The EHR &Nursing:What, Why & How

Annual Distinguished Alumni BanquetJamestown 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 Medical 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

EMR

Electronic Medical Record

CPOE eMar

All healthcare providers documentation

Radiology

Lab

Admitting

Financial

In short: Any area in the organization whereinformation is created, stored, or retrieved.

Definitions

Electronic Health RecordAn electronic record of health-related informationon an individual that conforms to nationally recognizedinteroperability standards and that can be created,managed, and consulted by authorized cliniciansand staff across more than one health care organization.

1 agency

EMR

1 agency

EMR

1 agency

EMR

1 agency

EMR

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 beingmanaged, shared, and controlled by the individual.

Personal Health Record

PHR

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

Data is objective

Data is objective

Data is objective

Data is objective

EXCEPT that what is collected…

Is subjective…

And determines what conclusions are made…

Nursing Data...What data do yourecord about an IV?

Type of solution, the site, the rate of flow, the time it was started etc.

Would this data convince an administrator, whois faced with saving $$, that it was necessaryto have RNs on the staff?

What in this data defines the practice of nursing?

What term

inology to use to

document our d

ata?

W U N D

B GA

Terms for a Heart Attack

Myocardial Infarction

MI

Heart Attack

Cardiac Infarction

StandardsStandards 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 NursingTerminologies

NANDA, NIC, & NOC Omaha SystemCCC

PNDSICNP

SNOMED-CT LOINC

Data must be in a structured format

Structured Data

Narrative notes…

Time Started

Solution Location Rate Time Disc

1015 NS Rt Wrist KO 1815

1400 D5W Lt Arm 38 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

Why 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 http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_10741_848133_0_0_18/10_2_hit_terms.pdf

References

http://dlthede.net/Informatics/Informatics.html

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