TNA/TONE Health IT Committee · EHR Satisfaction Survey of Nursing and Pharmacist • Findings of the survey were concerning related to potential unmet needs of nurses • Review
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* 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.