CareNet and UPMC- St. Margaret’s Emergency Department 1 The Process of Adopting and Implementing an Electronic Health Record: One Emergency Department’s Experience with CareNet Nancy Gorsha, Ellen Mering, and Audra Ziegenfuss University of Pittsburgh, School of Nursing Introduction to Nursing Informatics (NURSP 2075) Dr. Deborah Lewis, EdD, CRNP, MPH December 6, 2004
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CareNet and UPMC- St. Margaret’s Emergency Department 1
The Process of Adopting and Implementing an Electronic Health Record: One Emergency
Department’s Experience with CareNet
Nancy Gorsha, Ellen Mering, and Audra Ziegenfuss
University of Pittsburgh, School of Nursing
Introduction to Nursing Informatics (NURSP 2075)
Dr. Deborah Lewis, EdD, CRNP, MPH
December 6, 2004
CareNet and UPMC- St. Margaret’s Emergency Department 2
Abstract
The University of Pittsburgh Medical Center (UPMC) St. Margaret’s Hospital (SMH) has
recently implemented a computer information system (CIS) using Cerner Corporation software
application products. SMH was chosen to pilot the implementation of CareNet, a software
application designed for record keeping in acute care settings. The Emergency Department (ED)
has a unique patient flow and unique priorities compared to the rest of the hospital, and CareNet
facilitates documentation by automating the ED’s workflow. Consequently the ED has
encountered its own set of implementation issues that are gradually being resolved through a
variety of strategies developed by SMH’s eRecord team. Nurses are involved in each part of
CareNet’s life cycle. Their involvement has a direct impact on user satisfaction and success of
the CIS. Both the end-users and information system can be considered integrated parts of a
whole, both capable of influencing change in the other.
CareNet and UPMC- St. Margaret’s Emergency Department 3
Classes & Events,” “Health Sciences Library,” “Patient Education Materials” and “Schools of
the Health Sciences” (UPMC, n.d.) Health on Net Foundation (HON) has given UPMC a 97%
rating for the quality of its internet healthcare information (HON, n.d.).
Information System Applications
Organization
Enterprise Applications and Estimated Annual Clinical Information Systems Costs
There are numerous eRecord applications in clinical use within the larger University of
Pittsburgh Medical Center (UPMC) (see Table 2). These are part of UPMC’s agreement with
Cerner when they negotiated a figure encompassing an enterprise of applications rather than a
limited set. As a component of the UPMC Health System, SMH also has these systems
available. Although all of these applications have not currently been implemented at SMH, their
implementation is an option of the near future. CareNet Acute Care Management System, the
focus of this review, is a sub-component of PowerChart. PowerChart is the name for the
eRecord. Of the three applications that PowerChart offers (Enterprise Clinical Data Repository,
Enterprise Order Management, and Enterprise Documentation Management), CareNet is the
name of the documentation management application. A brief description of both PowerChart
and CareNet are given in Table 2, but a detailed description will follow in the discussion on the
application’s support of nursing practice.
CareNet and UPMC- St. Margaret’s Emergency Department 27
Table 2
Clinical Applications Currently in Use in the UPMC Network
Application Description
Ambulatory Computerized Physician Order
Entry Medication (EasyScript)
EasyScript is used for medication ordering
within the eRecord. Drug interactions and
allergies are checked and automatic updates to
the patient’s eRecord made.
Clinical Documentation & Orders Entry
(CareNet)
CareNet integrates nursing and physician care
by automating documentation and orders.
Emergency Department (FirstNet) FirstNet is integrated into PowerChart and is a
patient tracking and triage system.
Health Economy Architecture (HEA) HEA integrates many computer environments
across the UPMC network and provides for
continuity of care including the aggregation of
clinical information.
HealthTrak- UPMC Patient Portal This web-based application allowing patients
to be pro-active in their health care decisions.
Outpatient Practice Management (PowerChart
Office)
Multifunctional use is the key to this outpatient
practice management system. Its scope
supports both clinical and business activities
occurring in private practice.
MedTrak- UPMC Physician Portal MedTrak links inpatient and outpatient realms
for continuity of care both within and outside
the UPMC network.
Pharmacy Management (PharmNet) This is part of eRecord and provides
medication order entry, intravenous fill lists,
and medication administration records.
Positive Patient Identification (PPID) Barcode technology ensures the five rights of
medication administration are being met.
Results Review (PowerChart) Multi-disciplinary face of eRecord providing
an interactive, graphical user interface.
Single Sign On (CCOW/ Sentillion) Only one login per session is needed for
eRecord users to maintain the same patient
between applications.
Specialty Laboratory Management System
(PathNet)
Clinical and management applications are
automated and integrated into eRecord. It also
automates the process of organ transplant
services across UPMC.
Structured Clinical Documentation
(PowerNote)
Care documentation and ordering are
combined and alleviates the repetition
physicians encounter during note taking.
Surgical Scheduling and Documentation
(SurgiNet)
SurgiNet provides electronic surgical case
scheduling, picklists, intra-operative
documentation, and automated charging. Note. Adapted from ERecord status report. (2004, September). Copy Editor, 2-4.
CareNet and UPMC- St. Margaret’s Emergency Department 28
D. McCormick (personal communication, October 26, 2004), the Chief Information
Officer at UPMC- St. Margaret, discussed the costs involved in design and development,
implementation, and support of the electronic health records. As previously mentioned, SMH
was targeted for participation, since its financial status enabled support for the implementation.
Monetary costs involve three items of interest: cost of hardware and software, cost of education,
and intellectual resources (Simpson & McCormick, 2001). UPMC negotiated a twelve-year, $40
million dollar agreement with Cerner Corporation for the suite of software applications and
discounts on third party agreements. Of the $4.7 million dollars budgeted for SMH capital costs,
$1.5 million dollars was allotted toward the required hardware. In order to prepare SMH for the
upcoming information system, $250, 000 was allocated for implementation and support.
Education and intellectual resources fall under the capital annual budget for information science
(IS) services, and UPMC allowed for $50-60 million dollars toward these services for the entire
health system. Half of the initial IS figure was intended for implementation of the eRecord. For
the 2005 fiscal year, SMH has a budget of $1.5 million dollars in capital costs.
Relationship Between Administrative and Clinical Components
The clinical data input of CareNet provides the opportunity for administrative aggregate
analysis. The Institute of Medicine (2001, pp. 170-171) claims that “automated clinical and
administrative data enable …[assessments] of clinical outcomes…and care processes;
identification of best practice; and evaluation of effects of different methods of financing,
organizing, and delivering services.” Performance improvement measures provide a link between
the administrative and clinical components of CareNet. There are corporate benchmarks that the
UPMC Health System is targeting for performance improvement. These include community
acquired pneumonia, congestive heart failure, acute myocardial infarction, and central line
CareNet and UPMC- St. Margaret’s Emergency Department 29
infection. Theoretically, the functions of CareNet should theoretically facilitate improvements in
these areas by enhancing patient care. Performance improvement targets specific to the
Emergency Department are (1) leaving the Emergency Department prior to or following being
seen by a physician, (2) inquiries concerning a patient’s financial information prior to triage, (3)
length of stay, (4) and the use of moderate sedation. CareNet, and other components of the
greater clinical information system, also help facilitate improvements in these areas by forcing
health care providers to assess and evaluate a number of different aspects of their delivery of
patient care.
SMH’s own set of benchmarks was discussed earlier. SMH has developed an initiative to
improve and standardize clinical documentation through benchmarking particular areas for
measurement prior to and following implementation of the electronic health record (Electronic
Health Record Benchmarking Committee, 2003). Two targeted areas are advance directive
documentation which was only 61% compliant in September, 2003 and the time to admit a
patient to a general medical-surgical unit. Benchmarking is a quality assurance tactic and
important in the delivery of quality health care (D. Wolf, personal communication, November 3,
2004). Reports are generated on the benchmarked items and reviewed for quality assurance and
performance improvement. Currently it is not simple to retrieve data on any new item of interest
or query an investigator might have. The reports have to be customized, planned and scheduled
and are a time-consuming effort.
In addition to benchmarking, administrative and clinical components meet at the billing
function. Cerner applications send Charge Description Master (CDM) codes to the UPMC
billing system (McKesson’s MediPac) which is the patient billing application (D.McCormick,
personal communication, November 8, 2004). This is an automated function of the Cerner
CareNet and UPMC- St. Margaret’s Emergency Department 30
applications and cuts down on the time it takes for coding done by an employee devoted to that
function.
Finally, another source of interrelatedness of administrative and clinical components
takes place not within CareNet, but rather, outside the technology and in the meeting room. Both
administrators and clinicians, the end users of the administrative and clinical components, work
as a team to promote successful pre-implementation, implementation, and post-implementation
phases of the clinical information system. Relationships are formed among these
multidisciplinary groups of people. The success of the eRecord, comprised of CareNet and other
applications of the clinical information system, is the ultimate goal.
Nurses Roles in the Management of CareNet and other Applications
The success of the clinical information system is “increasingly dependent upon how well
the people and organizational issues are managed” (Lorenzi, Riley, Blyth, Southon, & Dixon,
1997, p. 79). Nurses are one group of primary end-users of the clinical applications, specifically
CareNet. Nurses do the majority of documentation and are held accountable for errors and
impediments to correct and accurate data recording. Therefore, it is logical that they should be
involved early in the process of adopting a new clinical information system. M. Berg (1999, p.
94) recognizes the need for a user-centered system and understands that being user-centered
involves more than “[graphical user interfaces], good communication or adequate training
programs.” Berg suggests that the end-users need to be the driving force behind design and
implementation and involved “early, thoroughly, and systematically” (Berg, 1999, p. 94).
Involving nurses in the process aids in the preparation and acceptance of the impact a
new system has on the organization. Organizational change will occur as a result of the
information system, but the information system must also change in response to the end-users
CareNet and UPMC- St. Margaret’s Emergency Department 31
needs. Nurse management of the information system facilitates this process. Lorenzi et al.
(1997) use Field Theory to explain the need for nurse involvement in the change process. Field
theory is based on the need for involvement of the people within the change to motivate them to
make it a success. If there is no involvement there will be no motivation, and the change might
be seen as a threat. Nurse involvement might be considered a tactic with positive impacts such
as having more involved staff, a better understanding of the influence of the changes on the
organization, a better understanding of the changes, and an enhanced ability to cope with the
changes (Lorenzi et al., 1997).
One specific example of how nurses manage the clinical information system are the use
of champions and superusers. Champions and superusers are nurses and physicians who act as
liaisons between their professional groups using the applications and the administrators
mandating them. The champion role begins early in the design and development process and
evolves into the post-implementation phase. The restructuring phase occurring after
implementation also involves nurses, but not as champions. Nurses’ roles as champions and
restructuring entities will be the focus of the next two sections.
Champions. The role of champions in the management of clinical applications is the
foundation for an increased acceptance of change. Champions do not serve a passive role in
success of the information system. They are involved in the “aggressive seeking of inputs at the
earliest possible stages of the overall process. . . . with continuous feedback on the status of the
inputs and detailed explanations of why some inputs cannot be utilized or implemented”
(Lorenzi et al., 1997, p. 88). J. Ash (1997, p. 103) describes champions as those who take
creative ideas and “bring them to life.” According to Ash, their contribution may include
promoting the new idea, building support, dampening resistance, and facilitating implementation.
CareNet and UPMC- St. Margaret’s Emergency Department 32
The champion structure (see Figure 4) is composed of nurses, administrators, and
physicians assigned specific roles. While acting within their roles, the champions act to create a
“smooth landing” for the end-users and facilitate communication between the project team and
the end-users. Champions allow the organization to influence the information system and the
information system to influence the organization.
Figure 4. St. Margaret Hospital’s Champion Structure.
___________________________________________________________________ Reprinted with permission from D. Wolf, Director of Nursing and Operational Informatics (2004).
Three topics of user involvement are discussed by Lorenzi et al. (1997). These include
cognitive, motivational, and situational topics. Nurses, and specifically champions, use each of
CareNet and UPMC- St. Margaret’s Emergency Department 33
these topics in the management of the clinical applications. Cognitive functions involve the
actual knowledge of technology. One role of the champions is to ensure that the end-users are
receiving sufficient knowledge and support. Therefore, they are not only motivators as Lorenzi
et al. (1997) indicate, but they are also reinforcers. Knowledgeable champions act as positive
reinforcers by explaining the system and designing the training. Superusers are other individuals
involved in cognitive functions. They are nurses and physicians on each unit or floor considered
to be the point-of-contact if any application support is needed.
Champions also serve a motivational function to try to understand the end-users’
motivation for using or not using the technology. Motivation encompasses a person’s self-
efficacy, beliefs and expectations, and interest. Situational topics involve those inherent to the
organization itself. Champions seek to understand the environment on particular units or floors.
If the environment is well understood, influencing application acceptance might be approached
appropriately. That is, if a particular floor is more resistant to change than others, advocating for
the system might be approached differently than if the floor was open to change.
Restructuring. The role of champions is primarily for the design and development and
implementation phases of adopting a new clinical information system. However, their roles do
not cease once implementation has occurred. Inherent in the word change is the notion that it
does not seem to come to an end. Implementation is not so distinct from the evaluation phase
and nurses’ management of the applications continues. The support structure changes and the
champion structure is phased out, but nurses continue to manage the application by acting as
superusers and voicing requests for application adjustments to the IS department.
CareNet and UPMC- St. Margaret’s Emergency Department 34
Utilization
Nurses Involvement in the Utilization of CareNet
The Emergency Department nurses utilize CareNet for their nursing documentation.
However, documentation has more to do with nursing data and support of nursing practice.
Nursing utilization involves more than just the functions within the application. Utilization also
involves acceptance and ownership of the application by the nurses. Nurses are involved in the
utilization by championing it and also by seeking ownership of it. If nurses do not feel as if they
own the application, they will not utilize it. Therefore, nurses need to be involved in seeking
ownership in order for it to be successfully utilized. Three themes emerge out of the concept of
nurse utilization—acceptance, ownership, and success.
Acceptance and ownership. As the primary users of CareNet, nurses must be willing to
accept the application in order for it to be successfully utilized. UPMC’s unsuccessful attempt to
implement CareNet is an example of a good system that was rejected by the end-users due to
their inability to “own” the system. There are numerous theories on acceptance and rejection of
various information systems, so the focus will be limited to ownership. Lorenzi et al. (1997)
create the idea of owning the problem and the solution and allowing technology to be an enabler
rather than a prohibitor. Lorenzi and Riley (as cited in Aarts et al., 2004, p. 209) expand on the
concept of ownership by describing how a “technically best” system can be brought to its knees
by people who do not feel ownership and resist implementation, whereas a “technically
mediocre” system may be extremely valued by its users.
If the Emergency Department nurses “perceive they own the problem and the solution,
they will work with the developers to make the system work” (Lorenzi et al., 1997, p. 94). If
CareNet is viewed as an enabler and empowerer for the Emergency Department nurses, they will
CareNet and UPMC- St. Margaret’s Emergency Department 35
support its development and implementation. The Emergency Department nurses, as a collective
unit at SMH, have gained ownership of both the existing problems and the solutions CareNet is
able to offer.
How nurses come to own the problem and the solution lies in how useful they perceive
the technology to be. Ash (1997) suggests that users must see the need for change in order to
support a change. The benchmarked areas that the UPMC network and SMH have indicated are
areas that need to be changed. For example, if bringing multiple disciplines together and
expediting the receipt of lab values and images decreases the time a patient spends in the
Emergency Department, CareNet has provided a solution to the problem of lengthy Emergency
Department stays.
Successful utilization. Success is distinct from acceptance. A clinical information system
can be successful and not accepted or accepted and not successful. How success is defined is
central to whether or not it exists (Ammenwerth, Mansmann, Iller, & Eichstadter, 2003, Aarts,
Doorewaard, & Berg, 2004). Delone (as cited in Ammenworth et al., 2003, p. 82) gives six
categories of success. These include “comprising system quality, information quality,
information use, user satisfaction, individual impact, and organizational impact.” Although it is
early in the course of its implementation, CareNet appears to be accepted by the majority of
Emergency Department nurses and some physicians. If its success is viewed in terms of
individual and organizational impact, deficits in the nursing process are visualized more clearly
and able to be rectified. Rectifying potential problems is useful in that it provides a solution
before the problem has ever been created.
CareNet and UPMC- St. Margaret’s Emergency Department 36
How Applications are Used to Capture Nursing Data and Support Nursing Practice
In November 24, 2003, CareNet was the only document management solution recognized
by the Nursing Information and Data Set Evaluation Center (NIDSEC) (American Nurses
Association, 2003). The NIDSEC cited CareNet for completeness, accuracy, use of appropriate
nomenclature, clinical content, clinical data repository, and good general system characteristics.
Beyond supporting nursing practice, information systems also hold the potential to advance
nursing knowledge (Graves & Corcoran, 1988). The application captures nursing data and
supports nursing practice in three ways—documentation, health care collaboration, and quality
assurance.
Documentation, health care collaboration, and the information gap. Although there are
different types of data, data specific to the nursing practice is considered patient-specific data
which is concerned with a particular patient and may be acquired from a variety of sources
(Henry, 1995). Data entry is facilitated by the use of a user-friendly graphical user interface
(GUI). There are a number of windows available for the nurse to capture patient data. Having
well-designed windows or screens discourages data entry errors (Nelson, 2001) because the
workflow of the Emergency Department nurse is replicated in the flow of windows presented to
him or her. In addition, the application is flexible enough to allow for the creation of specialty
documentation appropriate for a particular care area such as the Emergency Department.
Specialty documentation allows for what Feied, Smith, Handler, Gillam, & Pietrzak (2004,
p.121) refer to as a series of “rights” which include “the right information to the right clinician at
the right time, formatted in the right way to meet the information needs of the moment”.
Once the patient demographics are entered, the next available window might be vital
signs and pain assessment followed by a brief medical history including current medications. All
CareNet and UPMC- St. Margaret’s Emergency Department 37
of the entered data may be used many times “by different users for different purposes” (Nelson,
2001). In fact, the Institute of Medicine (2003) recommends having result management to allow
all providers to access data quickly to increase patient safety and the effective care. This reuse
and additive effect of data reduces redundancy and results in a streamlined approach to
documentation. By accessing data from a single location each time, PowerChart, geography no
longer becomes an issue. Multiple healthcare providers, including nurses, can simultaneously
access patient data from various locations (Cerner Corporation, 1998). This promotes healthcare
collaboration by allowing speedy communication among a variety of disciplines.
If a patient has been to a community facility such as SMH, which is different from the
academic core facilities, a patient history will be available to the triage nurse as he or she enters
the patient demographics into the system. Having a patient history available when a patient
presents to the Emergency Department reduces the patient’s length of stay, a benchmark for all
UPMC Emergency Departments (Stiell, Forster, Stiell, & van Walraven, 2003). A lack of
available information, termed infopenia by Feied et al. (2004), results in a large amount of time
dedicated to locating documents and test results and recording the information that someone else
has more than likely already recorded. Nursing practice is supported by eliminating the need for
the nurse to shuffle through papers and spend lengthy periods of time communicating to other
members of the team in person or on the phone. This allows the nurse to have a total picture of
the patient in a short amount of time in order to assess and plan an intervention.
Quality assurance. Identifying deficits in healthcare and gaps in nursing is a secondary
function of CareNet, or any electronic documentation system. The identification of deficits aids
in the process of quality assurance and supports nursing practice by demonstrating where
improvements should be made and allowing for standards to be created based on information the
CareNet and UPMC- St. Margaret’s Emergency Department 38
documentation provides. Hospitals ultimately compete with each other in the healthcare market
and the measures used to outrank one another are often based on the quality of care they provide
(Institute of Medicine, 2001). Henry (1995) suggests information on the quality and cost of
health care are needed for both internal quality management and external reporting to regulatory
agencies. Data that quality assurance assessments are based on might come from data entered by
a health care team member or data shared between various information systems (Henry, 1995).
One way CareNet promotes quality care is its elimination of errors related to poor handwriting.
Data that once might have been handwritten had the potential to be illegible and a source of
erroneous actions. If correct data is entered into an eRecord, erroneous actions directly linked to
illegible handwriting might be reduced thus increasing quality of care.
Analysis of data in the form of reports of benchmarked areas can help identify gaps. The
identification of gaps is essential to their elimination, and anticipation of gaps allows for
preparedness if they are encountered (Cook, Render, & Woods, 2000). If there is a deficit in
nursing practice, electronic documentation facilitates the auditing process in order to identify and
remedy those deficits. Nurses who were deficient prior to the implementation of CareNet will
most likely continue to be deficient after its implementation, but easier auditing of
documentation might increase the identification of nurses in need of additional support.
An example of improving an individual’s nursing practice is the case of a patient exposed
to rabies who entered SMH’s Emergency Department. The nurse responsible for her care needed
guidance from pharmacy as to an alternative route for administering the intramuscular rabies
vaccine due to the patient’s relatively small muscle mass. When the documentation was
retrieved to evaluate the situation, no skin assessment was made in the documentation. Since
skin assessment is a window available to the nurse, this should have guided her documentation
CareNet and UPMC- St. Margaret’s Emergency Department 39
and practice. If a paper chart was used, it might have taken longer for the pharmacy to retrieve
and evaluate the patient documentation. Among the number of papers involved in Emergency
Department cases, skin assessment might have been overlooked and not targeted by the evaluator
either. CareNet allows those with queries about particular assessments to locate that
documentation quickly and be skeptical about whether the assessment was made if the window
lacks data. Nursing practice is again supported by making nurses aware of their deficits so they
may be more effective practitioners.
If the documentation was not made, it might be assumed the care was not given.
Neglecting to provide appropriate care drives litigation against health care organizations.
Electronic documentation is a component of quality assurance and anti-litigation tactics. One
way CareNet ensures this by supporting accountability. Although all information on paper charts
should have the appropriate initials with it, the omission of this information can be a challenge to
accountability. CareNet embeds a security measure wherein all data that is accessed, inputted, or
updated is tagged with the end-user’s identification. Appropriate identification results in the
correct individual being held accountable for a medical error. A provider might be more diligent
in what he or she documents in he or she knows they will always be directly linked to that data.
Standardized Languages in CareNet
The use of standardized languages is another way a healthcare organization can support
quality assurance. CareNet’s standardized language is limited to SNOMED, although it does use
an in-house UPMC-accepted language (M. Bradley, personal communication, October 2004).
The SNOMED standardized language is a joint effort between SNOMED International and the
United Kingdom’s National Health Service (NHS) (SNOMED International, n.d.). It is a
common language enabling consistent “capturing, sharing and aggregating [of] health data across
CareNet and UPMC- St. Margaret’s Emergency Department 40
clinical specialties and sites of care” (SNOWMED International, n.d., p. 3). The use of
SNOMED enables accurate data recording, and it operates with various software applications
and other medical classifications such as ICD-9-CM, ICD-03, ICD-10, Laboratory LOINC and
OPCS-4. Having a common language helps to ensure the best health outcomes and to facilitate
the identification of disease trends.
SNOMED is a language primarily used by physicians. No standardized nursing language
is used. Without a standardized nursing language, it becomes difficult for nursing practice to
capture, store, analyze, and report on nursing-specific data (Zielstorff, 1998). CareNet would
benefit from a standardized nursing language that provides domain completeness, granularity,
parsimony, synonymy, non-ambiguity, non-redundancy, clinical utility, multiple axes, and a
combinatorial nature as suggested by Zielstorff (1998). The previously mentioned single entry,
multi-use data is a strong benefit to CareNet’s documentation. Standardized languages can
expedite storage and retrieval of patient-specific data, agency-specific data, and domain-specific
data (Henry, 1995).
Quality assurance and support of nursing practice also benefits from standardization. If
all the UPMC facilities used the same nursing language, gaps in practice might be even more
apparent leading to improvements of standards. If everyone is using the same language, similar
errors or similar effective practices are easier to identify and avoid or replicate. Graves and
Corcoran (1988) address the issue of a standardized nursing language when they discuss the need
for a nomenclature consistent with the discipline in order to facilitate data aggregation for the
purpose of guiding future practice. Telescoping further, Henry (1995) suggests the usefulness of
standardization in comparing organizations, communities, and regions. If all health care
CareNet and UPMC- St. Margaret’s Emergency Department 41
facilities used the same standardized language even more gaps in practice and more evidence for
changes in standards might occur.
Automated Decision Support
Data refers to points of information about a variable (Graves & Corcoran, 1989). Data is
processed into information, and information is processed into knowledge (Graves & Corcoran,
1989; Henry, 1995). Knowledge, specifically nursing knowledge, is “simultaneously the laws
and relationships that exist between the elements that describe the phenomena of concern in
nursing . . . and the laws or rules that the nurse uses to combine the facts to make clinical nursing