Workflow Viewpoints Analysis of Nursing Workflow Documentation in the Electronic Health Record

FEATURE: WORKFLOW

Luann Whittenburg, RN, FNP

here is increasing concern about EHR sys- Keywords tems streamlining the nursing process. Workflow, electronic health record, nursing, concept analysis. T The perception is that the EHR has a pro- Abstract pensity to overlook the data and contribution of nursing care to patient healthcare outcomes. This This article amplifies the emphasis on organizational workflow reignited by the Institute of Medicine reports concern originates from the clear absence of an on healthcare quality. The analysis of nursing workflow is objective method in electronic health record sys- central to understanding the power of technology to modify tems to collect structured, coded nursing data to the fundamental constructs of nursing practice. The aim analyze the benefit of the nursing process: assess- is to understand the evolution of nursing workflow and the concept of workflow from the management and computer ment, diagnosis, outcome identification, planning, science perspectives used in electronic health records and implementation and evaluation. computerized provider order entry. The understanding of An examination of nursing workflow may provide an under- the workflow models within health information disciplines standing of the nurses’ workflow and contributions. This article may improve the model of nursing workflow underlying the reports on the background of the conceptual development for the implementation of electronic health record systems. The concept of nursing workflow as nurses carry out patient care in an article follows the Walker and Avant evolutionary method of acute care setting using the EHR. 19 concept analysis. NURSING THEORY IN HEALTHCARE TECHNOLOGY Nursing informatics is a relatively young specialty2,8 with preced- ing research focused on problem-driven studies such as electronic health record implementations; the professional organization of nursing informatics as a nursing specialty; and nursing terminology in preference to research on concept development about nursing workflow in relation to technology.

www.himss.org volume 24 / number 3 n SUMMER 2010 n jhim 71 Early health information systems represented a workflow per- condition of a right foot pressure ulcer or observance of a patient’s spective different from the traditional nursing workflow. Today, or family member’s response to teaching. health information systems are compelling new nursing com- In general, informaticians accept that information, when given petencies and innovative nursing workflow strategies to accom- meaning through interpretation, becomes knowledge. Manage- modate the protean electronic health record systems installed in ment and computer science colleagues focusing on the impact of many healthcare facilities. computers in their disciplines have been preparing students for If the objective of nursing informatics is to improve nursing successful working relationships with computerized information practice through the use of technology, then nursing workflow systems for decades.18 Management views computers as support- must be established to guide the conditions for technology trans- ing the accomplishment of management objectives and supports formation and provide the appropriate constraints. While the the trends in information processing that encourage decentraliz- term “workflow” is a universal concept applicable to multiple ing data—for example, iPhone applications and social networking disciplines, this article used the Walker & Avant19 concept devel- by employees. opment framework to guide the review of the literature and identify the antecedents and consequences of nursing workflow along with empirical referents Early health information systems represented a and opportunities for further research. workflow perspective different from the BACKGROUND traditional nursing workflow. Today, health From any environment, at a basic level, a workflow information systems are compelling new represents a sequence of activities. At a practical level, workflow allows the assessment of activity in nursing competencies and innovative nursing context and the review of a sequence of work; such as all the nurse’s activities related to patient care workflow strategies to accommodate the on a given day on a given unit. At a greater level of protean electronic health record systems abstraction, workflow is a pattern of processes for information processing. installed in many healthcare facilities. In the early 1920s, F.W. Taylor and H. Gantt were intellectual leaders and pioneers of concept of workflow, with Gibbons and Smith7 report management results derive from the the Gantt Chart established as the iconic standard for the visual “workflow of the team,” while computer science defines workflow representation of workflow processes. Others participated in the as the scheduling of independent jobs on a computer and the set development of concepts involving information workflows includ- of relationships between all the activities in a project, from start ing M. Dewey of the Dewey Decimal System.20 to finish.6 However, the classic 1956 book on workflow was The Organiza- In this discipline, the common refrain is that data is less than tion Man by William H. Whyte. The 1920s to 1960s were the peak information; information is less than knowledge; and information periods of workflow formulation. By the 1980s, the concept of processing should be isolated from workflow. As derived from workflow was being dismissed by Abraham Maslow, who devel- past experience, the statements accurately reflect the data condi- oped the Hierarchy of Needs theory and gained wide acceptance tions in today’s healthcare information systems. in nursing schools as the key theory of the conceptualization of However, the purpose of collecting data, information and human needs.3 knowledge is to be able to make wise decisions (e.g., create wis- In the 1990s, the emphasis on organizational workflow was dom), and if data sources are flawed; meaning that if data is col- reignited by the Institute of Medicine reports on healthcare qual- lected in isolation from workflow, then one might reason that ity: To Err is Human11; Crossing the Quality Chasm.12 This period, management decisions based on a classic computer science model 1980-1990, experienced the emergence of Total Quality Manage- and interpretation of the established standard information work- ment and Six Sigma, and witnessed the evolution of Business flows will be flawed. Process Reengineering. The bright spot in the emphasis on qual- The net effect of an “isolated” workflow model must be sur- ity was that workflow again became the focus of management and mised to have transformed the data collection processes in health- researcher surveillance. care—and nursing in particular. Nursing data collection is more than discrete facts stored in a relational database. Nurses reply TRADITIONAL NURSING WORKFLOW on the data for patient care planning. Nurses transform the data The historical perspective of nursing workflow is as a clinical within electronic health systems by judgment into meaningful sequence of work focused on patient status, nursing interventions information. While the information by itself does not infer knowl- performed and the patient’s response. edge the cognitive and analytical ability of the nurse places EHR In the traditional view of nursing workflow, the nurse would data and information, in the context of the nursing workflow; and perform activities to detect changes in the patient’s condition. demonstrates that information processing for patient care deliv- Another example of traditional nursing workflow would be the ery should not be isolated from workflow for the confident deliv- work to observe a patient’s condition; e.g., no change in size or ery of healthcare quality.

72 jhim n SUMMER 2010 n volume 24 / Number 3 www.himss.org METHODOLOGY context of an activity in a workflow instance.10 As mentioned, the methodology used in this analysis is the Walk- Documentation. Nursing data collected as discrete facts, er and Avant concept analysis method.19 The general findings of stored in a relational database, processed, and transformed into the literature are that workflow articles were typically associated meaningful information.17 with specific problems such as patient safety, medication admin- Practitioner orders. Practitioner instructions, written or oral, istration, specific nursing units or specific departments such as for the treatment of a patient’s medical care. the emergency department. A review of the computer science literature through the Applied ANTECEDENTS AND CONSEQUENCES Science and Technology Abstracts database, which has abstracts The antecedents and consequential occurrences for the concept of and periodicals from 1983 to present in engineering, aeronautics, nursing workflow are: chemistry, computer technology and applications, earth sciences, Antecedent occurrences: Patient need. energy and environment, mathematics, metallurgy and physics, Consequential occurrences: Application of the American identified 805 articles using the term “workflow” primarily relat- Nurses Association (ANA) Nursing Process, actor self-efficacy ed to information messaging schemas. and care delivery. Clarification of the concept was accomplished by analyzing the common use of the concept through the way in which the concept ASSUMPTIONS was expressed.16 The literature included articles over a 29-year Ontological assumption: Human interaction is an endless pro- span, from 1970 to 2009, that is especially relevant to the evolu- cess of the fusions of horizons.15 tionary method of analyzing a concept over time. Epistemological assumption: Knowledge and understanding The articles selected from the multidisciplinary databases were of human existence is by understanding how a problem engages based on relevance and pertinence to the concept of nursing work- the present.1 flow in the electronic health record. The literature was identified by a combination of title, abstract and key word searches using CASES the terms: nursing workflow, electronic health record, workflow, Model case. Hospitals and other healthcare organizations are electronic health record, electronic medical record, CPOE and installing electronic health records mobile stations called Com- other terms combinations developed for use with the presentation puters-on-Wheels (COW), which support the nursing workflow engine at the time of the search. 24/7 with electronic access to patient information. Over the course of this article, more than 105 articles from three COWs perform as personal computers, despite being shared key disciplines—nursing, including social science, management among a team of nurses, and streamline the daily patient care task science and computer science—were selected for the evolutionary for nurses who need patient information readily available. concept analysis. References with similar concept content were The demand for the right information at the right time organized through a process of comparable analysis. A theme for the right patient at the bedside is the COW strategy that identified during the literature review was that workflow analysis achieves efficiencies in patient care. The nursing workflow has often been researched with the goal of improving efficiency. A with COWs, given greater access to information, translates classic study was the observation of routine tasks performed by into greater patient safety in high volume areas (e.g., electron- the operating room (OR) team by Cendan and Good.4 ic medical administration). For example, the nurse wheels the COW to patient’s door and CONCEPTUAL DEFINITIONS prior to dispensing initiates an electronic audit of the patient’s Workflow: medication schedule, dose, and allergies. In another example, a 1. A process description of how tasks are done, by whom, in what nurse assesses a patient after administering pain medication. The order and how quickly. Workflow can be used in the context of patient reports less pain and while in the room the nurse conducts electronic systems or people, i.e. an electronic workflow system another assessment. With the mobile electronic health record, can help automate a physician’s personal workflow.5 COWs, the nurse is able to coordinate with the patient’s care plan 2. The set of relationships between all the activities in a project, and incorporate nursing interventions and assessments from the from start to finish. Activities are related by different types of EHR, as well as any data from the patient, at the bedside instead of trigger relation. Activities may be triggered by external events going to a computer at the nurses station. or by other activities.6 This is the benefit of the COWs; the ability to adapt to the nurs- 3. Workflow is defined activities delivered by nurses to the pro- es’ workflow and support the availability of electronic information vider, patient or organization, regardless of technology.17 at the bedside. As a model case COWs is a non-disruptive nursing 4. The movement of documents around an organization for pur- workflow technology. poses including sign-off and evaluation.14 Borderline Case DEFINING THE ATTRIBUTES In a borderline care, computerized provider order entry (CPOE) The definitions of the essential attributes identified through the is EHR software installed using a component model. In CPOE, literature are listed below: nursing workflow must adapt to the capabilities of the electronic Work items. Representation of work to be processed in the health record. An immobile CPOE offers less data at the bedside

www.himss.org volume 24 / number 3 n SUMMER 2010 n jhim 73 and on every day, of any shift, the CPOE has a fixed location often research.”19 The analysis of the nursing workflow concept is to remote to the patient’s location of care. better understand the essential components of nursing care for CPOE is a borderline case since a majority of direct care by the electronic medical record to allow nurses to demonstrate their nurses—i.e., vital sign monitoring, input and output, performing contribution to patient healthcare outcomes as effective advocates patient Activities of Daily Living (ADL)—requires nurses to be for patients. tethered to the nursing station computer terminal. CPOE is effective for specific workflow tasks such as laboratory order messaging; however, the The analysis of the nursing workflow concept electronic nursing workflow is not completely sup- is to better understand the essential ported by the CPOE electronic health record application. components of nursing care for the electronic

Contrary Case medical record to allow nurses to demonstrate The contrary case is the complete opposite of the their contribution to patient healthcare concept being defined and can clearly show what the concept is not.19 The traditional workflow scenario outcomes as effective advocates for patients. is a contrary case because the attributes shown in the nursing workflow model case are missing. The traditional Nursing informatics research on the nursing workflow concept perspective of nursing workflow is a sequential account of the supports the development of electronic health record data systems patient’s care, nursing interventions performed, and the patient’s to collect and record the significant care knowledge and wisdom response. of nurses with standard, coded nursing terminology. In the traditional view, nursing would typically identify workflow as activities performed to care for a patient’s condition such CONCLUSION as progression, regression or the development of new problem; Nursing workflow documentation is a functional and essential for example, ambulating for three minutes and feeling tired or the component of nursing practice. This paper is an initial concept workflow included in providing treatment or medication and the analysis on the nursing workflow in relationship to the electronic nursing activities to assess the patient need, perform the nursing health record system to provide a basis for further research into action, teach the patient or family and manage any subsequent the impact of the electronic health record on nursing processes nursing intervention that contribute to the nurses’ traditional and to inform nursing education. Nursing workflow is patient- nursing workflow. centered and must be supported by electronic health record. The contrary case of nursing workflow documentation While, in general the concept of workflow is non-nursing-spe- reflects and describes the inability or missed opportunity of the cific, health data is unique in that much of the information and nurse to use the EHR. The nurse continues to work in the tra- knowledge is patient rather than discipline-related. While nurs- ditional manner. The nurse conducts all care processes in the ing considers the transformative affects of new technology and traditional manner during the nursing shift and provides all examines the interdependence between the electronic health care and interactions without the benefit of technology includ- record and nursing practice, the continuation of nursing infor- ing the Electronic Health Record. Therefore, nursing workflow matics research in this area is critical to harnessing new health tasks are managed in the traditional manner without electronic information technology to support nursing care. JHIM support for the following: a.) preparing patients for respiratory support such as oxygen, IVs, laboratory orders, and documenta- Luann Whittenburg, RN, FNP, received a MSN from Marymount University. She is tion of patient status and symptoms; b.) performing vital signs; Board Certified as a Nurse Practitioner in Family Practice and Nursing Informatics. c.) providing medication; and d.) monitoring any adverse effects She is a PhD candidate at George Mason University and Chief Nursing Informatics of therapies and medical regimens.17 Officer with Medicomp Systems, Inc. in Chantilly, VA.

IMPLICATIONS FOR NURSING PRACTICE AND EDUCATION The advantage of concept analysis is that “it renders very precise theoretical as well as operational definitions for use in theory and

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