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

marybethmitchell@texashealth.org

Donna.montgomery@baylorhealth.edu

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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

mtietze@twu.edu

Nancy Crider, DrPH, RN, NEA-BC

University of Texas

School of Public Health

Nancy.M.Crider@uth.tmc.edu

Co-chairs

Imagination is more important than knowledge

-- Albert Einstein