Nurse-Driven EHR Optimization

Optimizing nursing documentation through IT has long been a challenge for healthcare organizations and nurses. One nursing collaboration at Texas Health Resources, however, tackled this challenge head-on and created workflow optimizations in a number of critical areas including admission history, care plans, patient hand-offs, and blood administration workflow—all driven by nursing.

This continuous quality improvement project earned the 24-facility, 4,100-bed THR, which is based in Arlington, Texas, a finalist position in the Healthcare Informatics IT Innovator Awards that was presented at this year’s Healthcare Information and Management Systems Society (HIMSS) Conference in Las Vegas.To put THR’s initial challenges into context, a 2007 report from the Maryland Nursing Workforce Commission surveying 933 Maryland nurses found nurses were producing redundant documentation; spending excessive time documenting, taking them away from patient care; and staying beyond their scheduled work hours to finish documentation. In this sample, 36 percent used electronic documentation, and most felt that its use increased redundancy and time spent on documentation, yet also increasing completeness and quality of the documentation.THR’s electronic journey started in 2005 with its implementation CareConnect (an internally-branded moniker for the core electronic health record (EHR) from the Verona, Wis.-based Epic), and over the ensuing five years, the health system implemented all nursing documentation, order entry, CPOE, pharmacy medication management, and clinical decision support. In October 2010, THR completed the initial phase of a full EHR implementation for its 13 hospitals and installed three major upgrades from its vendor. There was also some clinical rework done as part of the documentation provided by a third-party vendor for evidenced-based care.THR Nurse ChampionsDuring September and October 2010, a detailed analysis of the CareConnect functionality and user acceptance of the EHR at all 13 hospitals was conducted by Mary Beth Mitchell, R.N., chief nursing information officer. As a result of that analysis, the Nurse Champion EHR Optimization collaboration was created to improve several of the nursing workflows and documentation requirements within CareConnect.A 23-member team, consisting of staff RNs from all 13 hospitals within THR, met to represent all specialties and subspecialties within nursing. In addition, nursing informatics analysts representing the CareConnect build team participated as well. This group self-managed and guided project implementation over the course of a year, committing a full day a week for the initial eight weeks. During this time, priorities were established for changes to CareConnect and recommendations were made for optimization. Mitchell got approval with the IT department for the entire nurse optimization process before it kicked off and scoped out what resources would be needed beforehand. Each project would be filed as one ticket, and all tickets would be addressed quarterly.Streamlining Admissions HistoryOn the first meeting day, the nurses brainstormed improvements to the admissions history process, and were only able to tackle a small section of the workflow; so the team decided they needed to be more efficient and be proactive for each meeting. Each month, prior to the meeting, Joni Padden, R.N., EHR clinical education specialist in THR’s Innovative Technology Solutions division and Tia Reinhardt, R.N., EHR builder/analyst e-mailed the team an agenda for the meeting, with screenshots and recommendations for team members to review with staff in their hospitals, in order to bring a collective view to the meetings. “I was amazed that they all went to their nurses and got the feedback and came with their list of comments attached to their screenshots,” says Mitchell. “They represented their own hospital’s point of view, even more than their own.”

Mary Beth Mitchell, R.N.The group made recommendations for changes, along with input from the CareConnect build analysts. Team members ultimately reviewed and discussed every single nursing documentation component within CareConnect, and arrived at a consensus for final revision.Initially, the team decided to replace a third-party evidence-based documentation tool and focus on their own build, getting rid of unused selections. The team reorganized the admissions history, reducing the content requirements from 286 separate entries to 150, thus reducing the average time of completion from 45 minutes to about 20 minutes.Navigating Blood AdministrationAnother project that the team worked on was creating an organized navigator to guide nurses through the entire blood administration process. “Because blood administration is so heavily regulated and there are so many checks and balances, there are challenges within the ordering of blood products—challenges with the transfusion, and then the documentation of the completion,” says Mitchell. “So there are several steps in blood administration and every one of them is in a certain sequence.”In the previous vendor workflow, the system required the previous step to be completed before moving on to the next screen, but the blood administration steps were not organized. “So what we did was take all those steps and put them in a navigator, which is a step-by-step sequence, and we put the instructions so that you’d know your next step and also put in the prompts to complete the previous step before going to the next one,” Mitchell says. The blood administration workflow optimization was so highly praised at the Texas Health Presbyterian Hospital Dallas it achieved Nursing Magnet status.Other EHR optimization activities included reorganization of nursing flowsheets to reduce redundancy, refinement of patient reports, as well as a total rework of care plans, providing better coordination between identification of a problem, goals, and interventions associated with flowsheet documentation. First, the collaborative tackled three care plans, the basic plan, heart failure, pneumonia, and will work on diabetes and acute myocardial infarction care plans next. “Care plans have been problematic for years and years, and my sense is we need care plans to be straightforward to guide the nursing process—helping the nurse see the total scope of the patient, what their needs are, to intervene on those needs, and report on how they’re doing [to meet those] needs,” says Mitchell.Over the course of 13 months as these changes were implemented, the nursing team also assisted with training and support of the staff at their hospitals, along with other hospital nursing super users. With the last upgrade, in September 2011, workflow revision was completed. After the initial eight-week project, many of the same RN's have continued to meet and the group has now evolved into a Nursing Informatics Council that makes all recommendations for advancing technology, including, but not limited to CareConnect.“This group, not only did they totally bond and become the experts, they became well-known as the go-to group to vet anything nursing-wise,” says Mitchell. “So everyone in IT, or in any other group, says they need to have the Nurse Champions look at this.”The Nursing Informatics Council is currently reworking a patient handoff that tells the patient’s story with key data like relevant labs, alerts, and patient needs to communicate to other units or to other nurses at shift change. The group is also working on a nursing shift checklist that has color-coded prompts to show what has and has been accomplished during a shift.