What nurses want

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GHIT Notebook

March 31, 2008

What nurses want

By John Pulley

The health care industry’s continued reliance on paper astounds Lillee Gelinas, vice president and chief nursing officer at VHA Inc., an alliance of hospitals and non-acute-care facilities.

Gelinas was making rounds at a major hospital recently when she came upon a familiar sight: a nurse struggling with a huge pile of paper files. A work shift had just ended, and Gelinas assumed the nurse was catching up on the day’s charts. Instead, the nurse told her she had come in on her day off to manually gather data for review by the hospital’s quality committee, which was meeting the following day.

“We have a nursing shortage going on,” Gelinas said. “Is that the best use of people’s time?”

As the country faces a protracted nursing shortage and increased concerns about patient safety, health care vendors and policy-makers are beginning to focus more attention on frontline caregivers and the information technology they need to do their jobs. Moreover, nurses are becoming more involved in the development, procurement and deployment of next-generation IT solutions.

“Nurses are at the forefront of leading change,” said Linda Kloss, chief executive officer of the American Health Information Management Association and leader of the American Health Information Community’s Health IT Workforce Panel. “It is essential that attention be paid to nursing’s role in health IT.”

A powerful force for change Nurses have always had a place at the table when health IT is discussed. More often than not, however, their participation has been limited. Even among observers who acknowledge nurses’ historical role in shaping IT development and policy, there is a sense that their influence has been disproportionately small.

“Nurses are perhaps the most potent force for change in the work process,” Kloss said. “Do I think that in their numbers and criticality to health care they could be an even more potent driver? Sure.”

Gelinas is acutely aware of the long-standing frustrations involved in persuading industry and government to put effective IT into the hands of nurses. As a member of the American Academy of Nursing (AAN), she and her colleagues have worked to identify technology solutions that would make nurses’ work easier, more efficient and safer for patients. But at times the results have been disappointing.

A few years ago, for example, AAN convened a panel of technology vendors with the intention of facilitating development of IT products “at the sharp edge of what frontline bedside nurses need,” she said. “We invited the whole industry, and only eight or 10 showed up. That was perplexing to me.”

Around the same time, Health and Human Services Secretary Mike Leavitt established the American Health Information Community, a multidisciplinary advisory panel of health IT leaders. When Leavitt neglected to appoint a nurse to the panel, the American Nurses Association lobbied to add one.

“My appointment was a last-minute addition,” said Gelinas, who serves as the only nurse on the 18-member panel. “It was an afterthought.”

What do nurses want? Pamela Cipriano, chief clinical officer and chief nursing officer at the University of Virginia Health System, has a pretty good idea of what nurses want when it comes to health IT. As chairwoman of AAN’s Workforce Commission, Cipriano has been involved in one of the most extensive efforts to date to answer that question.

Most proposals for solving the nursing shortage have focused on training more people to enter the profession. However, that approach is constrained by the relative scarcity of nursing school instructors, many of whom are reaching retirement age, and the limited capacity of he alth care facilities to accommodate nurses in training.

Instead, AAN is focusing on the demand side of the equation. The average nurse spends only about 31 percent of his or her time in direct patient care, according to a Robert Wood Johnson Foundation study. That level of inefficiency exacerbates the supply problem and compromises patient safety. Rather than trying to produce more nurses, AAN advocates making better use of the nurses who are already in the workforce, primarily by deploying technology that will reduce the burden of activities that do not involve direct patient care.

“We believe technology can be a major solution,” Cipriano said.

Using grants from the Johnson foundation, the Workforce Commission asked nurses and other health care providers at 25 sites nationwide to compare their work processes and environments against an ideal standard. A gap analysis identified eight areas in which participants consistently recommended IT solutions: communications; medication administration; documentation; admission, discharge and transfer; care coordination; patient movement; care delivery; and supplies and equipment.

Specifically, nurses want completely electronic records, which only about 10 percent of the country’s health care providers use. Instead, nurses typically work with hybrid systems that combine automated elements with paper-based ones. “The combination is very disruptive,” Cipriano said.

Nurses want computerized order entry systems to eliminate handwriting legibility issues. They want touch-screen or voice-activated technology for documentation. They want automated networks that collect and download vital information directly into patients’ electronic records. They want more hands-free applications, particularly wireless technology that “frees them up from having to look for fixed hardware,” Cipriano said.

Nurses want smart beds that monitor patient movements and use pressure sensors to reduce the incidence of bedsores. Nurses told AAN that they want greater use of radio frequency identification tags for tracking people, supplies and equipment, and greater use of robotics for delivering supplies.

Nurses want interoperable systems that allow a full view of patients’ records without toggling or entering multiple passwords. They want multifunction solutions, such as “a single device that allows a lot of work to be done at the point of care,” Cipriano said. Right now, “nurses have to have a tool belt” to keep up with all the electronic devices they must use, she said.

Finally, nurses want IT that enhances workflows rather than disrupting them.

“When bar code administration was developed, the systems didn’t allow work at the bedside,” Cipriano said. “Nurses figured out how not to use it or they used it in a way that negated safety features.”

Connie White Delaney, dean of the University of Minnesota’s School of Nursing, said nurses will embrace “clinical information systems that are truly responsive to patient care situations and the interprofessional and interdisciplinary nature of the health care environment, [particularly] applications that truly have been built to integrate into workflow processes.”

“The more they are deeply involved in the actual design of these applications, the greater the likelihood we will get applications that are not impractical but fit the actual care delivery system,” Delaney said.

A clinical — not IT — project Twenty years ago, efforts to automate health care practices tended to revolve around registration and finance systems, said Lynne King, a registered nurse and electronic health record (EHR) project director at University Hospitals in Cleveland.

“Back then, there was not much involvement of nurses at all,” she said. “I&rs uo;ve learned over the past 10 years, and especially the last three years, that nurses are playing an increased role in the procurement of health IT.… Times have changed from focusing on finance to focusing on clinical systems.”

When University Hospitals decided to buy a major IT system, it brought together 400 nurses and other health care providers to help determine the organization’s needs. A core group of 30 people visited various sites to see firsthand what worked and what didn’t.

“We found from nurses that we needed to automate the workflow [to eliminate] a lot of redundant rewrites,” King said. “The leadership understands that nurses need to have a key role in the design and implementation. This is a clinical project, not an IT project.”

She added that when organizations make technology selections without involving nurses, their implementations often falter.

As a result of its review, University Hospitals chose a configurable product from Eclipsys that is being deployed at five hospitals. The system displays information on LCD monitors installed in critical areas. Gone are the stacks of paper, the grease boards and the need to hunt down paper records. The next phase of the deployment will automate order entry, medications management and nursing documentation.

“There is no running to find charts,” King said. “The staff is constantly looking at the tracking board. If a family member comes to see a patient, everyone knows where that patient is.”

The deployment parallels the work King performs as a member of the Certification Commission for Healthcare IT’s Inpatient EHR Work Group. CCHIT’s mission is to accelerate the adoption of health IT by creating an efficient, credible and sustainable certification program for products.

“It’s exactly what we’re trying to do here,” King said. “It’s an interdisciplinary approach to provide the best care for patients through IT.… We’re in an information business. The whole goal is to get the knowledge needed at the point of care to make the next right decision.”

Training health IT professionals Efforts to bridge the gap between health IT and the people who rely on such systems appear to be gaining momentum.

The American Medical Informatics Association (AMIA) has begun training 10,000 nurses and other health care professionals in applied health and medical informatics with the goal of completing the program by 2010.

“If you want to improve quality and safety a lot, it’s absolutely crucial that you have people to intermediate between the clinical challenges and the IT side of it,” said Dr. Don Detmer, AMIA’s president and CEO. “They need to be part of the decisions and discussions.”

Giving nurses and other medical professionals the IT they need was the impetus behind the founding of Champions in Healthcare, a new consulting firm that provides guidance and strategic planning related to health IT adoption. All of the firm’s consultants are physicians and clinical informatics experts.

“It is incumbent on vendors, developers and designers to invite, welcome, respect and be willing to be led by clinicians in the design and development of their systems,” said Dr. Samuel Bierstock, the firm’s founder.

By John Pulley

View Comments

Posted by sjgiuliani on April 1, 2008

What nurses want is respect and not to be treated as second class citizens or employees with no power or input into their careers. Understaffing and hospital mandation after a 12 hour shift is what is keeping the profession non professional and stopping responsible minded individuals from the profession. Working under intense pressure to expedite patient care with staffing that is close to crijinal and hoping after each shift that you don;t jeopardize your license doesn't help add to that administration (nursing supervisiors who could care less) and you have all the makings of job dissatifaction and a sense of hopelessness. I just pray that some day it will improve!!!!!!!!!!!!

Posted by shammyrock on April 2, 2008

I am an RN of 2 years working in the midst of our nursing shortage, and I am burned-out ready to leave the profession. I would like to bring to your attention the fact that part of the shortage is due to the stressful working conditions nurses deal with everyday. Please note that hospitals are assigning too many patients to one nurse during a shift making burn-out a significant part of this shortage. In addition, fueling this dilemma is the hospitals bottom line to increase profits. Thus, hiring fewer nurses cuts the hospitals costs leading to stressful work environments and finally, for the nurse, burnout!

It is my belief lack of employee retention is a contributing factor to the nursing shortage. Hospitals need to be less focused on their profits and more focused on the reality of the stressful work environments the employees endure on a daily basis.

Posted by RN4SafePtCare on April 2, 2008

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Posted by HealthSparks on April 4, 2008

Why don't any of these studies ever address the needs of nurses who don't work in a hospital? I am the HIV Program manager for a Washington DC Medicaid MCO. We desperately need the ability to communicate with our hospitals, clinics, pharmacies, labs, physicians and patients in a way that doesn't compromise HIPPA and that is considerably less complicated than encryption. We waste more people hours that I care to say and that can, and occassionaly does, translate to delayed patient care. I never seem to see our need for reliable, effective IT addressed. Maybe it is time?

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