improving operational efficiency through elimination of...

Improving Operational Efficiency through Elimination of Waste and Redundancy Work group report

Using Innovative Technology to Enhance Patient Care Delivery

American Academy of Nursing Technology and Workforce Conference July 12-14, 2002 Washington, DC

State of the Science Nursing is facing an internal crisis. Nurses enter the field to make a difference and find reward in the interaction with patients and families. However, a large percentage of nursing time is spent on non-direct care tasks such as scheduling, documenting and communicating with other departmentsi. Additional challenges include a nursing shortage that is expected to worsen over the next decade, and the rapid aging of both the registered nurse workforce and the population.ii The healthcare environment is growing increasingly high tech, and includes a multitude of devices that gather volumes of data about patients. It is time to utilize technology to support the work of nurses, ease their workload, streamline paperwork, transform data into information and knowledge, and eliminate redundancy. In a recent survey of Chief Nursing Officers, only sixty percent believed that information technology would improve efficiency and decrease paperwork.iii Effective utilization of technology to support the work of nurses in today’s healthcare environment is haphazard at best. While many technologies are available to enhance nursing productivity and eliminate waste and redundancy, they are not applied consistently across, or even within, healthcare organizations. Wireless technology and personal digital assistants, expected to be the most important technologies in healthcare in the next two years, have the potential of enabling access to data and information at the point-of-care and supporting a nurse’s typical work flow.iv Deficiencies of note include a general lack of automation, duplication of effort, a dependence on manual documentation, minimal use of decision support capability, and lack of timely access to data and information at the point-of-care. Clinical information systems have been identified as the most important application area in healthcare in the next two years.v However, current installations do not reflect a base of applications that support the work of nurses.vi

A pplica tio n T O T A L # T O T A L %P harmacy 3 6 9 6 9 1 .3 0 %Lab o ra to ry 3 6 6 8 9 0 .6 1 %O rd e r C o mmunica tio ns/R esults 3 4 5 8 8 5 .4 2 %R ad io lo gy 3 2 7 0 8 0 .7 8 %C linica l D a ta R ep o sito ry 2 0 4 2 5 0 .4 4 %Emergency D ep artment 1 0 1 8 2 5 .1 5 %P A C S 6 1 8 1 5 .2 7 %

N u m b e r o f I n s t a l l a t i o n s

Dorenfest, 2001

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Improving Operational Efficiency through Elimination of Waste and Redundancy Work group report Barriers According to nurse executives, key barriers include cost, pushback from physicians and administration, a lack of willingness to set clinical transformation as a top priority, and a paucity of available tried and true products and implementation processes that are integrated, easy to install and easy to use.vii Other barriers include lack of standardization, multiple nursing terminologies, lack of a cohesive vision for nursing, reluctance to embrace technology, and few published success stories or sharing of best practices. Opportunities The nursing shortage has captured the attention of the nation as a public policy issueviii, and the increasing dependence on technology to reduce medical errors has created an environment that is primed for radical change. The expanding role of Informatics Nurse Specialists provides the industry with a resource that has the knowledge and skills necessary to identify and implement innovative solutionsix. These experts utilize their clinical and technical expertise to evaluate work flow, design effective patient care delivery systems, and transform data into information and knowledge. Key nurse leaders are currently focused on the issues and are gathering the necessary resources to redesign nursing practice and care delivery environments, while creatively addressing the non-direct care aspect of the demand side of the workforce equation.

Challenges In spite of this renewed focus on the need for change, the availability of resources in terms of time, funding, and talent are limited. There is also a general lack of understanding of the necessity for clinical process transformation to enable the successful implementation of

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Improving Operational Efficiency through Elimination of Waste and Redundancy Work group report technology. Vendor consolidation, frequently changing product lines, and inconsistent quality of product support have created a general distrust of the marketplace. Current Available Technology Although not widely implemented, clinical information systems are currently being utilized at client sites to enhance nursing productivity. Many of these applications were designed from their inception by clinicians to support the efficient patient care workflow of nurses and other members of the healthcare team, at the point-of-care or wherever the clinician needs to enter or access patient information across the continuum. A growing number of facilities have deployed these applications using point-of-care devices, including stationary bedside terminals, wireless laptops mounted on mobile carts, and handheld devices. Available features include an integrated clinical desktop that provides quick and easy access to patient records, “virtual libraries” and knowledge bases; access to 3rd-party products and enterprise e-mail; and access to the Internet and a facility’s intranet. Using this desktop, clinicians are able to enter all necessary data into the patient’s record, including orders, care plans, and notes. They can also view individual patient results and summaries that provide an overview of the current patient status combining diagnostic results, the Medication Administration Record (MAR), nursing documentation, and current orders on one screen. Clinical Data Repositories (CDR) store historical data across episodes of care, ensuring that patient information gathered by one clinician (e.g., allergies in the clinic or during a previous acute care stay) is available on-line to authorized users during ordering and documenting, alerting them to issues and eliminating redundant charting. Charting tools such as the admission assessment can automatically copy-forward pertinent and recently charted patient information. This capability, combined with the CDR cross-continuum data-storage feature, enables the nurse to build on the information collected by colleagues in the Emergency Department, for example on a patient being newly admitted. The inpatient nurse can quickly chart any new or abnormal findings using selection menus or free-text, view and validate patient data that was entered during the ED visit and is now displayed in the admission assessment profile. A major irritant of patients, as well as a source of wasted time for nurses, are redundant questions asked by multiple clinicians during one episode of care. This same copy-forward capability when applied to on-going clinical documentation during the acute care stay enables an automated version of charting-by-exception. The nurse can choose to modify only those elements that have changed since the last assessment saving time in redundant charting and allowing the nurse to focus on documentation that is meaningful. Computerized provider order entry (CPOE) enables physicians and other providers to enter orders directly into the system in combination with real-time clinical decision support that can warn of unsafe and unnecessary duplication of orders. The use of CPOE in an integrated environment has the potential to reduce medication errors and adverse drug events, while enhancing efficiency of the order entry processx. Implementation of this functionality also reduces the need for nurses to call the physician to clarify an order, decipher or transcribe medical orders, or perform unneeded patient care tasks.

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Improving Operational Efficiency through Elimination of Waste and Redundancy Work group report Nurses can enter care plans, problem lists, or clinical pathways quickly on-line using a pre-defined, tailorable template containing evidence-based clinical content. By activating an auto-scan feature at initiation of a care plan, they can be guided automatically to the most appropriate problems for their patient based on assessment data entered for the patient by all care givers. Outcomes and interventions linked to the problem and included in the template can be modified, added, or deleted by the nurse to make the plan patient specific. All orders, interventions, and expected outcomes (whether from a physician, care plan, or clinical path) automatically generate scheduled events on the on-line Kardex, MAR, and worklist. The nurse charts against the integrated plan of care, and automatically accesses the appropriate charting tool by selecting the appropriate activities. The data is charted once and can be displayed in multiple formats, supporting the special needs of various clinicians who access the data for decision-making while not requiring redundant documentation by the nurse. Clinical information systems can save the nurse time in order management by tracking each charting activity and auto-completing any order that has a termination indicator when the last scheduled event is charted as performed. Other sites are moving to an architecture using the power of the Internet on a Microsoft.NET platform that delivers clinical solutions in a revolutionary new way: anytime, anyplace. Users can step away from their desktop computers and still access the Internet through portable devices. This technology enables software solutions to be built once and brought to any device, supporting decision-making at the point of care. When a clinical solution is built on a .NET platform, an application transcends device boundaries and fully harnesses the connectivity of the Internet: Users can access applications seamlessly on any device, including personal computers, handheld devices and cellular phones, without maintaining a separate application for each device. By using the .NET platform, integration capabilities translate into seamless delivery of intelligent guidance and workflow tools that support the core processes of healthcare: clinical care, patient flow, revenue and administrative management and consumer relations. Tools provided with today's software enable the customer to modify systems to meet their unique requirements. Customer-definable rules are easily constructed to enable time-saving, automatic compliance with policies, such as a referral being automatically sent to Social Services when, on the patient’s admission assessment, the nurse documents a financial concern. Activation of a “conditional” order can be triggered automatically when a nurse documents certain information in the patient’s record. For example, if a physician enters an order for “blood cultures for temperature > 102°F” and the nurse documents a temperature of 102.1, notification can be sent via the clinical system to the phlebotomist to draw blood cultures, saving the nurse time in looking up the order and notifying the lab. Clinical documentation can include imbedded logic that prompts the nurse real-time to document additional information when certain data is entered in the automated note, and can warn the nurse if entered data falls outside the normal range based on patient-specific criteria. Wireless technology can also have a significant impact on the nurse’s workflow. The benefits of wireless technology empower clinicians to be highly effective in improving patient admission, clinical documentation, medication administration and other care processes throughout the organization. Documenting at the point-of-care gets nursing back

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Improving Operational Efficiency through Elimination of Waste and Redundancy Work group report into “chart as you go” workflow, eliminating long hours of overtime charting at the end of the shift as they struggle to remember what they did hours earlier or search through pages of notes on their shift assignment. Using wireless technology for clinical and non-clinical applications enables members of the healthcare team to perform tasks such as patient admission and administering medication at the point-of-care, improving both the efficiency and quality of these processes. The discussion above illustrates many, but not all, of the capabilities available with current technology that can enable the staff nurse to spend more time in direct patient care and less time on administrative tasks, and to improve operational efficiency through elimination of waste and redundancy. Future Information Technology Future capabilities to enhance nursing productivity and patient safety include adding bar-coding for the medication administration process to support the five rights (right patient, right medication, right time, right dose, right route), speech recognition, and fine-tuning of the graphical user interface to make it more robust and intuitive for a clinical user. Small form factor Web applications are being developed to enable deployment of the clinical information system via personal digital assistant (PDA) technology. Multi-media capability is being added to incorporate diagnostic images, dictation, and photography into the CPR. The ability to integrate standards-based systems utilizing a technical framework such as the Integrating the Healthcare Enterprise (IHE) initiative will be wide spread. Today, many organizations utilize clinical practice guidelines and care maps in the paper medical record. In the near future, clinicians will be able to access Clinical Practice Guidelines electronically via clinical information systems, and utilize evidence-based, diagnosis specific knowledge that reflects interdisciplinary scopes of practice and enables nurses to chart outcomes and variances. These systems will be part of a national health information infrastructure that provides true interoperability and access to patient information from disparate systems and locations.

Future uses of information technology in healthcare

The future is NOW!

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Improving Operational Efficiency through Elimination of Waste and Redundancy Work group report The Ideal Care-delivery System for Nursing The ideal nursing care-delivery system enables staff nurses to increase their productivity, job satisfaction, and the quality of care they are able to provide by spending more of their time in direct care activities. This system must include information technology that replaces the paper-based, administrative tasks with a paperless, point-of-care, computer-based patient record imbedded with intelligent, rules-based capabilities that automate the manual workflow processes, policies, and procedures, and that support the nurse’s critical thinking. Benefits and advantages of this system that would lead to increased productivity and time in direct patient care include:

saving time in organizing work saving time in charting and clinical documentation timely charting of patient data for access by other members of the healthcare team

and use in medication administration, CPOE and clinical decision support saving time in deciphering/transcribing physician orders, call-backs to physicians to

clarify orders and/or inform physician of order conflicts/contraindications increasing accuracy by eliminating manual transcription of orders and providing

data, information, and knowledge at the point-of-care saving time and increasing accuracy/appropriateness in creation of the plan of care reducing redundancy and unnecessary variance in patient care activities saving time in searching for pertinent data, and eliminating the messenger role and providing built in alerts and alert escalation of an

occurring event or condition. The automated system should include:

Enabling Technologies point-of-care devices such as wireless, mobile cart-based terminals, and bedside-

based terminals, and hand-held devices speech recognition device interfaces to monitors, ventilators, IV pumps, and other equipment

Features and Functions on-line, consolidated patient summaries that display at-a-glance patient-status

information such as recently entered diagnostic results, images and reports, medications administered, most recent vital signs and I&O and assessments, problem lists, diagnosis, allergies and precautions, unusual events (e.g., resuscitations, falls, etc.), and procedures (e.g. lumbar puncture, tracheostomy, etc.) CPOE with imbedded real-time clinical decision support and automated order

communication to all departments

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on-line, computer-generated Kardex that displays order information as well as patient information documented through assessments (such as allergies, precautions, and individualized instructions) on-line MARs and worklists generated as a by-product of orders on-line worklists/MARs that automatically display the appropriate charting tool for

data entry when the nurse indicates on the worklist that a patient care activity has been performed automatic reminders for scheduled tasks that are overdue on-line views and reports to monitor the workload and charting progress of

unlicensed staff assigned to work with the nurse intelligent, rules-driven admission assessment and other charting tools that

copy-forward pertinent and appropriate patient data (such as allergies, precautions, vital signs, systems assessments)from previous visits/previous charting for validation and modification as needed support detailed documentation related to assessment or health-pattern

categories with abnormal findings, and automatic documentation of “within normal limits” (or other facility-specified notation) for assessment or health-pattern categories free of abnormal findings

charting tools that automatically send referrals to other disciplines based on facility policy and triggered by data charted by the nurse seamless evidence-based guidance during the planning of care, such as

the ability for the computer to scan assessment data documented by all care-givers for a patient and to present the nurse with a list of likely problems for which to plan care pre-defined care plan template with expected outcomes and associated

interventions, and the ability to modify/add/delete outcomes and interventions an needed to customize for a specific patient on-line, context-driven reference material

real-time alerts (via on-line flags and paging) that prompt the nurse to review newly entered orders and patient data, and that indicate the level of urgency related to that information on-line, up-to-date reference material related to drug information and leading-

practice information via access to automated facility-specific tools and Internet-based references context management that provides a standards-based, user-centered environment

with integration of applicationsxi.

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Automated Support for the Nurse’s Workflow

Assess

Plan

Implement

Evaluate

Historical data from previous episodes and encounters

On-line admission assessment

Online on-going assessmentsData from previous assessment

Order entry tools (CPOE)

Care plan templates

Clinical path templates

Rules and alerts based on patient-specific data and evidence-based criteria

On-line Charting/Clinical Documentation

• Assessments / VS / I&O / Ht&Wgt

• Treatments

• Pt education

Data from previous assessment

On-line charting/viewing results of expected outcomes

Diagnostic results viewer

Data from on-line references



Automatic referral

Automatic referral

On-line:• Kardex• MAR• Worklist• Patient Summaries

Taylor, 2002xii

Conclusion: Now is the time to galvanize the industry, bringing together key stakeholders, removing barriers, and utilizing innovative solutions to support the work of nurses. Nurses, administrators, and industry leaders must work together to transform the delivery of patient care. Authors: Joyce Sensmeier MS, RN, BC, CPHIMS, Director of Professional Services, Healthcare Information and Management Systems Society Robin Raiford BSN, RN, BC, CPHIMS, Clinical Product Consultant, Eclipsys Corporation Sheryl Taylor BSN, RN, Nursing Informatics Director, Per-Se Technologies Charlotte Weaver, RN, PhD, Chief Nursing Officer and VP, Cerner Corporation

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i Healthmedx (2002). Productivity loss is greatest in non-patient care activities http://www.healthmedx.com/about/challenges.asp. Last accessed June 3, 2002. iiSteinbrook, R. (2002). Nursing in the Crossfire, New England Journal of Medicine, 346(22), 1757-1766. iii IBM/VHA (2002). Survey of Chief Nursing Officers, IBM and Voluntary Hospitals of America. iv Healthcare Information and Management Systems Society (2002), 13th Annual HIMSS Leadership Survey, Healthcare Information and Management Systems Society and Superior Consultant. vHIMSS (2002), Ibid. vi Dorenfest, S. (2001) The Dorenfest Integrated Healthcare Delivery System+ (IHDS+) DatabaseTM 2001 Data vii IBM/VHA (2002) Ibid. viii Tieman, J. (2002). Nursing the nurse shortage, Modern Healthcare, May 20, 2002, p. 20. ix American Nurses Association (2001). Scope and Standards of Nursing Informatics Practice, Washington, DC: Author. x Landa, H. (2002). Patient safety and CPOE into the future. Presentation for HIMSS 2002 Summer Conference, Las Vegas, NV. xi Seliger, R. (2002). Standards-based integration of a multi-vendor, multi-technology clinical web portal. Presentation at HIMSS 2002 Summer Conference, LasVegas, NV. xii Taylor, S. (2002). Automated support for the nurse’s workflow. Graphical presentation for American Academy of Nursing Technology and Workflow Conference: Washington, DC. Copyright 2002 Healthcare Information and Management Systems Society. All rights reserved. No part of this publication may be reproduced, adapted, translated, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. HIMSS 230 E. Ohio Chicago, IL 60611 312/664-4467 [email protected]

http://www.healthmedx.com/about/challenges.asp

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