Electronic Health Records

Nursing approach to meaningful use, EHR adoption: CIO series

For a healthcare system focused on achieving the highest stages of EHR adoption based on the HIMSS Analytics EMR Adoption Model (EMRAM), the objectives and thresholds required by the meaningful use of certified EHR technology in the EHR Incentive Programs represent a small step rather than a giant leap forward.

Take computerized physician order entry (CPOE), for example. CPOE might appear daunting to a healthcare organization or provider adopting an EHR system for the first time in Stage 1 Meaningful Use. However, for a health system like Texas Health Resources attempting to achieve a fully-paperless care environment, the ability to use telephone and verbal orders for meaningful use falls short of supporting its mission to become a Stage 7 hospital.

Another dichotomy that emerges in EHR adoption focuses on the end result of using this technology among clinicians, namely physicians and nurses. Whereas physicians generally look to improve clinical workflows and efficiency, nurses tend to look to this technology to improve patient experience and safety.

In this installment of the CIO Series, Mary Beth Mitchell, MSN, RN, BC, who serves as the Chief Nursing Informatics Officer (CNIO) for Texas Health Resources, describes the differences between EHR adoption and meaningful use as well as the approaches of physicians and nurses to using EHR and health IT systems.

Describe the organization’s implementation of EHR and achievement in terms of EMRAM?

We’ve implemented the EHR in 14 wholly-owned hospitals from 2006 through 2012, and our latest hospital, Texas Health Harris Methodist Hospital Alliance, opened as a Stage 7 hospital. We’ll go back and pick up the remaining pieces from Stage 6 to Stage 7 at our other 13 hospitals. So we did this full implementation and what we learned along the way in the first 13 hospitals was key to allowing us to open Texas Health Alliance as a Stage 7 hospital. We did our implementation primarily through 2011 for the first 13 hospitals, and then we spent about a year really trying to optimize. By the time that we got Texas Health Alliance up this past September, we had done a lot of optimization.

What does that EHR optimization entail?

Working with the end-users to define workflows that need to be redone, redefined, or maximized. For nursing, one of the things that we have a really good opportunity to optimize was our admission process, and we had about 300 elements in our admission process. We brought together a group of end-users to work on that and we got it down from 45 minutes to about 20 minutes and decreased the number of flow sheet entries by about half. It’s looking at the things that we built when we didn’t really have a lot of history or background learning from that, and then making it more efficient, faster, fewer clicks, make more sense, and match with the clinical workflow.

How do nurses differ from other clinicians in their use of EHR and health IT?

We care about things like how to better navigate within the EHR to get where we need to go. We’re not as concerned about that as physicians; physicians are really interested in time savings and efficiency, and really note things such as the number of clicks to get to a certain part of the record, for example. We’re looking at efficiencies in combination with how it makes sense clinically; we’re also looking at it from a patient perspective.

What examples best demonstrate this difference in approach?

One of the things we care about in nursing is we don’t want to have to sit with our back to the patient to use a computer, for instance. And we don’t want to ask the patient the same questions over and over, so if they asked it at registration, in the emergency room, when they got up to the floor, we see that as inefficient because it impacts the patient experience. While we care about nursing efficiency, we also care about the patient impact and making those things work for the patient. And then we’re also hugely concerned with safety. The EHR and especially Stage 7 afford us some real safety opportunities. Through barcode med administration and device integration, we have decreased the potential to administer the wrong medication to the patient as well as the possibility of documenting vital signs on the wrong patient. It has provided an additional safety net for us.

How has the organization’s approach to EMR adoption help it achieve meaningful use?

That’s hard for me because we have always met the meaningful use requirements, so I don’t think we even look at meaningful use as a differentiator. We look at Stage 6 and Stage 7 as goals — we’re trying to attain Stage 7 — but meaningful use, we’ve always met that. We attested all 14 of our hospitals on Day 1, so that’s been almost 2 years now. We’re already well-positioned for Stage 2, so the quest for Stage 7 supports our ability to meet meaningful use, but I don’t see that meaningful use is a real struggle for us.

What’s an example of where meaningful use would cause the organization to fall short of Stage 7?

One of the harder things to manage sometimes is the utilization of CPOE. It’s easy to say that we have full CPOE because from a meaningful use and Leapfrog’s perspective, that counts telephone and verbal orders. But when you’re looking at it from a Stage 7 perspective, telephone and verbal orders need to be low, less than ten percent. It’s a different way of looking at that because it’s not just the clinician putting in orders; it’s really the physician or provider putting in the orders. So making sure we have good physician adoption for orders is key also.

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