Nursing Leaders Serving As a Foundation for the Electronic Medical Record Courtney Edwards, BSN, RN, CCRN, CEN

LEADERSHIP DEVELOPMENT

Nursing Leaders Serving as a Foundation for the Electronic Medical Record Courtney Edwards, BSN, RN, CCRN, CEN

3 ABSTRACT and coordination of care. The EMR has been shown to Transitioning health care information to an electronic medical provide signifi cant health care savings, reduce medical record is one of the newest policies to reach the health care errors, and improve the health of Nursing Advancing 4,5 agenda. Nursing leaders are at the forefront to affect the EMR 2 patients. Nursing leaders are at the forefront of design, development, implementation, and reception of an their institutions to impact the reception, design, devel- electronic medical record. Because of their clinical work- opment, and implementation of an EMR. This is because fl ow knowledge, decision-making capacity, and leadership of their clinical workfl ow knowledge, decision-making role, nursing leaders are able to achieve high-quality EMRs. capacity, and leadership role that nursing leaders are Being proactive in the reception, design, development, and able to achieve high-quality EMRs. implementation of an EMR plays a role in creating an organi- PURPOSE OF THE PROGRAM zational culture that allows for the fl ow of data effi ciently and accurately. The following studies offer many examples of how nursing administrators, nursing leaders, and nursing frontline Key Words staff can contribute to a triumphant transition to an EMR. Electronic medical record, EMR, Emergency department, By being proactive in the reception, design, develop- Nursing leadership ment, and implementation of an EMR, the nursing leader can contribute to an organizational culture that allows for the fl ow of data effi ciently and accurately. Nursing execu- tives and leaders are in a position to make decisions that he electronic medical record (EMR) is the “electronic can drastically impact the EMR. Successful implementa- record of health-related information on an individual tion of an EMR requires a full understanding of existing that is created, gathered, managed, and consulted systems and the capabilities of the EMR, strong organiza- by licensed clinicians and staff from a single orga- tional planning, a design centered on a committed inter- Tnization who are involved in the individual’s health disciplinary team, development catered to the needs of and care.”1 Because of regulatory health policies initiated the organization, and a supported implementation. The by The Joint Commission,2 the Accreditation Association guidance and knowledge nursing leaders can offer are for Ambulatory Healthcare, former President George W. imperative for any successful implementation of an EMR. Bush, and current President Barrack Obama, transition Nursing leaders are in a position to lobby their institu- of health care information with the development of an tion in order to implement an EMR. There is no shortage in EMR is one of the newest policies to reach the health the literature identifying the benefi ts of an EMR. Hillestad care agenda.3 In 2009, 11.9% of US hospitals reported and associates4 wanted to achieve a better understanding adopting some form of an EMR.3 However, only 2% of of the role and importance of the EMR in improving health US hospitals reported having EMRs robust enough to care in order to maximize benefi ts and increase EMR us- meet the federal government’s “meaningful use” criteria, age. Through their extensive comparisons, many of the supporting the priorities of patient engagement, reduc- benefi ts of an EMR were specifi cally identifi ed. Electronic tion of racial disparities, improved safety and effi ciency, medical records were recognized to provide effi ciency savings by decreasing the length of stay, decreasing nurses’ administrative time, and reducing drug usage.4 Two-thirds Author Affi liation: Trauma & Disaster Management, Parkland Health & of preventable adverse drug events in an outpatient set- Hospital System, Dallas, Texas. ting were avoided with computerized provider order en- The author declares no confl ict of interest. try.4 Electronic medical records also demonstrated great Correspondence: Courtney Edwards, BSN, RN, CCRN, CEN, Trauma & Disaster Management, Parkland Health & Hospital System, 5201 Harry benefi ts in the management of preventive medicine and Hines Blvd, Dallas, TX 75235 ([email protected]). chronic disease management. Through implementation of DOI: 10.1097/JTN.0b013e31825629db evidence-based recommendations, the EMR was able to

JJTN200160.inddTN200160.indd 111111 225/05/125/05/12 9:149:14 PMPM identify patients needing specifi c services based on pa- the best choices and optimal effi ciency in creating a tient data, thus resulting in increased patient compliance smooth cultural transformation.6 and improved communication.4 The use of EMR can also With involvement of senior nursing leadership, the facilitate the comparison of nursing practice across popu- EMR has the capacity to improve documentation and care lations, demonstrate and project nursing care trends, aid patients receive within an institution. A prospective pre- in clinical research, support decision analysis, and guide test posttest interventional study conducted at a Veterans professional and organization performance improvement Affairs nursing home revealed a signifi cant improvement programs. In summary, Hillestad and colleagues4 demon- in documentation of patient preferences concerning life- strated a potential annual savings of 346 billion to 813 sustaining care and compliance between patient prefer- billion health care dollars. The transition to EMR sooner, ences and medical orders.7 Prior to the EMR intervention, rather than later, can be impacted by the efforts of nurs- only 4% of admissions within the nursing home received ing leadership through the education of their colleagues documented discussion regarding advance directives by regarding the benefi ts of an EMR at their institution. their primary clinician.7 That number increased to 63% Once the decision to move toward an EMR is ap- of admissions following implementation of the EMR in- proved, the planning process begins. Fifty percent of tervention. The increase in advance directive discussion information system projects fail because of a lack of staff notes increased the percentage of subsequent do-not-re- acceptance and willingness to use the system.5 A cru- suscitate orders.7 Ninety-eight percent of individuals who cial step in the design, implementation, and reception expressed interest in advance directives documented with of an EMR is for administrators and project managers to the EMR intervention had a medical order placed to sup- assess the attitudes of all staff within the organization. port those decisions.7 This study demonstrated on a lim- McLane5 disseminated a fi xed-choice Likert-type ques- ited scale how a smoothly designed EMR enhancement tionnaire 18 months prior to implementation of an EMR can improve the documentation performance and, conse- on a 52-bed blood and bone marrow transplant unit quently, the care provided to patients within an organiza- specifi cally addressing the attitudes of staff toward the tion. Improved patient care is a goal of nursing leaders use of computers in the clinical setting and their general across the nation, and the EMR offers an alternative pro- expectations. While this study was not generalizable to cess for achieving that goal. the entire nursing population of the organization, this Nursing administrators and frontline nursing staff must step enabled planners to infl uence the development of be continuously involved in the ongoing development positive attitudes, perceptions, and expectations, and to and evaluation of an EMR already put into operation. After correct any misinformation.5 implementation of an EMR at a tertiary care pediatric hos- One major determinant to successful development of pital, Green and Thomas8 examined physicians’ percep- an EMR is a high level of end-user satisfaction.5 This can tion of nursing documentation through a quality improve- be achieved by assembling a product designed to meet ment project, using a survey instrument. Their fi ndings the needs of the clinicians in the practice setting, creating indicated that the largely checklist system only refl ected a system useful for providers with easy system usability.5 patients’ changes from normal physical states, resulting Nursing leaders have the capability to directly impact these in the lack of the nursing narrative component that often issues to support a project directed toward success by cre- played a part in their medical decision making.8 This lack ating an environment centered on staff involvement in the of nursing narrative resulted in incongruent views among development and promotion of an EMR. physicians and nurses regarding pertinent patient data and Wilhoit et al6 demonstrate the power of utilizing a lack of documented nursing observations of patients’ clinical frontline nurses in their pursuit for an EMR. psychosocial issues. An EMR must enable nurses to rap- They offer a detailed description of how a health care idly and precisely document all aspects of patient care to system, consisting of 9 hospitals in Tennessee, brought provide safe, quality care for patients, successful collabo- together 120 selected individuals for the purpose of ration with physicians, and legal protection of health care selecting an EMR business partner.6 Throug h the or- organizations.8 It is the responsibility of nursing leaders ganization’s support in providing the frontline nurses working closely with health care technology to ensure that with the knowledge of information systems, the wis- this is achieved. dom they already possess from meeting the needs of patients and their families while providing safe clinical SOURCE DESCRIPTION OF THE PROGRAM care resulted in the creation of an outstanding EMR.6 Hospitals are in the process of designing, developing, This process was achieved because of the persever- and implementing EMRs. Nursing leadership has the op- ance of the chief nursing executive and the chief nurs- portunity to learn from one another, build upon others’ ing offi cers within this health care system in know- knowledge, and create a culture focused on the evidence. ing that frontline nursing involvement wo uld lead to A large urban academic level 1 Trauma Center assumed

JJTN200160.inddTN200160.indd 112112 225/05/125/05/12 9:149:14 PMPM leadership roles in the development, training, and imple- readily assist another clinician with questions that may mentation of the EMR. have both a technical issue and a therapeutic issue. These First, Town Hall meetings were conducted with all staff services were offered continuously for 2 full weeks after members to identify EMR requirements specifi c to their implementation and then scaled down in a stair-step fash- individual needs and roles within the institution. Current ion over the following 2 weeks. workfl ows and processes were described to information Six months postimplementation, an anonymous survey systems technologists detailing the fl ow of patients, the was sent to all staff. In addition, Trauma Center staff met fl ow of information, and the fl ow of time while caring for in Town Hall meetings to refl ect upon the EMR. Inclusion patients. Trauma Center nursing staff and information sys- of Trauma Center clinical nursing staff as team members tems technologists then began to hypothesize their ideal of the Emergency Services project team was identifi ed as fl ow of patients and information with the implementation a major contributor to successful implementation, result- of an EMR. ing in inclusive documentation easily incorporated into With the support of the director of trauma and di- current workfl ows. Trauma Center staff described design saster services, Trauma Center clinical nurses joined the and validation sessions as good communication tools; emergency services EMR project development team. This however, communication from senior management and was to ensure that the EMR would meet the needs of the between supplementary project teams needed improve- clinical nurses at the bedside. The clinical nurses worked ment. Training was identifi ed as one of the most impor- together with information systems technologists, each tant factors to successful implementation of the EMR. observing the other in their natural environment. Nurses Using individuals familiar with the clinical situation was began to understand the specifi c EMR product and its helpful in teaching documentation. Unending efforts by programming limitations. Information system technolo- frontline staff allow for ongoing updates and revisions to gists learned to appreciate the high stress, high demand continue to improve the documentation product. of patient care, and the need for an EMR that would not Upon completion of the EMR implementation for obstruct the level of care needed to provide optimal care emergency services, the emergency services project to the patient. manager had equal participation with the information Frontline Trauma Center nurs ing staff participated in management team and the clinical specialty services in- multiple design sessions and product validation through- cluding the emergency department, Trauma Center, Ur- out the build process of the EMR. This interaction served gent Care Clinic, Women’s Intermediate Care Clinic, and as a line of communication allowing for information ex- Psychiatric Services. Together, select members from both change between the information system technologists information systems and the clinical end users came to- and Trauma Center clinical nursing staff to discuss deci- gether to create the emergency services EMR team and sion rationales and offer suggestions for improvements if guided a successful implementation of a fully integrated necessary. Demonstrations of the EMR were given to the EMR (Figure). Trauma Center clinical nursing staff throughout its design to seek opinions on functionality. The design sessions CONCLUSIONS and product validation allowed all persons involved an The research available to nursing administrators con- opportunity to express their opinions and to continuously cerning EMRs is not optimal and mostly qualitative. The improve upon the product. bulk of literature in regard to EMR is centered on the In preparation for training and implementation, the identifi cation of the benefi ts and barriers to implemen- clinical project team members became certifi ed trainers tation. Recent literature is, however, beginning to focus of the EMR project, completing all necessary steps by the on the entire process of creating an EMR. Nursing lead- EMR vendor to teach others how to use the product. This ers are in a position to learn from the available litera- was spearheaded by the support of nursing leadership. ture what techniques can be successful and how it may The training of all clinical staff was coordinated and led impact the transition to an EMR. Serious consideration by clinical staff. Topics of education included function- must be given because of the lack of generalizability. ality, merging EMR into workfl ow, utilization of paper Because of the incomplete volume of literature in re- medical records, and role-playing as data entry practice. gard to EMRs, this may be an opportunity for many Multiple approaches to training, including transcription of nursing leaders to offer quality research as they them- actual paper medical records, mock codes, and free play, selves begin to transition to the EMR. There is a great were incorporated. deal of wisdom and knowledge that a nursing leader During implementation, staff were supported by a possesses. As the world begins to move toward advanc- command center structure and assistive personnel in the ing health care information systems and the develop- clinical setting. Clinical project team members wore “red ments of EMRs, we must teach one another how best to shirts,” making them clearly visible as a clinician able to achieve this colossal obstacle.

JJTN200160.inddTN200160.indd 113113 225/05/125/05/12 9:149:14 PMPM Figure. Organizational chart for emergency services electronic medical record design team.

REFERENCES health benefi ts, savings, and costs. Health Aff. 2005;24(5): 1. National Alliance for Health Information Technology. The 1103-1117. National Alliance for Health Information Technology Report 5. McLane S. Designing an EMR planning process based on staff to the Offi ce of the National Coordinator for health infor- attitudes toward and opinions about computers in healthcare. mation technology on defi ning key health information tech- CIN Comput Infor Nurs. 2005;23(2):85-92. nology terms. http:րրwww.nahit.orgրimagesրpdfsրHITTerms 6. Wilhoit K, Mustain J, King M. The role of frontline RNs in the FinalReport_051508.pdf. Accessed December 1, 2008. selection of an electronic medical record business partner. CIN 2. The Joint Commission. Future goals and objectives. http:րրwww. Comput Infor Nurs. 2006;24(4):188-195. jointcommission.Orgրassetsրlր187SIWG_Vision_paper_future_ 7. Lindner SA, Davoren JB, Vollmer A, Williams B, Landefeld goals.pdf. Accessed April 17, 2010. CS. An electronic medical record intervention increased 3. Jha AK, DesRoches CM, Kralovec PD, Joshi MS. A progress re- nursing home advance directive orders and documentation. port on electronic health records in US hospitals. Health Aff. J Am Geriatr Soc. 2007;55(7):1001-1006. Nursing Advancing 2010;29(10):1951-1957. EMR 10. 4. Hillestad R, Bigelow J, Bower A, et al. Can electronic 8. Green SD, Thomas JD. Interdisciplinary collaboration and the medical record systems transform health care? Potential electronic medical record. Pediatr Nurs. 2008;34(3):225-240.

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