nursing, technology, and information systems · special repor t: nursing, technology, and...

SPECIAL REPORT:

Nursing, Technology, and Information

SystemsThis special report is sponsored by Cerner Corporation and the Healthcare Information and Management Systems Society (HIMSS). All articles contained in this special report

have undergone peer review according to American Nurse Today standards.

SR2 American Nurse Today Volume 8, Number 11 www.AmericanNurseToday.com

Versions of this article appear inAmerican Nurse Today (UnitedStates) and Nursing Times (Unit-ed Kingdom) to acquaint readerswith common goals, challenges,and advances in using health in-formation technology to enablenurses to provide safer and moreefficient care.

Around the globe, inevery setting, nurses seekto provide care to pa-

tients and families to keep themsafe, help them heal, and returnthem to the highest possible lev-el of functioning. Nowhere is thestruggle to achieve these simpleaims more apparent than inhospitals. The tightrope of bal-ancing what nurses believe to beadequate resources for high-quality care and the affordabili-ty of these required resources areoften at odds. Disagreementamong leaders in healthcare de-livery systems as to how to allo-cate nursing resources has led totension and discord. Despitedecades of research showing thatthe amount of care provided byregistered nurses directly affectsmortality and morbidity, nurseleaders continue to have to justi-fy requests for nursing resources.

Universally, the desire tomake care more affordable hasfueled efforts to make care moreefficient and effective. The publicrecognizes this means examin-ing all aspects of care in the pur-suit of cost-reduction measuresthat will not reduce quality. Inthe United States, nurses contin-uously rank as the nation’s mosttrusted professionals by theGallup Poll and have the pub-lic’s support whenever belt-tight-

ening issues come to the fore-front. On the other hand, in theUnited Kingdom (UK), the de-bate over resources that hasbeen playing out in the mediahas caused confusion and publicuncertainty as to whom to be-lieve, undermining confidence inthe system as a whole. The nurs-ing profession hasn’t beenspared this negative view andhas needed to reassure the pub-lic of its core values and pur-pose—that caring and compas-sion are part of the core businessof nursing.

Nursing is what nurses do,and what nurses do is coordi-nate and deliver care. So al-though the context, technology,and health needs of our popula-tions have changed, nurses re-main the foremost providers andcoordinators of care.

Why state something so obvi-ous? Showcasing the caring aspects of nursing in a techno-logically dominated world ischallenging. Technology enablescare and enhances safety by au-tomating functions both simpleand complex. It doesn’t replacenurses. As one expert cautions,automation should occur innursing, not of nursing. The val-ue of technology hinges on howit’s used and whether it helps orhinders care.

Changing nursing practicesafely So why do nurses have to strug-gle so hard to get the technologywe need to support our practice?And when this technology isavailable, why don’t we reap the

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s Enabling the ordinary: More time to care Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN, and Susan Hamer, DEd, MA, BA, RGN

The value oftechnology in

automating andimproving

patient care —

www.AmericanNurseToday.com November 2013 American Nurse Today SR3

benefits we’ve been seeking forour practice?

For years, many in the health-care community believed nurseswere too slow to embrace newtechnologies and might disruptor even obstruct the changeprocess. Had they ever visited aneonatal or intensive care unit?Although their description ofnurses and nursing wasn’t accu-rate, it had become a mantrawithin a wide variety of organi-zations.

What they failed to grasp,and continue to misunderstand,are the practical realities of howprofessions change and how tosupport innovation in practice.For generations, nurses havechanged their practice success-fully and have adapted to newchallenges, such as coping withrising patient acuity, safely de-livering dangerous drugs, andpreventing adverse events. Andthey did this in a world wheremanagement theories were onlybeginning to address nursingand healthcare settings.

At times, the need for changehas been critical and the re-sponse of the nursing professionhas been swift. Of course, wecan all acknowledge there areaspects of care we should havechanged but have resisted. Nurs-ing professionals have sought tounderstand how to change ourpractice and increase the avail-able evidence on which to baseour care. We understand how tochange practice safely and howto sustain those changes.

Shared vision fortechnology: Enhancing care The United States and UK sharesimilar goals for technology in-novation but differ in the eco-nomics and delivery-system con-figurations. (See Comparing theU.S. and UK health systems.) Withthe technology explosion, manyhealthcare organizations havesought to add new systemsrather than integrate existingones—usually without knowing

if the addition would increasethe workload or change workpractices or whether it would beacceptable to patients. Organi-zations supported technologyimplementation to achieve busi-ness goals, whereas nurses sawpractice development as the real goal.

The focus on the business caseaddressed primarily organiza-tional benefits, such as the de-sire for technology to replacestaff time and the ability to market to patients the use of“cutting-edge” devices and elec-tronic record systems, not pa-tient experience and outcomes.

Many of these organizationstreated technology to help nurs-es deliver care as a separatecase, viewing it as an additionalcost to services rather than amechanism to enhance care.Thus, the possibility of being un-able to sustain the technologywas always real.

Increasingly, health technolo-gy projects have been seen asspecial projects that need specialteams set up by senior man-agers, some of whom are unfa-miliar with the care setting.These managers seem to strugglewith focusing on supportingfrontline practitioners to delivercare. Managers have failed re-peatedly to enable ordinary day-to-day care with technologies.

The need for technology tosupport practice was demonstrat-ed by findings from the Technol-ogy Drill Down project of theAmerican Academy of Nursing’sWorkforce Commission. Frontlinenurses and other multidiscipli-nary care team members stressedthe importance of involving di-

Comparing the U.S. and UK health systems Despite some fundamental differences, healthcare delivery systems in the UnitedStates and the United Kingdom (UK) share a national commitment to quality andthe role of nurses in improving care. In both nations, nurses are expanding the useof health information technology tools to improve safety and efficiency andinvolve patients in their care. The chart below compares some features of the U.S.and UK health systems.

Feature United States United Kingdom

Payer(s) • Government • Government• Private insurance companies (National Health Service [NHS])• Self-pay • Private insurance companies

• Private payers

Delivery • Hospital centric (government • Strong community-based care system or private) with primary-care focus

• Increasing shift toward • Hospitals run by trusts illness prevention and more (public-sector corporations ambulatory, home, and providing services for the NHS)post-acute care

Technology • Electronic health record • Paperless system by 2018vision for all citizens by 2014 • Improved availability,

• Improved availability, quality, quality, and safety of and safety of information information

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EPORT: Nursing, Technology, and Information System

s

The United States and UKshare similar goals for

technology innovation butdiffer in the economics

and delivery-systemconfigurations.


rect caregivers in technology de-sign, selection, and testing—stepsoften overlooked in the haste ofacquiring systems or devices. (SeeMaking care safer and more effi-cient with technology.)

Technologies designed for andused by nurses at the point ofcare haven’t always been easy touse. A recent international sur-vey seeking to identify prioritiesfor nursing informatics researchon patient care acknowledgesthat despite the growing evi-dence base on the design andevaluation of health informa-tion technology (HIT), thesetechnologies focus mainly onmedical practice. The studyfound that the two most highlyranked areas of importance werethe development of systems toprovide real-time feedback tonurses and assessment of HIT’seffects on nursing care and pa-tient outcomes.

Agenda for leadershipWe know how to support high-quality professional practice de-velopment and what conditionsenable professions to changerapidly. If a profession is encour-aged to annex new forms ofknowledge and opportunities, itcan rapidly develop appropriatepractice to self-adapt. This is theroute to successful, sustainableinnovation. Nurses must addressthe leadership challenge of howto respond to and accelerateadoption of technologies to sup-port practice. We need nurseleaders who see technologies aspromising solutions, not prob-lems, and are able to integratetechnology into their vision formeeting practice needs. Nurseleaders need to model and pro-mote examples of enabling tech-nologies and demand systemsthat meet practitioners’ needs.

As technology matures, nursesand other healthcare profession-als should be able to collect in-formation only once and see itreused often. Management infor-mation should serve as a

byproduct of excellent clinicalpractice and drive standards for high-quality data from nurs-es. The profession has madeprogress in dispelling the myththat nurses are slow technologyadopters. With the help of nurs-ing informatics experts, nursingleaders must continue to debatethe issues that will help us lever-age technologies to improve careand efficiency and achieve thepromise that health technologycan transform care. n

Selected referencesAiken LH, et al. Effects of nurse staffing andnurse education on patient deaths in hospi-tals with different nurse work environments.Med Care. 2011;49(12):1047-53.

Bolton LB, Gassert CA, Cipriano PF. Technol-ogy solutions can make nursing care saferand more efficient. J Healthc Inf Manag.2008;22(4):24-30.

Cummings J, Bennett V. Compassion in prac-tice: Nursing, midwifery and care staff: Our vision and strategy. December 2012.www.england.nhs.uk/wp-content/uploads/2012/12/compassion-in-practice.pdf. Ac-cessed September 27, 2013.

Dowding DW, Currie LM, Borycki E, et al.

International priorities for research in nurs-ing informatics for patient care. Stud HealthTechnol Inform. 2013;192:372-6.

Evenstad L. Cameron announces £100mnurse tech fund. E-Health Insider. October 8,2012. www.ehi.co.uk/news/ehi/8109/cameron-announces-%C2%A3100m-nurse-tech-fund. Accessed September 22, 2013.

Hamer S, Collinson G. Achieving Evidence-Based Practice: A Handbook for Practition-ers. 2nd ed. Baillière Tindall; 2005.

Newport F. Congress retains low honesty rat-ing. Nurses have highest honesty rating; carsalespeople, lowest. December 3, 2012.www.gallup.com/poll/159035/congress-re-tains-low-honesty-rating.aspx. Accessed Sep-tember 22, 2013.

Plochg T, Hamer S. Innovation more than anartefact? Conceptualizing the effects of draw-ing medicine into management. Int J Health-care Manag. 2012;5(4):189-92.

Simpson RL. The softer side of technology:How it helps nursing care. Nurs Adm Q.2004;28(4):302-5.

Pamela F. Cipriano is a senior director for GallowayConsulting in Marietta, Georgia, a research associateprofessor at the University of Virginia School ofNursing, and editor-in-chief of American Nurse Today.Susan Hamer is the organizational and workforcedevelopment director at the National Institute forHealth Research Clinical Research Network at theUniversity of Leeds, England.

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Making care safer and more efficient with technology The American Academy of Nursing’s Workforce Commission recognized theimportance of effective technologies in improving the safety and efficiency ofcare and in helping to return time to nurses for essential care. The Commission’sTechnology Drill Down (TD2) project, funded by the Robert Wood JohnsonFoundation, addressed another looming nursing shortage in an attempt toreduce demand for nursing care. Aimed at finding technological solutions toworkflow inefficiencies on medical-surgical nursing units, TD2 brings togethermultidisciplinary teams to review the current state of nursing workflow, designthe desired future state, and brainstorm technology solutions to fill gaps—withthe over arching goal of providing safer, more efficient care.The Commission found that in the 25 acute-care hospitals involved in the

TD2 project, most units already had supply storage systems, electronic nursedocumentation, provider order entry, and several other automated systems inplace, such as telecommunications equipment and drug-dispensing units.Nurses wanted technology solutions to eliminate or automate work, performrequired regulatory functions, and provide ready access to resources. They weredisappointed that much of the existing technology wasn’t user-friendly andrequired work-arounds. Nurses also stressed the importance of vendors listeningto the voice of the staff nurse to make technology more functional andmeaningful. They recognized the value of technology in eliminating waste in thenursing workflow due to inefficient work patterns, interruptions, or distractions;missing supplies; and inaccessible documentation. These findings support thebusiness case for using technology to return more time to direct nursing careand to improve communication and implement other safeguards availablethrough smart devices.

Technology implementationin the clinical setting isn’t a project but rather a

transformation of the deliverysystem. As healthcare services in the United States and UnitedKingdom (UK) embrace technol-ogy to drive reforms in qualityand efficiency, growing opportu-nities exist to share experiencesbetween the two countries. To-day, many global nursing dia-logues are sharing lessons aboutcommunity-care delivery mod-els, nursing governance andadoption, interprofessional com-munication tools, and patientportals.

Now is the time to share prac-tices in nursing informatics globally. This is essential to thesuccess of the journey towardhealth information technology(HIT)-enabled transformation.Although many nurses might focus on differences in paymentmodels and delivery methods between the United States andthe UK, significant commonali-ties and experiences exist thateach country can share with theother. These were explored inJune 2013 by a group of UKnursing leaders who visited theUnited States.

Nursing informaticsimmersion study The 2013 UK Nursing Informat-ics (UK NI) Leadership U.S. Im-mersion Study was a joint effortby the Healthcare Informationand Management Systems Socie-ty (HIMSS), HIMSS Europe, andCerner Corporation. These part-ners launched a year-long initia-

tive aimed at promoting UKnurses’ role in implementingand using information technolo-gy (IT).

A hosted nursing-leadershipdelegation trip to Chicago culmi-nated the initiative. A 10-persondelegation of nursing informat-ics leaders was selected fromacross the UK to meet with U.S.nursing informatics leaders, visitkey U.S. healthcare facilities thatuse nursing informatics to deliv-er care, and meet with otherproviders, suppliers, and govern-ment leaders. The delegation ex-plored innovative technology,met with nurse executives, andspoke with nursing informatics

colleagues at three Chicagohealthcare facilities, all of whichhave achieved Magnet Recogni-tion® from the American NursesCredentialing Center. ManyMagnet® attributes became ap-parent to the delegates duringthese visits. (See Understandingthe Magnet Recognition Program.®)

Each of the three facilities hada specific focus:• Advocate Illinois Masonic

Medical Center: Connectingthe community through in-formatics

• Northwestern Memorial Hos-pital: The connected patient

• Ann & Robert H. Lurie Chil-dren’s Hospital of Chicago:Technology architecture anddesign.

Emerging ideas Introduction of robust and so-phisticated clinical informationsystems has prompted signifi-cant transformation in healthcare and focused greater atten-tion on patient safety and out-comes. Healthcare systems areunder increasing pressure to improve efficiency while stan-dardizing and streamlining organizational processes andmaintaining high-quality care.

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Collaborating on technology: A learningexchange between U.S. and U.K. nurses

Christel Anderson, MA, and Cathy Patterson, MSN, RN, MHA

An immersion studyfound that sharedgovernance helps

healthcareorganizations keep up

with technology. —

Understanding the Magnet Recognition Program® The Magnet Recognition Program® is an international organizational credentialgranted by the American Nurses Credentialing Center that recognizes nursingexcellence in healthcare organizations. It’s based on research indicating thatcreating a positive professional practice environment for nurses leads toimproved outcomes for patients and staff. Standards for obtaining MagnetRecognition® are based on research. Components of the Magnet® Model include: transformational leadership; structural empowerment; exemplaryprofessional practice; new knowledge, innovations, and improvements; andempirical outcomes.



The current knowledge explo-sion in health care requires cli-nicians to learn about and inte-grate information systems intotheir already demanding dailypractice.

As part of the nursing infor-matics immersion study, severalkey concepts common to boththe U.S. and UK nursing profes-sions emerged. These include a culture of inquiry, shared gov-ernance and accountabilitythroughout the organization,visible nursing leadership, andreal-time data reporting throughthe use of quality dashboards.

Culture of inquiryWorking closely with bedside cli-nicians and the IT department,the nursing informatics team isresponsible for development, im-plementation, and support ofnew systems. It’s also instrumen-tal in fostering a culture of in-quiry among the workforce. Giv-ing frontline staff access to dataprovides a scholarly approach tochange and transformation thatemphasizes evidence-based prac-tices and research.

Shared governance and accountabilityThe shared governance modelgives clinical nurses a voice indetermining nursing practice,standards, and quality of care.This empowers nurses to usetheir clinical knowledge and ex-pertise to develop, direct, andsustain their professional prac-tice. Interprofessional councilsand committees allow the nurs-ing informatics team to con-tribute to and share accountabil-ity for decisions made aboutpatient-care delivery. Patients also participate in councils tobring their unique voice.

Visible nursing leadership Presence of fully engaged nurs-ing leaders with a shared visionaligns with the Magnet philoso-phy and the Magnet model com-ponent of structural empower-

ment. Professional practice flour-ishes under influential leader-ship, creating an environmentwhere innovation is encouraged,adopted, and sustained. Al-though the three organizationsthe delegation visited had differ-ent leadership models, an under-lying theme was the need for aclinical leader, such as chiefmedical information officer(CMIO), chief nursing informa-tion officer (CNIO), or director ofinformatics. Nursing informaticsleadership is integral to help pro-mote and drive the organiza-tion’s clinical vision and providethe underpinnings for a success-ful roadmap.

Real-time data reportingwith quality dashboards Quality data are informing prac-tice at the bedside through real-time dashboards at each facility.The electronic systems were de-signed to monitor and captureadherence to indicators requiredby government and nursingstandards. One of the facilitieshad unit-based quality messageboards that informed patientsand families of monthly qualityoutcomes.

Key findings The immersion study foundthat organizations that empow-er their staff structurally by us-ing interprofessional shared-governance models have thecapacity and agility to deliverclinical decisions and transfor-

mation to keep up with tech-nology. Another key findingwas that supporting leadershiproles, such as chief clinical information officer (CCIO),CMIO, and CNIO, championthe clinical voice and bridgethe gap between the IT depart-ment and clinical staff. (SeeDelegates’ comments.)

Clinical transformation is acontinuous process that involvesassessing and continually im-proving the way patient care isdelivered at all levels. It occurswhen an organization rejects ex-isting practice patterns that de-liver inefficient or less-effectiveresults and instead embraces thecommon goals of patient safety,improved clinical outcomes, andquality care through process redesign and implementation. By effectively blending people,processes, and technology, clini-cal transformation occurs acrossfacilities, departments, and clini-cal fields of expertise. Constantmeasurement and analysis ofhow practice has developed orchanged from the point of deliv-ery is crucial for ongoing qualitydelivery. Analysis of clinicians’workflow is needed to determineif the current amount of directcare being delivered is enough toprovide not only good outcomesbut also compassionate bedsidecare. n

Christel Anderson is director of Clinical Informaticsat HIMSS in Chicago. Cathy Patterson is a nurseexecutive at Cerner in London, England.

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Delegates’ comments Delegates from the United Kingdom Nursing Informatics Leadership U.S.Immersion Study made the following observations during their visit to threeAmerican healthcare facilities:

“Informatics is taken very seriously across all levels of this organization and isintegral to care delivery. Nurses are fully engaged in the process.““Informatics, safety, quality, process change, education, and research were allpulled together into one nursing department.““If you separate technology from the normal clinical practice of nursing teamsand put it on top of the nurses’ normal workload, you’re doomed to fail.“

In 2010, Tenet Healthcarelaunched an aggressive roll-out of electronic health

records (EHRs) at 49 hospitals in12 states, to be completed byspring 2014—only 4 short years.Although federal meaningful-use incentives contributed to ourdesire to accelerate the schedule,the main driver was to improvepatient care through technology,achieving both meaningful useand meaningful care.

To reach this goal, we knewour project, called IMPACT (IM-proving PAtient CAre throughTechnology) had to be clinician-driven. We needed to design arepeatable methodology thattargeted sustainment, not imple-mentation, as the success crite-ria. Our challenge was to in-volve clinicians at all levels ofthe organization in planningand implementing the EHR so

they would own the “care andfeeding” of the clinical systembeyond the go-live date. As a re-sult, nurses have played, andcontinue to play, critical roles atall levels, including project andhospital leadership, standardsand governance, and trainingand support.

Project leadership As Tenet’s vice president of ap-plied clinical informatics, au-

thor Liz Johnson is the executiveleader for IMPACT. Her focus ison maximizing use of the elec-tronic record environment to im-prove care, rather than just im-plementing clinical systems. Aregistered nurse, Johnson is co-chair of the implementationworkgroup of the federal HealthInformation Technology Stan-dards Committee. In 2010, shereceived the Nursing InformaticsLeadership award from theHealthcare Information andManagement Systems Society(HIMSS). She brings both clinicaland public policy perspectives tothe project. One-third of John-son’s senior directors and half ofher directors are nurses, provid-ing a balance of clinical andtechnical talent to the leader-ship team.

Hospital leadership Every Tenet hospital has a clini-cal informatics director—a nurse


How nurses drive rapid electronic recordsimplementation

Liz Johnson, MS, CPHIMS, FHIMSS, RN-BC, and Dorothy I. DuSold, MA, CPHIMS

Nurses in one largehealthcare systemare involved at all

levels of EHRimplementation. —

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who serves as the clinical leaderduring EHR implementation andacts as clinical guardian forpost-implementation system andworkflow optimization. Eachhospital’s chief nursing officer(CNO) leads the multidiscipli-nary clinical-process improve-ment committee that definesnew workflow, policies, and pro-cedures to improve efficiency inthe electronic environment. Inmany Tenet hospitals, the CNOalso serves as the hospital exec-utive sponsor for IMPACT, pro-viding the drive and sense of ur-gency to the organization.

Standards and governance To realize the full benefits of theEHR, our organization recog-nized the importance of devel-oping and maintaining the clin-ical standards that are usedacross our hospitals. As EHR im-plementations reach a criticalmass, this will enable us tomine the data in a meaningfulway, identifying opportunities toimprove patient safety and gainefficiencies.

Nurses play a key role indefining these clinical standards.They participate in clinical advi-sory teams with other cliniciansto set the standards embedded inthe EHR. Hospital nursing repre-sentatives collaborate with re-gional and national nursingleaders on the nursing advisoryteam. Nurses also participate inthe clinical leadership council,comprising chairs of all advisoryteams, to approve standards thatcross multiple disciplines. In ad-dition, teams of nurses are re-sponsible for translating clinicalstandards into clinical systemdesigns that are built into theEHR. Each team specializes indifferent aspects of the system,such as obstetrics, emergency de-partment, surgery, perioperativeservices, general nursing, orders,and others.

Training and support Nurses play a significant role in

EHR training and ongoing sup-port throughout the organiza-tion. At the hospital level, nursesfill most of the training and “su-per-user” roles during EHR imple-mentation to prepare colleagues.After implementation, many con-tinue their roles to provide newemployee training, refresher ses-sions, and support during clinicalsystem upgrades, enhancements,or added functionality. At the en-terprise level, nurses account fora high percentage of our clinicalsupport teams, including a spe-cial clinical help desk that servesphysicians.

Tenet’s EHR project has led tonew career-development opportu-nities for nurses within the organ-ization. Many nurses continue to provide post-implementationoptimization and new function-ality design. The most significantaddition to Tenet’s core compe-tencies is the creation of a clini-cal informatics director positionat each of its 49 hospitals. Nurs-es in this role represent all clini-cal disciplines, ensuring align-ment of workflow and practicesacross the continuum of carewithin each hospital. They alsoserve as change agents and areeducated on the principles of be-havioral-change management,following a formal methodology.The organization has developeda formal clinical informatics pro-gram to recruit, educate, andcontinuously mentor our clinical

informatics directors.Since the inception of IMPACT,

we’ve hosted three clinical infor-matics academies, providingcontinuing education credits tomore than 70 nurses. We’ve alsodeveloped a skills assessment toprovide guidance to clinical in-formatics directors in their de-velopment and performance.Recently, we conducted a behav-ioral analysis of our clinical in-formatics population and identi-fied the “behavioral DNA” ofour top performers.

Tenet nurses are playing acritical strategic role in en-abling rapid EHR implementa-tion across our health system.They’ve had a tremendous in-fluence on the continuous im-provement of our repeatableEHR implementation methodol-ogy, which accounts for ourability to sustain an aggressiverapid rollout schedule across alarge enterprise. We conductformal “lessons learned” ses-sions after each hospital imple-mentation and incorporate follow-up actions in ourmethodology for future imple-mentations. Because of suchfeedback, our 2013 hospital im-plementations achieved higherperformance in such areas ascomputerized provider order entry use and online medica-tion reconciliation use, com-pared to initial hospital imple-mentations. Our nurses areinvolved at all levels of theproject implementation, as wellas the ongoing operational sup-port systems. n

Selected referencesJohnson L, DuSold D. Driving changethrough clinical informatics. Paper present-ed at: ANIA-Caring; 2012; Orlando, FL.

Johnson L, DuSold D. The purpose-drivenclinical informatics leader: A behavioralanalysis. Poster presented at ANIA-Caring;2013; San Antonio, TX.

The authors work at Tenet Healthcare Corporationin Dallas. Liz Johnson is vice president of AppliedClinical Informatics. Dorothy I. DuSold is seniordirector of Applied Clinical Informatics.

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Tenet’s EHR project has ledto new career-development

opportunities for nurseswithin the organization.

Many nurses continue toprovide post-implementation

optimization and newfunctionality design.


Older adults account formore than one-third ofacute-care hospitaliza-

tions and 58% of hospital days in Ontario, Canada. Leaders andstaff at Mount Sinai Hospital inToronto, Ontario, recognized thatthe current hospital system wasdesigned to meet the needs of ayounger population, not frail older adults. To better address theneeds of frail older adults, thehospital sought to develop pro-grams and tools that would helpcaregivers deliver the right care inthe right place at the right time.

Acute Care for Eldersstrategy Mount Sinai was able to seam-lessly implement and enhance itsAcute Care for Elders (ACE) strat-egy with its frontline cliniciansand informatics department, inpart because Cerner Millennium®

was already established as thehospital’s electronic healthrecord (EHR) platform. The infor-matics department staff met fre-quently with frontline caregiversto understand their needs andthe care they sought to provide.

Key components of the ACEstrategy include six evidence-based admission order sets (thegeneral ACE unit order set andsets for older patients with chron-ic obstructive pulmonary disease,heart failure, cellulitis, pneumo-nia, and hip fractures). The ACEsuperset contains several admis-sion order sets and ensures ACE-specific protocols are used in thecare of every older patient. Theyalso ensure patients receive opti-mal medications and care proto-

cols as quickly as possible so thatconsultations with specialists andallied health providers can beginmuch earlier.

ACE also integrates documenta-tion of key geriatric clinical pro -cess and outcomes indicators intoMount Sinai’s existing clinical doc-umentation tools. These indicatorspopulate the vital signs section ofthe health record to better supportthe care of frail elderly patientsand help monitor the overallquality of care being delivered.

Also, a more seamless inte-grated service delivery model hasbeen implemented at severalpoints in the hospitalizationprocess and within severalteams. This model promotes ini-tiation of appropriate care in theemergency department (ED) and

helps coordinate patient care inreal time. Development of a real-time ACE report providing the lo-cation of ACE-designated pa-tients across the hospital helpsstaff identify these patients moreeasily, aids transfer prioritizationto the ACE unit, and allows staffto initiate best-practice care pro-tocols wherever they may be.

Linked communication system In addition to these hospital-basedstrategies, point-of-care interven-tions across the continuum of carehave been enhanced by the cre-ation of an email-notification andcommunication system regardingfrail community-dwelling patientsin the Mount Sinai/CommunityCare Access Centre (CCAC) Inte-grated Client Care Project (ICCP)and the House Calls program. Ifone of these patients requires anunscheduled trip to the ED, thepatient’s arrival in the ED triggersemail notification, promotingcommunication about the pa-tient’s care.

The goal of this linked com-munication process using secureemail is to enable important in-formation exchange among clini-cal team members who know thepatient at different points alongthe care continuum. Ideally, thisinformation exchange is solutionfocused, aimed at avoiding hospi-talization whenever possible andhelping the patient return to thecommunity as soon as possible. n

Barb Duffey-Rosenstein is the director of nursinginformatics at Mount Sinai Hospital in Toronto,Ontario Canada. Samir K. Sinha is the director ofgeriatrics at Mount Sinai and the University HealthNetwork hospitals.

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How electronic health records areimproving health care for elderly patients

Barb Duffey-Rosenstein, RN, MSc, and Samir K. Sinha, MD, DPhil, FRCPC

Innovativeinformation

technology tools helpensure patients getthe right care at the

right time. —

What an exciting time tobe a healthcare providerin the United States. All

types of providers, along withtheir patients, are realizing thepower of health information tech-nology (HIT) as a tool to assisteach person’s journey toward bet-ter health and better care at lowercost. From where I sit in the Officeof the National Coordinator forHealth Information Technology,I’m encouraged every day by theleadership and clinical innova-tion occurring across the nationin this time of profound change—especially among nurses.

So let’s look at how we got towhere we are today. Passage oflandmark healthcare reform legis-lation, including the Health Infor-mation Technology for Economicand Clinical Health (HITECH)component of the American Re-covery and Reinvestment Act in2009 and the Affordable Care Act(ACA) in 2010, has changed thelandscape of the U.S. healthcare

industry forever. HITECHcreated the ElectronicHealth Record (EHR) Incen-tive Program, administeredby the Centers forMedicare & MedicaidServices and the Office ofthe National Coordina-tor for Health Infor-mation Technolo-gy. The programprovides fi nan-cial incentivesto eligible pro-fessionalsand hospitalsthat im-plement,

adopt, and meaningfully use cer-tified EHRs.

The program has worked. In 4 short years, EHR adoption hasrisen dramatically. As of July2013, 60% of eligible profession-als (312,072 of 521,600) and 81%of eligible hospitals (4,051 of5,011) were participating in thevoluntary program and had re-ceived a Medicaid or MedicareEHR incentive payment for eithermeeting the meaningful use crite-ria or fulfilling the requirementsfor adoption, implementation, orupgrade of a certified system.

The Obama Administrationencouraged EHR adoption withthe passage of HITECH in 2009,because EHRs are an integral ele-ment to drive healthcare qualityand efficiency improvements andare foundational to the health-care delivery and payment re-form needed to transform the in-dustry. Thus, EHRs are critical tothe broader healthcare improve-ment efforts that are part of theACA. These efforts—improvingcare coordination, reducing du-plicative tests and procedures, focusing on high-quality out-comes, and rewarding providersfor keeping patients healthier—are all made possible by wide-

spread use of EHRs and datasharing among EHRs throughhealth information exchange.EHRs manage health informationin ways that are patient centeredand give all providers the abilityto better coordinate care, consis-tently deliver best practices, andreduce errors and readmissionsthat can cost more money andleave patients less healthy.

From silos tointerconnectedness During this transformation fromdisconnected, inefficient, paper-based “silos” of care delivery to aninterconnected, interoperable datasystem driven by EHRs, the impor-tance of nurses and nursing infor-matics has become increasingly evident. For decades, nurses havecontributed proactively to the de-velopment, use, and evaluation ofinformation systems. Today, theyconstitute the largest group ofhealthcare professionals working inHIT and are integrally involved inEHR selection, implementation,and optimization. Nurses serve onnational committees and initiativesfocused on HIT policy, terminolo-gy and standards development,health information exchange, andEHR adoption. In their frontlineroles, they are having a profoundimpact on healthcare quality andcosts, and are serving as leaders inthe effective use of HIT to improvethe safety, quality, and efficiencyof healthcare services. Yes—it’s aremarkable time to be a nurse inthe United States. n

Judy Murphy is Deputy National Coordinator forPrograms and Policy at the Office of the NationalCoordinator for Health Information Technology, U.S.Department of Health and Human Services.

Progress report: Electronic health recordsand HIT in the United States

Judy Murphy, RN, FACMI, FHIMSS, FAAN

Electronic healthrecords, HIT, and

nursing informaticsare transforming

American health care. —


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Nurses on the front line ofcare in the NationalHealth Service (NHS) of

the United Kingdom (UK) areacutely aware of the pressuresfacing the health service. Risingdemand for services (particularlyemergency services) and a tightfinancial environment mean weall need to do more with less.

We’re also well aware of theimpact these pressures place onour daily jobs and ability tospend valuable time with pa-tients. To maintain a focus onquality, last year NHS Englandlaunched the “Compassion inPractice” nursing and midwiferystrategy. This brought togetherthe “6 Cs”—care, compassion,competence, communication,courage, and commitment—asthe underpinning values of theprofession.

Given this pressured environ-ment, why did UK Health Secre-tary Jeremy Hunt in January setout his priority for the NHS to bepaperless by 2018? The answer issimple: Only by embracing tech-nology can the NHS meet thechallenges it faces over the nextdecade and beyond.

While the history of health in-formation technology (HIT) in theNHS is a complicated one, there’sno doubt that technology has thepotential to contribute directly toimprovements in care. Technolo-gy can free up nursing time bydigitizing such processes as earlywarning scores, nurse rounding,device integration, digital pensfor the community, and support-ing communication between cli-nicians. What’s more, the simple

act of capturing patient informa-tion on an electronic rather thanpaper record means patients’ de-tails and medical history can bemade available to clinicians atthe point of care easily and accu-rately. Earlier this year, NHS Eng-land detailed a vision for makingan integrated digital care recordfor each patient available acrossthe NHS—one that reinforces theactive role nurses must play inembracing technology to captureand share patient informationelectronically.

The next step will be for nursesacross the NHS to use this infor-mation to change and improvethe way they work, closing thefeedback loop on the careprocess. Based on electronic pa-tient records, the UK govern-ment’s care.data initiative willdraw together and link individ-ual patient information fromacross primary, secondary, andacute-care settings, making itavailable to clinicians, providers,payers, and patients themselves.This will allow analytical insightsto be drawn on how all parts ofthe health system can contributeto improvements in outcomes.

However, the NHS must becareful to avoid information

overload. Too often, centralizeddata reporting requirements thatstart with the right aims becomebureaucratic burdens on nurses’time. NHS England is workingwith providers through the NHSConfederation on the “BustingBureaucracy” campaign to re-move duplications and redun-dant data from the system, mak-ing sure it captures only the data most valuable to improvingoutcomes.

Clearly, getting the most fromtechnology requires investment.The first aspect is financial: Thegovernment recently released adedicated £100m nursing-tech-nology fund (equivalent to about$160 million U.S. dollars) to helphospitals get the systems theyneed. This is backed up by abroader £500m investment inhealth technology made avail-able to acute trusts over 3 yearsto 2015-2016.

The second investment is aprofessional one. Getting valuefrom technology and informationrequires training,strategic planning,and an appetite to usehealth data to improvethe way we work. Itwill require nurses,midwives, and healthvisitors to take onthe leadershipchallenge acrossall levels of or-gani zations. n

Anne Cooper is clinicalinformatics lead (nursing) for NHS England.

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Paperless in the United Kingdom: National Health Service goal for 2018

Anne Cooper

The National HealthService must

embrace technologyto meet the

challenges it faces. —

www.AmericanNurseToday.com SR11

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The single biggest changeto nursing in a generationin the United Kingdom

(UK) is the transition to a pa-perless National Health Service(NHS, the publicly fundedhealthcare system) by 2018. Itoffers an opportunity to radical-ly improve the quality of careby using better information tomake faster, safer clinical deci-sions. The challenge for nursesis to seize control of thatchange, using our expertise toshape the technology ratherthan letting the technologyshape us.

The lesson from early NHSadopters of information technol-ogy (IT) is clear: Success hingesnot on IT wizardry but on nurses’willingness to lead the changethey want to see. We have thechance to redefine what excel-lent care looks like. The test nowis to make that a reality.

When challenging timelinesare set, it’s all too easy to focuson the “when.” But for transfor-mation to succeed, nurses firstneed to understand the “why.”That means putting informationat the heart of clinical strategy.Too often, we make crucial deci-sions based on the pieces of in-formation we have, not the com-plete picture we’d like to have. Ifwe get it right, it’s in spite of theinformation, not because of it.That’s frustrating for us anddangerous for patients.

As early adopters of the infor-mation challenge, we’ve seenhow things can be different.Where nurses have access to in-formation at the bedside, they

can make quicker decisions.Where they’re free from admin-istrative burdens, they havemore time for patient care.Where automated alerts preventmedication errors, patients aresafer. Information underpinsimproved care.

A chance for nurses toinfluence the IT agenda The drive to a paperless NHS in2018 is an opportunity to influ-ence the information agenda.It’s a chance to shape the un-derpinning technology, ensuringit provides the data we need tomake the right decisions. Thedanger is that nurses may failto grasp the scale of this oppor-tunity. We all need to under-stand that this isn’t a back-office IT project with a startpoint and end point. It’s a clini-cal transformation project thatwill continually improve thequality of care. Technology isthe means to enhance out-comes, not the end in itself.

The NHS isn’t facing this chal-lenge from a standing start.Some trusts already are usingimproved information to im-prove patient outcomes. Experi-ence from early adopters offers

valuable lessons for those whowill follow in their footsteps. (SeeFirst things first: Assess existingpro cesses.)

Visible clinical leadership Clinical improvement requiresvisible clinical leadership. Clini-cians must define medical ob-jectives and communicate howthese will be achieved. Whenthe authors helped design thetechnology systems for our ownhospitals, we provided a moreholistic view of patient care, ad-vising on the patient’s needs ateach stage. That helped ensurethe information flow aligned di-rectly with the patient pathway.When our IT colleagues becamedistracted by project details, webrought the focus back to pa-tients. What matters isn’t what’stechnologically possible butwhat’s clinically essential.

The trend toward appointingchief medical or nursing infor-mation officers in the UnitedStates and chief clinical infor-mation officers in the UK is es-sential to strengthen clinicaloversight of information proj-ects. These officers help bridgethe gap in understanding be-tween the IT and clinical com-munities. The result is care trans-formed by data, which drivesmore proactive interventionsand allows outcomes measure-ment. As we prepare for 2018,we need to see more nurses em-brace the challenge of informat-ics leadership.

Clinical leadership fostersclinical credibility. Disruptingthe status quo by asking nursesto change how they work is nev-er easy. But it’s far more likely to

Preparing for electronic health records in the UK

Gerry Bolger, MHM, RN, Fergus Keegan, MBA, DMS, RGN, and Cathy Patterson, MSN RN, MHA

The transition to apaperless health

system is a chancefor nurses to shape

the technology. —


succeed if led by someone thenursing community respects. Toensure that nursing is key in thetransition requires someone whocan speak the nurse's languageand engage nurses. Ideally, thisperson should be a nurse. Com-munication and leadership skillsmatter more than titles.

Helping nurses embracechange Nurses need to be persuaded, notcompelled. We need to acknowl-edge that change can be unset-tling. That’s why engagementshould be at the heart of theprocess, not an afterthought.Talk of code upgrades will cut little ice on a busy unit. Instead,nurses need to understand howbetter information will stream-line their work, promote moreinformed decisions, and releasemore time for them to pro-vide care. Nurses willbe more tolerant ofbumps in thejourney ifthey knowwhy

they’re on the journey and howit will benefit patients.

Visibility is crucial to per-suading skeptics to embracechange. Even the best-plannedchange processes will encountercritics. It may be tempting todefer engaging difficult groupsand instead focus initial ener-gies on more persuadable col-leagues. But difficult though itis, early engagement is far moreeffective. Where hostility festers,it grows stronger and risksspreading. Clinical leadersshould take the time to under-stand nurses’ concerns, schedul-ing training early to help allayfears about what’s coming.

Establishing simulation unitsto demonstrate new technologyis particularly effective in coun-tering

latent resistance to technology.Nurses who can visualize achange are less afraid of it.Clinical leaders should be a visi-ble presence on units, answer-ing questions and ensuring staffbelieve their opinions are heard.

Using information to trans-form the quality of care is a ma-jor change for the NHS, but it’sclinically essential. Putting infor-mation at the heart of care maynot be easy, but if we fail to em-brace the challenge, we’ll failour patients—and that’s not anoption. Instead, we have to seizethe information agenda and of-fer the strong clinical leadershipit needs. It will succeed only ifnurses are clear about what theyneed and step up to the job ofmaking it happen. That meansassuming responsibility for infor-matics leadership rather thanhoping someone else does. Weknow our jobs better than any-one, and we understand whatour patients need. It falls to us toset new standards in the qualityof care. n

Gerry Bolger is nurse lead for Clinical Systems andInformation and Communication Technology atImperial HealthCare NHS Trust in London, England.Fergus Keegan is deputy director of nursing at the

Kingston Hospital (UK) NHS Foundation Trust.Cathy Patterson is a nurse

executive at CernerLimited (UK).

First things first: Assess existing processesBefore we can improve our use of information, we have to acknowledge wherewe currently get it wrong. When preparing for any change, it’s easy to focus onwhat’s new. For nurses consumed with hectic workloads, this is an understandableinstinct. But that approach misses the chance to step back and assess existingprocesses. A poor digitized process is still a poor process. Instead, the starting point should be to identify how duplicated documents

and unnecessary bureaucracy can be removed from the workflow before they’redigitized. Such disruptive innovation isn’t always popular, but it’s essential iftechnology is to drive transformation.

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Ten years ago, VirginiaCommonwealth UniversityHealth System (VCUHS)

embarked on a safety journeywith a vision of becoming Ameri-ca’s safest health system. Thegoal—zero events of preventableharm to patients, employees,and visitors.

While safety and quality havebeen an ever-present part of ourculture, our focus was on compli-ance with state, federal, andJoint Commission regulatorystandards. We implementedprocesses to meet core measurerequirements, created a falls pre-vention program, and instituteda rapid response team (RRT).And while we saw each of thesesucceed, we knew we wanted toachieve more than just regulato-ry compliance. How could wetruly achieve our vision of offer-ing patients the safest healthcare in the nation?

In 2008, 5 years into our jour-ney, our leadership team deter-mined we needed to acceleratethe rate of quality and safety im-provement. Instead of thinkingvertically, we needed to think

horizontally across all existingprograms to create a true cultureof safety. VCUHS decided to im-plement behavioral expectationsto prevent errors and manage theorganization using a high-relia-bility performance model—oneused successfully by nuclear pow-er plants and air-traffic controlsystems. To bring our culture ofsafety to life, we needed a mix ofbehavioral changes and techni-cal approaches. Every member ofour organization from the board-room to the bedside received edu-cation on safety, reliability, effec-

tive teamwork, communication,and collaboration. We believethat by harnessing the knowl-edge and skills of our people todesign safe processes and usetechnology appropriately, our or-ganization will become more reli-able and safer for our patients,team members, and visitors.

Behavioral changes VCUHS developed a “Safety FirstEvery Day” behavioral changestrategy to challenge all staff tothink about safety first—all day,every day. This strategy includes:• senior leaders’ commitment to

safety through daily roundingon clinical units and discus-sions with nurses on safety

• recognition of staff membersby the chief executive officerfor “everyday” safe behaviorand error prevention for pre-venting harm and reportingnear misses. More than 140employees have been recog-nized since 2008. Safety starexemplars are displayed onevery computer throughoutthe organization using ourscreen-saver system, Net Pre-senter. More than 12,000 em-ployees and physicians havecompleted training on theprinciples of safety and how toachieve sustainable improve-ments. All nurses are speciallytrained in all aspects of effec-tive teamwork, communica-tion, and relationship man-agement. The nursingprofessional practice modelprovides a foundation ofshared governance and sup-ports the values of caring,knowledge, leadership, andcollaboration.

A Case Study: Using Technology to Build a Culture of Safety

Deb Zimmermann, DNP, RN, NEA-BC

An emphasis on aculture of safety andappropriate use of

technology help theorganization deliver

safer and moreefficient health care. —


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• 50 clinical nurses serving vol-untarily as safety championsand providing peer coachingon use of safe behavioral anderror-prevention strategies

• an innovative 15-minute dailyconference call that reviews thesafety status of more than 30operational areas of the hospi-tal. In a roll-call format, everyarea reports on such concernsas patients holding in theemergency department, patientfalls, patients in restraints, orpatients on suicide precau-tions. Team-member injuriesand blood and body fluid ex-posures also are reviewed. This15-minute call keeps leadersconnected to frontline opera-tions and focused on safety.Concerns are addressed imme-diately, and follow-up is report-ed to the entire health systemon the next day’s call. Hun-dreds of staff members partici-pate in this call each day.

Technical approaches Technology has played a majorrole in the ability of VCUHS toprovide safer patient care. Everyday, more than 2.5 million trans-actions are processed through ourelectronic health record (EHR),powered by Cerner. VCUHS nurs-es have documentation availableat their fingertips about a pa-tient’s full continuum of care.This saves valuable time and,more important, creates a saferenvironment because nurses canget timely, accurate patient datafrom all specialty disciplinesacross the continuum of care.

Also, recognizing that datamust be acted on to achieve bet-ter outcomes, we’ve implemented653 active EHR alerts to provideclinical-decision support. The sys-tem can provide a crosscheck fornurses, warn about a negativemedication interaction, or offerguidance that could decrease pa-tient complications.

What’s more, VCUHS nursescan view a safety dashboard thatidentifies high-risk situations or

patients’ safety-risk information.Nursing units conduct daily safe-ty huddles and use a safety dash-board as part of their huddles.For all patients on a unit, thedashboard displays on a singlescreen the key indicators of a pa-tient’s care and health status,such as fall risk; need for physi-cal restraints; presence of I.V.lines, urinary catheters, and sur-gical drains (all of which in-crease the risk of infection); andany overdue medical orders.With this ability to quickly assessat-risk patients, nurses can inter-vene before a problem occurs.The dashboard is accessed morethan 300 times daily, and thecore indicators displayed havedemonstrated measurable im-provement. For example, wehave reduced the rates of patientfalls and falls with injuries by50%. The dashboard has led toorganization-wide additional ed-ucation in deep vein thrombosis,pressure-ulcer reduction, and useof physical restraints.

Perhaps the most exciting ex-ample of effective leveraging oftechnology to improve care isour Medical Early Warning Sys-tem and Pediatric Early WarningSystem (MEWS/PEWS). Inspiredby one of our critically ill pedi-atric patients, we recognized theneed for our nurses and RRT tohave a real-time monitoring sys-tem that continuously measurespatient acuity and severity. Usinginformation from the EHR,MEWS/PEWS identifies the most

critically ill and decompensatingpatients and assigns each one ascore. Clinicians and the RRT usethe information to interveneproactively and escalate care.

The results for the first year areremarkable. The RRT uses the da-ta as its compass to guide prioriti-zation of our sickest patients. TheRRT doesn’t wait to be called if apatient is in distress. Instead, theteam accesses the MEWS/PEWSscore on mobile devices and ar-rives at the bedside to assess andintervene—at times, ahead of theprimary team and nurse. Sincelaunching MEWS/PEWS, there hasbeen a 5% reduction in in-housemortality and a 30% reduction incardiopulmonary arrests outsidethe intensive care unit. (SeeAchievements at the 10-year mark.)

At VCUHS, we consider it anhonor and a privilege to care forthe citizens of our community.It’s up to us to make sure ourwork is achieving the outcomesthat patients deserve and expect.Clinicians have always workedhard. Now, we work smarter aswell, partnering with interprofes-sional colleagues, technology ex-perts and, most important, pa-tients to provide efficient andeffective health care and createhealthier populations. n

Deb Zimmermann is chief nursing officer and vicepresident of Patient Care Services at VirginiaCommonwealth University Health System inRichmond, and chair of the American NursesCredentialing Center’s Commission on the MagnetRecognition Program®.

Achievements at the 10-year markTen years into our campaign to reach zero events of preventable harm topatients, employees, and visitors, Virginia Commonwealth University HealthSystem (VCUHS) has achieved great results, thanks to safety-behavioral changesand technical approaches. During the past 4 years, VCUHS has: • reduced mortality by 30% and hospital-acquired infections by 88%• sustained low rates of hospital-acquired pressure ulcers, restraint use, andfalls with injuries

• improved skin integrity rates.

In fact, we’ve seen statistically significant improvements in all 12 of the keysafety themes we measure. We expect results to improve even more as theVCUHS culture of safety continues to grow and thrive.

Introduction of the stetho-scope in the 1800s met greatresistance among clinicians,

who considered it invasive andcontrary to current clinicalpractice. In 1834, The Times ofLondon quoted a British physi-cian’s opinion of the stetho-scope: “That it will ever comeinto general use, notwithstand-ing its value, is extremelydoubtful because its beneficialapplication requires much timeand gives a good bit of trouble,both to the patient and to thepractitioner because its hue andcharacter are foreign and op-posed to all our habits and as-sociations.”

Today, few clinicians couldimagine providing clinical care

without the aid of a stetho-scope. The tool has become sointegrated with their practicethat most clinicians consider itpart of their standard uniform,

wearing it proudly as a symbolof their knowledge and profes-sional standing. But it’s not thetool itself that has transformedclinical practice. Rather, it’s theeffective use of the stethoscopein the ears of an experiencedclinician that can distinguishgood sounds from bad and dramatically affect patient outcomes.

Similarly, in the 21st century,health information technology(HIT) has met resistance amongsome clinicians. Nonetheless,it’s fundamentally changingthe skills and behaviors re-quired in the workplace. No -where is this change more pro-found than among the 3.1million nurses, who make upthe largest segment of the U.S.healthcare workforce.

Technology, transformation, and the nursing workforce

Mark D. Sugrue, RN-BC, CPHIMS, FHIMSS

Nursing informaticsprofessionals areready to lead the

transformation to atechnology-enabled

healthcareenvironment. —

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Nursing informatics professionals at the leading edge Since the earliest days of tech-nology adoption in health care,nursing informatics profession-als have been at the forefrontof leading change. Early pio-neers included nurses who ef-fectively combined the scienceof nursing with computer andinformation science to supportthe clinical workflow, addingvalue to the organization asthey began their journey to jointhe digital revolution. In 1992,the American Nurses Associa-tion formally recognized nurs-ing informatics as a specialty.Since then, the field has grownand the demand for nursing in-formatics professionals hasbeen increasing at unprecedent-ed rates. Authors of the 2011Nursing Informatics Work-force Survey from the Health-care Information and Manage-ment Systems Society (HIMSS)noted that the average salaryfor nursing informatics profes-sionals was almost 17% higherthan it was in 2007 and 42%higher than in 2004.

Today, one of the key roles ofnursing informatics profession-als—and a role in which theyadd significant value—relates toclinical transformation. Accord-ing to the HIMSS 2011 ClinicalTransformation Survey, “Clini-cal transformation involves as-sessing and continually improv-ing the way patient care isdelivered at all levels in a care-delivery organization. It occurswhen an organization rejectsexisting practice patterns thatdeliver inefficient or less effec-tive results and embraces acommon goal of patient safety,clinical outcomes, and qualitycare through process redesignand IT implementation. By ef-fectively blending people,processes, and technology, clini-cal transformation occurs acrossfacilities, departments, and clin-ical fields of expertise.”

Experience shows that simplyoverlaying technology atop ex-isting processes doesn’t work.Yet many organizations, in theirhaste to become more connect-ed or achieve government in-centives related to electronichealth information, are imple-menting technology withoutconsidering the need to trans-form clinical practice or the

workflow. And in many cases,this is happening without quali-fied, experienced, and creden-tialed nursing informatics resources. In organizations lack-ing a strong workflow andprocess advocate, the technolo-gy may take on a life of its ownand begin to lead and inhibitclinical transformation ratherthan support and enable it. Ul-timately, this results in signifi-

cant resistance, workarounds,and unintended consequences.

Nursing informatics profes-sionals also are helping to ac-celerate the changing skills andbehaviors required for the 21st-century nursing workforce. Rec-ognizing the need to adapt toan increasingly rich and tech-nology-enabled environment, agroup of nursing informaticsleaders formed the Technology,Informatics, Guiding Educa-tion Reform (TIGER) Initiativein 2006. The goal of TIGER is tobetter define workforce compe-tencies and effectively inter-weave evidence and technologyinto practice, education, and re-search. In addition to basiccomputer literacy, TIGER com-petencies include informationliteracy and clinical informa-tion management competenciesfor all practice levels. TIGERserves as a valued resource andcontinues to advance the inte-gration of health informatics totransform practice, education,and consumer engagement.

Without doubt, technology-enabled tools affect every aspectof the nursing process in everycare-delivery environment.From clinical documentationsystems used to collect and storeassessment data to closed-loopmedication systems and wirelessdevices that promote adherenceto the six “rights” of medicationadministration, these changesare occurring in all practice set-tings (including the patient’shome). Nursing informatics pro-fessionals stand ready not onlyto support but also to lead thetransformation to a technology-enabled healthcare environ-ment. With the right leadershipand the right approach, HITcan achieve its promise and be-come as integrated into clinicalpractice as the stethoscope. n

Mark D. Sugrue is Director, Health IndustriesAdvisory of PricewaterhouseCoopers LLP in Boston,Massachusetts, and chair of the HIMSS NursingInformatics Committee in Chicago, Illinois.

Today, one of the key roles

of nursing informatics

professionals—and a role in

which they add significant

value—relates to clinical

transformation. According to

the HIMSS 2011 Clinical

Transformation Survey,

“Clinical transformation

involves assessing and

continually improving the

way patient care is

delivered at all levels in a

care-delivery organization.“

http://www.thetigerinitiative.org



http://www.himss.org/files/HIMSSorg/handouts/ClinicalTransformationSurveyFullResults.pdf

http://www.himss.org/files/HIMSSorg/handouts/ClinicalTransformationSurveyFullResults.pdf

http://himss.files.cms-plus.com/HIMSSorg/content/files/2011HIMSSNursingInformaticsWorkforceSurvey.pdf




As military leaders know,no battle plan survivesits first contact in battle;

too many variables exist. Thesame can be said of nurse staff -ing. In health care, the “firstcontact” occurs when staff mem-bers call in sick and patientnumbers or acuity increase or decrease more than planned.

Scheduling and staffing aren’tsimply a matter of achieving acertain ratio; the cost of mistakescan be measured both in dollarsand human lives. Applied tech-nology is improving our abilityto assemble real-time, actionableinformation to support staffingdecisions and resource alloca-tion. New evidence-based soft-ware computes large amounts ofdata and applies algorithms thathelp match the right nurse to theright patient at the right time—and at the right cost. This articledescribes how nursing leadersare using and benefiting fromtechnology that integrates pa-tient demand, nursing workforce

as a resource, and evidence-based practice for staffing.

Resource-demandmanagement Catholic Health Initiatives (CHI)has combined technology, busi-ness processes, and a collabora-tive care management strategyto optimize care delivery andmanage length-of-stay bench-

marks. A nationalnonprofit health sys-tem based in Colo rado,it operates nearly 90hospitals in 18 states.To update each pa-tient’s progress contin-uously, CHI uses a so-lution with real-timeinterfaces with the hos-pital’s admissions, dis-charges, and transfers(ADT); the electronichealth record; andconcurrent coding sys-tems. As nurses docu-ment patient care, acu-

ity is calculated based on thewhole patient, including activi-ties of daily living; physical, psychosocial, educational, andperceived needs; and family sup-port. The system automaticallycalculates the staffing levels andskill mix needed to help the pa-tient progress and adjusts thelevels based on ADT activity.

The healthcare team roundstogether in the patient room anduses the information obtained tomanage the patient’s care towarda single departure date and time.Carol Wahl, chief nursing officer(CNO) at CHI’s Good SamaritanHealth Systems in Kearney, Ne-braska, states, “Patient satisfac-tion has skyrocketed… caregiversreport that combining care man-agement with case managementis delivering better, more coordi-nated patient care.”

Workforce-managementsolutions Midland Memorial Hospital(MMH), a not-for-profit hospitalserving northwest Texas, usesworkforce-management technol-ogy to optimize the quality ofcare and control costs. Centeringon a web-based portal for real-time schedule management, thesoftware is fully integrated withhuman resources, education,and time and attendance data.MMH has automated its sched-uling, established self-schedulingpractices, and created a fatigue-management guideline. Selectednursing competencies, such asadvanced cardiac life support,are visible on the staffing page,alerting nurses to keep their li-censure and certifications active.Nurses can self-schedule into an

Using technology to make evidence-basedstaffing assignments

Amy Garcia, MSN, RN, and Kate Nell, MA, RN

Workforce-managementsoftware andoperational

integration helpmatch the right nurseto the right patient at

the right time. —

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open slot only if they meet therequirements of that role.

MMH also uses a patient-assignment tool that recognizesthe importance of continuity ofcare. The technology helps nursesand leaders achieve balanced as-signments while creating an elec-tronic record of primary and reliefassignments. The nurse leadercan use drag-and-drop functional-ity to assign nurses additional du-ties, such as crash-cart checks,narcotics counts, and refrigeratorchecks. Transparency of assign-ments can change nurses’ percep-tion of the fairness and equity ofthose assignments (a key compo-nent of nurse satisfaction).

ShiftAlert is an important toolthat frees up time for staffing offices and charge nurses, whotypically spend hours each daycalling nurses to fill gaps in theupcoming shift. This system com-municates urgent, short-termstaffing needs to qualified staff viatext messages, email, and interac-tive voice response. Using theunit’s supporting business process-es, ShiftAlert first offers the openshift to nurses qualified to work onthat unit who wouldn’t be earningovertime or premium pay. Thesoftware eases the administrativeburden of charge nurses, helpingthem focus more on patients andstaff development.

The technology MMH uses to optimize the workforce andprogress of patient care hasyielded significant returns. Ac-cording to CNO Bob Dent, “Theimprovements in costs were cap-tured in the reduction in andelimination of high-cost labor,such as overtime and agency usage. At MMH, the return oninvestment for the technologyhappened within the first year.”

Technology that integratesoperations Florida Hospital System, an inte-grated system serving central Flori-da, is installing command centersto serve as operational headquar-ters where staff can see at a glance

whether patient flow, staffing, andcare coordination are operating atequilibrium. “Dashboard” viewsdisplay bed management, surgery,emergency department, trans-portation, environmental services,and equipment status simultane-ously in real time. Such integra-tion of operations that previouslyexisted in silos helps staff makeactionable decisions to maximizeoperational efficiency and clinicalexcellence.

Nursing leaders make decisionson staffing resources every day,but determining if those decisionsare good ones can pose a chal-lenge. Dan Roberts, associate di-rector for nursing at Stony BrookMedicine, a teaching healthcaresystem in Long Island, New York,uses technology to inform the fol-lowing questions: “Did we maxi-mize people, processes, and tools?Did we have the right patient onthe right unit with the right planof care with the right staff doingthe right things?” He comments,“These new operational ‘rights’ ofnursing point to access, quality,and cost. If you have these rightsas a part of your nursing model,how do you know you have themcorrect…in real time? These ques-tions are particularly important asgovernments and payers encour-age reductions in length of stayand tie reimbursement to meas-ures of quality and satisfaction.”

Systems that provide real-time staffinginformation CHI, MMH, Florida Hospital Sys-tem, and Stony Brook Medicineuse technologies that provide real-time, actionable informationon safe staffing. These technolo-gies give nurses transparencyabout patient acuity, intensity, stability, and progress so they canmore easily make assignmentsthat take into account continuityof care, educational and profes-sional characteristics, skill mix,and work environment. Nursescan use reports to predict patients’needs prospectively and can use

shared-governance models to cre-ate schedules using systems pro-grammed to account for unitcharacteristics, union contracts,and labor law. With the aid of thistechnology, they can fill staffinggaps and understand the financialimpact of moment-to-moment de-cisions. They can link demand forcare and hours worked to nursing-sensitive quality measures.

Imagine a future where nurs-ing is reimbursed for the valuenurses bring—where nurses haveeasy access to staffing, patientprogress, and financial informa-tion; where they maximize tech-nology to clearly establish the relationships between an invest-ment in nursing care and betterpatient outcomes; where theywork with the finance officer to make the right investment.Imagine a future where technol-ogy helps us match the rightnurse to the right patient at theright time. That future is now. n

Selected referencesAmerican Nurses Association. ANA’s Princi-ples for Nurse Staffing. 2nd ed. SilverSpring, Maryland: Author; 2012.

Caspers BA, Pickard B. Value-based resourcemanagement: a model for best value nursingcare. Nurs Adm Q. 2013;37(2):95-104.

Creating value for patients for business suc-cess. Leadership. 2011;25-8. www.hfma.org/Content.aspx?id=3685 Accessed September24, 2013.

Dent R, Bradshaw P. Building the businesscase for acuity based staffing. Nurs Leader.2012;10(2):26-8. www.nurseleader.com/article/S1541-4612(11)00341-7/abstract. Accessed September 24, 2013.

Garcia A. A patient acuity checklist for thedigital age. Nurs Manag. 2013;44(8):22-4.

The authors work at Cerner Clairvia in Kansas City,Missouri. Amy Garcia is the chief nursing officerand Kate Nell is the director.

Nursing Times Learning has producedan online learning unit on nursing doc-umentation. “Clinical Record-keeping”features case-based scenarios to helpnurses relate their learning to practice,and learners can print out a person-alised certificate on successful com-pletion. For more information go to:www.nursingtimes.net/record-keeping.

http://www.nursingtimes.net/record-keeping

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