mastrian, K. (2018). Nursing informatics and the foundation of knowledge (4th ed.). Burlington, MA: Jones and Bartlett.
- Chapter 16: Patient Engagement and Connected Health pp.323-338
- Chapter 17: Using informatics to promote community/population health pp.341-355
- Chapter 18: Telenursing and remote Access Telehealth pp.359-388
Sipes, C. (2016). Project management for the advanced practice nurse, Springer.
- Chapter 1: Basic Project Management for Advance Practice Nurses and Health Care Professionals; Examples of APN Projects/Roles. pp. 4-11
- Chapter 1: Basic Project Management for Advance Practice Nurses and Health Care Professionals; Project Management: Why do we need it? Pp. 12
- Chapter 2: Advanced practice nurse role description and application of project management concepts; Chapter 2, pp 16-24
Visit the following site http://www.fiercehealthcare.com/it (Links to an external site.)Links to an external site. (explore healthcare technology news on CPOE, EMRs, E-prescribing, HIE, PHRs, HIT stimulus, and other health IT news)
Visit the following site www.fierceemr.com (Links to an external site.)Links to an external site. (this site contains weekly newsletter on EMRs, meaningful use, ARRA and privacy. Select 1 of 5 Topics/Popular Content of the Week to use in the weekly discussions)
This week, we look at new demands placed upon the nurse for information knowledge and informatics skills which includes ways to facilitate the collection and use of multiple data and information streams for the generation of knowledge and wisdom, whether that occurs in a patient care setting, educational context, management/ administrative settings. It also includes the increased need for information and knowledge in when developing policies, communication with healthcare consumers and interdisciplinary collaborations. Consideration is given to the information, informatics skills and knowledge needs of the masters prepared nurse
- Evaluate HIT capability to promote safety.
- Examine technology options to support all facets of nursing and patient care.
- Develop a view of different types of patient-care technologies.
- Explore informatics competencies and health information technology (HIT) that supports patient care and documentation.