The EHR &Nursing: What, Why & How Annual Distinguished Alumni Banquet Jamestown Community College May 5, 2010 Linda Q. Thede, PhD, RN-BC © Linda Q. Thede, 2010

Healthcare Informatics is: Intersection of – Information Science – Computer Science – Healthcare Addresses healthcare information in terms of its: – Acquisition – Storage – Retrieval – Use

Healthcare Informatics

Definitions Electronic M edical Record An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization. 1 agency EMREMR

Electronic M edical Record CPOEeMar All healthcare providers documentation Radiology Lab Admitting Financial In short: Any area in the organization where information is created, stored, or retrieved.

Definitions Electronic Health Record An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one health care organization. 1 agency EMREMR EMREMR EMREMR EMREMR EHR

Regional Health Information Organization (RHIO) HEALTHeLINK of Western New York

An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled by the individual. Personal Health Record PHRPHR

What Data? Structure? Protocols? Access? Meaningful Use Nursing

What Data for Documentation?? Purposes of a healthcare record – Communication – Permanent, record of a patient's care: a legal document – Provide best care – Secondary data use What data would best serve each of the above uses?

Data... Data is objective

EXCEPT that what is collected… Is subjective… And determines what conclusions are made …

Nursing Data... What data do you record about an IV? Type of solution, the site, the rate of flow, the time it was started etc. Would this data convince an administrator, who is faced with saving $$, that it was necessary to have RNs on the staff? What in this data defines the practice of nursing ?

What terminology to use to document our data? WUND BGA

Terms for a Heart Attack Myocardial Infarction MI Heart Attack Cardiac Infarction

Standards Standards are an agreed upon way to record and exchange data within and across information systems. Standardized terminologies are content standards that represent a focus of concern. A nursing standardized terminology represents content that is a focus in nursing.

Standardized Nursing Terminologies NANDA, NIC, & NOC Omaha System CCC PNDS ICNP SNOMED-CTLOINC

Data must be in a structured format

Structured Data

Narrative notes… Time Started SolutionLocationRateTime Disc 1015NSRt WristKO D5WLt Arm38 gtts/min 2200 “IV of normal saline started at 10:15 in the right wrist at a keep open rate.” “ Discontinued at 18:15 IV in right wrist of normal saline that was at a keep open rate and started at 10:15” Same data in a structured format

Benefits of Electronic Documentation Less documentation time, more accuracy, patient safety, etc. No looking for a chart Ability to search and extract information Real time information Backup of information Data only needs to be entered once

W hy does my agency need to be concerned? Remuneration is going to decrease Reimbursement is going to be tied not to units of care, but quality and outcomes and readmission rates To improve quality an agency needs “actionable” data Best way to provide “point of care” information – including patient care guidelines

It is impossible to achieve these tasks without technology! And in our case this means an Electronic Medical Record.

Moving Forward (Outside the Agency) Network!!! – HIMSS/AMIA – ANIA-CARING/Rutgers/SINI – Listservs /Journal Articles/Web – College courses/Degrees – Certification

Moving Forward (Inside the Agency) eMAR – Does it make your life easier? – How could it be made better? CPOE – What role will you play? Nursing Documentation – Has this even been talked about? – How should it work?

Working Together Gain support from the “C” suite Work with the IT department Form a clinical informatics group – Broad representation – Everyone a stakeholder – Focus on usability Delegate at least one nurse to be a nurse informatician and help her/him to gain the education needed

Have Fun On The Journey

National Alliance for Health Information Technology. (2008, April 28). Defining Key Health Information Technology Terms. Retrieved January 21, 2010, from 0_10741_848133_0_0_18/10_2_hit_terms.pdf References Note, feel free to use any of these slides, but please acknowledge the source. Thede, L. Q. The Electronic Health Record and Nursing Keynote Jamestown Community College, Jamestown, NY, May 5, 2010