Nursing Systems Could Be a Platform for Quality Improvement

rninformatics, DNP, RN · Nov 5, 2008

Excellent "Perspectives" Article from iHealthbeat!!

by Tonushree Jaggi

"Complexity Compression" -- a term coined by the Minnesota Nursing Association -- aptly captures the essence of today's nursing world. More demanding regulations on patient documentation, multifaceted IT initiatives, new training requirements and a sicker population are heightening both indirect and direct care workloads for nurses. Indeed, we are often expecting our nurses to do more with less.

There is a widespread belief among health care leaders that IT has the potential to help. Nurses already use IT extensively in their day-to-day work. In fact, it's nurses, not physicians, who use the majority of electronic health record applications.

Unfortunately, IT has not yet had much success in improving nursing workload. In many cases, siloed architecture, poor presentation of data and poor design often result in IT systems adding to -- instead of mitigating -- the complexity of nursing workflow.

In a recent survey by the Advisory Board Company's Nursing Executive Center, senior nursing leaders from a wide range of institutions expressed deep frustration with existing documentation systems. An overwhelming 89% of respondents report they are either dissatisfied or ambivalent about their institutions' documentation systems.

Anecdotally, nurse leaders report being overwhelmed by the demands of documentation systems on staff nurse time, the need to incorporate the growing burden of regulatory requirements, and the inefficiency and redundancy of many existing systems.

Perhaps the greatest driver of dissatisfaction, however, is the continued prevalence of hybrid documentation systems, or those consisting of both paper and electronic components.

In the same survey, the vast majority of respondents were using electronic systems to record at least one key care component: assessments, vitals, intake and output, flowsheets and care plans. Unfortunately, 47% of institutions report practicing in a hybrid environment, and anecdotal evidence from the frontline suggests this number might be greater.

The good news is that despite their concerns with existing systems, frontline nurses and nursing leaders remain bullish on the potential for IT to improve care quality.

A 2006 survey conducted by CDW Healthcare revealed that 86% of frontline nurses believe IT improves clinical quality. At the executive level, health care leaders, including nurse executives, are increasingly citing quality and patient safety as their primary rationale for investing in clinical information systems.

Clinical Quality, Not Productivity, the Greatest Potential Benefit

Despite the best efforts of institutions migrating from paper to electronic documentation systems, automation unfortunately does not guarantee any reduction in the amount of time staff nurses spend documenting.

In an analysis of peer-reviewed studies on how automated documentation affected staff nurse time, the Center found mixed results. Where time savings were reported, it was virtually impossible to disaggregate whether time saved resulted from process improvements made during implementation versus the technology itself. Worse yet, one meta-analysis revealed that organizations that are able to achieve time savings in the short term often find it difficult to sustain those gains over the long run.

For this reason, an efficient documentation system should not necessarily be viewed as one that reduces overall time spent documenting, but rather as one that leverages that time to produce the highest quality output.

More compelling and consistent evidence exists to suggest that automation can greatly improve clinical quality through increased documentation completeness and true clinical decision support. A study conducted at Columbus Children's Hospital revealed that automated systems led to significant increases in compliance with every aspect of documentation evaluated, including care plans and patient education.

Nursing systems also provide a useful platform for delivering clinical decision support. Although ample literature demonstrates the power of clinical decision support in improving care quality, the vast majority of existing systems target physicians rather than nurses. Among the few organizations that provide decision support for nursing, systems are typically limited to pop-up alerts that remind staff nurses to document various elements in the electronic chart.

Pop-up alerts are well-known to be disruptive to clinician workflow and therefore should be deployed judiciously. Rather than simply promote documentation compliance, organizations should design and prioritize alerts that elevate care quality -- such as alerts that remind nurses of preventive care interventions, streamline referrals to ancillaries, highlight vital signs or lab values outside of normal ranges, and aid with administration and ongoing monitoring of patient drug regimens.

Technology Far From Plug-and-Play

Admittedly, developing a fully functional and quality electronic documentation system is no small task. Beyond the arduous process of reconciling and integrating hundreds of distinct paper documents, the most difficult work that must be undertaken in advance of system implementation is process mapping. Automating clinical documentation requires organizations to possess a detailed understanding of an overwhelming number of clinical processes and workflows.

The American Academy of Nursing and the Robert Wood Johnson Foundation published a 2007 report that cited more than 812 nursing processes that are affected by technology. Mapping these processes in a sufficient level of detail and understanding how they play out at any given institution is a highly resource-intensive and time-consuming task. Yet, institutions that cut too many corners run the very real risk of automating broken processes.

Creating nursing systems that enhance clinical quality while minimizing workflow disruptions requires both clinical information system vendors and hospitals to reevaluate current practices.

First, vendors must address historically overlooked nursing applications. A 2007 report published by KLAS, an independent research company that evaluates vendors based on survey data obtained directly from hospital participants, assessed eight different vendors on their nursing functionality. Even the best-rated system scored, on average, just 23.3 out of a total of 40 possible points. Fortunately, the report has prompted multiple vendors to upgrade the design and functionality of their nursing products.

Second, health care providers must design and implement nursing systems to maximize system efficiency and meet ambitious care quality goals. To do so, providers must achieve nursing-IT collaboration that goes from merely hiring nurses in IT to supporting permanent informatics expertise in the IT department. In addition, providers can enhance care quality by integrating nursing care plans with all aspects of nursing documentation and insist on interdisciplinary utilization of shared documentation.

For example, Fairview Southdale Hospital, a 390-bed hospital in Edina, Minn., offers a single, standard tool for both charting and care planning that is used by nursing, respiratory therapy, nutrition, and all the other relevant clinical disciplines. This unified tool helps clinicians avoid redundant tasks and assessments and enables the entire care team to have a consistent, holistic view of patient care.

Finally, while nursing systems are unlikely to produce significant productivity gains, hospitals should, at the very least, undertake extensive process redesign and offer a range of devices to ensure that electronic documentation does not negatively affect nursing efficiency.