Behind the Wires
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During a wide-ranging IT planning meeting with a dozen chief nursing officers at Aurora Health Care, Judy Murphy, R.N., poses a question that is at once practical and strategic. Wondering how tethered barcode readers would work in patient rooms, Murphy asks, “How many water pitchers will be knocked down?” She segues to describing a radio-frequency alternative to barcoded medication administration. Then a nurse raises the issue of infection control on IT devices. Murphy listens attentively, then makes a case for standardized patient educational materials. “It’s easy for a congestive heart failure patient to go home with multiple sets of instructions,” observes Murphy, the vice president of information services at the 13-hospital, Milwaukee-based integrated delivery network.
If anything, Murphy’s 30-year career has been all about best practices. An indefatigable presence on the IT lecture circuit, Murphy has risen in the industry ranks since her days as a surgical staff nurse at Aurora, becoming a visible proponent of nursing informatics. Responsible for all clinical and business applications across the sprawling IDN, she serves as Aurora’s project executive for its decade-long electronic medical record initiative. Using clinical IT as a foundation, Aurora hopes to standardize best clinical practices across hospitals used to doing things their own way. Aurora has poured more than $100 million into EMR technology, much of it from Kansas City-based Cerner Corp. “The core system runs throughout our 100 clinics and 13 hospitals,” Murphy says. “The goal is one Aurora.”
Serving central Wisconsin, Aurora has made steady headway, building a clinical data repository of some 3.5 million patient records. Caregivers can access a wide array of medical records across both the inpatient and outpatient settings, including lab and radiology results, dictated reports and discharge summaries. The massive IT project has countless moving pieces, resulting in sluggish system response and occasional downtime. Nevertheless, Murphy is confident her next three projects will move the IDN to better patient care—once infrastructure issues are resolved.
1. Computerized physician order entry
Now in pilot at Aurora’s Oshkosh facility, CPOE is, Murphy reminds, “not just about eliminating bad physician handwriting and automating orders so they can be read. We are encouraging and enabling best practices by organizing orders around evidence-based medicine.” For the past two years, Aurora has been developing standardized order sets around common diagnoses such as congestive heart failure, or routine procedures such as total hip replacements. Some 200 sets have been completed by the physician-driven orders committee, which Murphy supports. A module of the Cerner hospital information system, the order application will ultimately span medication, lab, radiology, activity, nurse and dietary orders, she adds.
Murphy’s well aware of CPOE’s checkered reputation among physicians. But she figures that building a catalog of order sets before widely deploying the technology should go a long way to enhancing physician acceptance. Physicians accustomed to handing off orders to unit nurses face a major change in their workplace routines with CPOE, she concedes. “It’s why we are careful during physician training not to use the ‘M’ word,” she says, referring to a potential medical staff “mandate” to use the technology. “We hope that if we build it, they will come.”
In plotting Aurora’s CPOE strategy, Murphy’s nursing background comes in handy. She’s well-versed in physician work habits and expectations. “Physicians don’t learn in groups,” says Murphy, who dispatched 10 analysts to the Oshkosh hospital to assist physicians during the pilot’s early stages. Managing CPOE in the inpatient setting also requires understanding how physicians cover for one another on the job. “When you move CPOE into OB, you have many issues to work around,” she says. “Who’s on call? Who takes what for whom?”
2. Automated nursing care plans
Closely related to CPOE is another Cerner module that enables nursing documentation and orders. A physician may order a patient to be up four times a day, but nurses carry out the orders and fill in the details, such as how far to walk, Murphy explains. With the care plan application, Aurora’s nurses can build their care around best practices in such areas as pain management, medication compliance and patient education. Unlike CPOE, the nursing plans are not necessarily driven by diagnoses and procedures. “Some areas, such as medication compliance, span all diagnoses,” she says. “Nurses document to both outcomes and activities. They can look at our database and see which interventions create positive outcomes.”
Aurora has deployed the nursing care plan application in two hospitals thus far, with the rest expected to come online by the end of 2007. To support the effort, Murphy has tapped into Aurora’s shared governance model. Nurses at the local, regional and system level of the IDN participate in creating evidence-based care plans that will be built into the application. “The physician may order ‘up as desired,’ but it is nurses who put that order into action,” she says.
3. Barcode medication administration
During the past year, Aurora has used barcode technology in limited areas. Its lab has used barcodes to track specimens. More recently, patients have been issued barcoded wristbands for identification purposes. Aurora hopes to capitalize on the technology by affixing barcodes to medications, then using the Cerner software to make sure patients are being given the proper drugs. Aside from the safety aspect, the technology would also streamline the documentation of medication administration, because the transactions would flow into the patient’s electronic chart.
But the project is problematic. “Getting meds barcoded makes me tired,” Murphy sighs. That’s because medications are not shipped with barcodes already attached to the unit dose, where it counts. Usually, barcodes are stuck to the packing box, leaving it up to hospitals to figure out how to apply the labels to individual doses. To tackle the issue, Aurora is considering adopting a centralized distribution model. All medications would originate from a central facility, where barcode packaging will be applied; in the previous arrangement, medications were shipped to individual hospitals. Murphy plans to introduce the technology across six hospitals in 2007.
To make it work, Aurora’s nurses must figure out how to adapt the barcode technology to the bedside. Part of the equation is where barcoded meds are stored on the unit. “The workflow is confounding and confusing,” Murphy says. “But barcoding can boost safety and save nurses time. That’s why we are charging ahead with it.”
Gary Baldwin is technology editor of HealthLeaders magazine. He can be reached at firstname.lastname@example.org.
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