This article appears in the February 2012 issue of HealthLeaders magazine.
Although the title of chief nursing informatics officer or nurse informaticist isn't exactly commonplace, data is increasingly becoming a part of nurses' day-to-day working lives. Typically the largest employee population, nurses also have the most frequent direct contact with patients. And so getting data into their hands can have a big impact on patient care.
"Every nurse needs to be able to understand the power of data, because nurses are knowledge workers. We have always collected data and information. So we need to understand the data that's at our fingertips. It's something that every staff nurse should be able to do," says Toni Hebda, PhD, RN, BSN, MNEd, MSIS, a professor in the master of science nursing degree program at Chamberlain College of Nursing, which has campuses in seven states and is headquartered in Downers Grove, IL.
"For us to be adept at what we need to do, we need to be able to work with the technology and use it at the optimal level so that we can reap the benefits, both for our work methods, as well as patient safety and improved outcomes," she says.
Still, some say adding a chief nursing information officer to the executive team is another example of C-suite bloat.
And Hebda agrees that not every department in the hospital needs a chief informatics officer. But she adds that it is a mistake to think that informatics should be solely the domain of doctors.
"From a political standpoint, a lot of people still prefer to reference 'medical informatics,'" Hebda says. "And some people innocently think that just encompasses everything within the healthcare profession," although in industry-speak that phrase refers to physicians. "There are many areas within healthcare or medical informatics that represent the different disciplines," she says.
That attitude isn't an issue at the 330-licensed-bed Catholic Medical Center in Manchester, NH, says Mercedes Fleming, the organization's manager of nursing systems and support.
"I've mostly worked at community hospitals. And honestly my experience is that at community hospitals the nurse has tremendous autonomy. And the doctors here are actually accustomed to nursing taking a leadership role in caring for the patient. I'm not saying we operate outside our scope of practice. But we do keep a pretty close watch over what is going on with our patients. That's really nothing new for us," she says.
Resources and responsibilities
CMC started its nursing informatics work in 2007 with a clinical documentation system—it used a knowledge-based charting program that merges evidence-based practice and clinical practice guidelines.
"It dramatically improved the quality of the documentation and put all nurses on the same page in terms of caring for the patients," she says. "It moved all nurses to that same level of care."
The program, a product by Grand Rapids, MI–based software firm Elsevier CPM, measures patient outcomes by asking nurses to determine the patient's condition—if it is improving, declining, or stable.
"That was a higher level of practice than we had employed prior to that time," she says.
Then the hospital decided to make its nurses experts in a number of different systems, starting with computerized physician order entry.
"We are a community hospital so we don't own most of our medical staff. And being community-based, we had to come up with a different strategy [for CPOE]. We thought that if all of our nurses became experts in the system first, then they would support the medical staff," Fleming says. "Nursing really has provided a great deal of support for medicine."
Empowering nurses in this way has also led to innovation, particularly in the design arena. Involving the end user in design is critical, she says. "People make the assumption that [if] you're electronic, you're automatically safer. That is not true." Poor design leads to as many or more errors as existed in a paper world, except that in the digital world "the errors happen faster," she says.
"The nurses and department coordinators will come up with things that nobody else has thought of," she says.
Jennifer Torosian, RN, MSN, NE-BC, administrative director of nursing services at CMC, agrees that there's a huge benefit to giving nurses that kind of responsibility. At CMC, when nurses have a concern, they don't hesitate to take it to the administration, in part because "they really believe we're going to do something about it," she says.
In some cases, the hospital was doing the right thing—such as removing catheters on time—but just wasn't proving it. Data helped there, too.
"We're pulling from the Foley insertion date. We need to work with nursing and make sure the nurses know how important it is to document the date," Torosian says.
Now the organization can run a report to calculate catheter days with an insertion date and a removal date. "I can go on at any time and print out and see how many patients in-house have catheters, the date they were inserted, and the date they were removed. And I can also see if one of the nurses hasn't documented an insertion date and work with the nurses to give them the feedback and the education that this is really important," Torosian says.
"It's definitely giving us a good starting point. We're able to give fairly close to real-time feedback. It's just a matter of figuring out who's going to monitor those reports," she says. "It's great that you have all these reports, [but] who validates? How are you going to validate the data, and who's going to monitor it and run the reports? I think we've done a great job in empowering the department coordinators to do that."
"We have seen a significant decrease in the number of missing insertion dates. Previously, on any given day we would have on average six patients on the report with no insertion date; we are down to an average of two," Torosian says.
Nurses are also doing a better job completing patient profiles. A year ago there could be 15 incomplete patient profiles in one month. That number steadily declined over the year—and in November 2011, there were no incomplete patient profiles for the month.
Order reconciliation is another area where informatics has made dramatic improvements, says Fleming.
On admission, nurses enter patients' historical or home medications. "Medication reconciliation has always been a challenge, but now the nurses are entering historical medications with the expectations that they are accurate, allowing the attending provider to convert it to an inpatient order. The nurse makes every attempt to confirm the correct medication, dose, unit of measure, frequency, how the medication was prescribed, and how the patient is actually taking it—all of that information is critical," Fleming says.
Accurate medication reconciliation has a significant impact on patient outcomes and readmissions at CMC.
"When we're able to accurately identify the patient's home medications, the provider can more effectively order medications during the patient's hospitalization and on discharge. Accurate admission and discharge reconciliation positively impacts patient outcomes, and nursing is responsible for a large part of that." Fleming says. "Nursing does not perform the reconciliation, but the quality of the historical information they gather can directly impact the patient as well as the efficiency and accuracy of the provider."
The shift from paper to electronic records has transformed the process. "On paper, the nurse or provider was free to leave key prescribing information blank on the home medications list." Fleming says. "With electronic historical medication entry, the nurse is guided to complete all elements of a complete historical medication order. The nurses are now routinely following up with PCP offices and home pharmacies to determine the correct and complete home medication information."
CMC reports that the improvements are leading to better quality. For example, CMC has decreasing door-to-balloon times, and its key performance indicator scores have exceeded expectations, with 44 excellent and 28 notable scores. CMC achieved best practice thresholds in 72 KPI categories.
And improving clinical documentation has had a positive financial impact. By decreasing lost billable charges, the organization's emergency department increased revenue by 48% in the first 6 months, and continues to see appreciable monthly increases in expected revenue capture. Total overall charge capture for FY2011 showed an average monthly increase of 33%.
Unlocking the data
Oklahoma Heart Hospital bills itself as one of the nation's first all-digital hospitals. But like many organizations that are early adopters of electronic medical records and other health IT systems, the organization's leaders were struggling to figure out how to make better use of it.
"We had this great EMR that had all this data that we couldn't get out very easily," says CIO Steve Miller.
So the 145-staffed-bed Oklahoma City organization, which encompasses two campuses and 60 affiliated clinics, started investigating how to use technology to unlock that data, make it actionable, and get it into nurses' and physicians' hands.
Today, the organization uses a number of techniques and technologies to improve clinical quality, workflow, and patient satisfaction.
Getting alerts on the go
"A lot of hospitals spend a large amount of time and personnel around centralized monitoring," Miller says. "Most hospitals have a centralized monitoring room where you'll have dozens and dozens and dozens of monitors and a 24/7 staff who are just sitting there staring at the monitors waiting for critical alerts."
Instead, Oklahoma Heart Hospital sends near-real-time critical alerts from hardwired heart and vital-sign monitors directly to nurses' smartphones using an integration engine from Boulder, CO–based Connexall USA.
The mobile alerts include an image of the patient's heart rhythm so the nurse can evaluate the severity of the alert. (If for some reason the patient's assigned nurse does not respond, the alert automatically escalates to another caregiver.)
Of course, monitors still give alerts in patients' rooms and at nursing stations. "But in our facility, nurses could be in another room taking care of patients. So the idea was to give them the best possible way to know as quickly as possible that there's an alert. You don't want to wait till the next time you're at that nurses' station or rely on hearing it in the room," Miller says.
The system allows nurses to not only spend more time at the bedside but also respond to patients more quickly, says Janet Fundaro, APRN-CNP, chief nursing officer. And the facility's EMR allows nurses to perform documentation faster, as well. She encourages nurses to document in the room while they're with the patient. It's more efficient and accurate, and also presents a chance to talk to and educate the patient about his or her care.
"That does help with our patient satisfaction because of the quality and quantity of time," Fundaro says.
Integration with the organization's EMR is another important piece of the alerting system. "Inside our EMR, we have multiple alerts that are designed to really help stay ahead of all the factors that may contribute to the overall care of that patient," Miller says. Alerts automatically generated from EMR data include risk for infections, falls, out-of-range lab values, and more.
"We try to make our alerts as automated as we can because that's where you can get value," Miller says. "The No. 1 [advantage] is to be able to take care of the patient in any kind of critical situation as quickly as possible … to respond to that patient and provide whatever they need as quickly as possible."
The organization plans to expand its mobile alerting system. "We're looking at integrating more of our EMR alerts that today go to them in the charts and instead send those to the smartphone," Miller says.
Assessing acuity
At the 624-staffed-bed Mission Hospital in Asheville, NC, nurses use informatics to classify the acuity of every patient on every unit every day. That data tells them how many hours of care each patient will need so that they can deploy staff accordingly.
"You can look at the acuity of every patient every day," says Brenda Shuford, RN, management systems coordinator. "The nurse on the unit providing the care to the patient that day goes in and does what we call a classification of her patients. So there are certain indicators that are weighted based on how valuable they are in translating the needs of the patient into their hours of care that were needed for the day … Once they get all the patients on that unit classified, they're able to run a report and see what kind of staffing recommendations they're going to need for the next shift."
When Shuford was a nurse manager in the pediatric ICU, she instinctively knew that although the number of patients in any given unit didn't change dramatically over time, the severity of illness did. "And the staffing—hiring and change of mix—had not kept current to the patient changes," she adds.
But when Shuford asked for more RNs and a change in skill mix on the units, the answer was no. Budgets are created based on patient days and because the historic data on patient days hadn't changed, neither would the nursing staff configuration or budget.
Using an acuity system by Reston, VA–based QuadraMed when she became management system coordinator, Shuford and her team tracked patient data for two years and ultimately convinced finance leaders to create parallel budgets—one based on acuity system data and one based on historical data.
It turned out the acuity assessment–based budget and the historical budget weren't so different. The former would save the organization just one half of a full-time equivalent position. But although staff levels stayed more or less the same, nurses are now deployed where they are most needed each day.
"It really did show … the units that were overstaffed and the units that were understaffed," Shuford says.
"We knew the nurses knew what staff they needed. They just needed some way to prove that. And the QuadraMed system gave that opportunity to prove that. Nurses really know from being there a few hours what the flow of patients is and how sick they are and whether they've got the right number of staff. Being able to respond and get the finance end of the healthcare business to understand and see that nurses need to be in charge of that was an issue. But with this system we were really able to accomplish that," Shuford says.
Better deployment of resources had an impact on satisfaction, as well.
"We increased not only our staff satisfaction, which had been really low in the pediatric ICU because of the feeling of being overworked, but also patient and family satisfaction," Shuford says. "Before we got the additional staffing, I had numerous conversations with families who were disgruntled that their child did not get the care that they needed at the time that they needed it—it wasn't a timely response."
The assessment takes a nurse who is familiar with the system and its indicators about 20 seconds per patient.
Ultimately, the organization plans to automatically send the Cerner documentation system to the organization's QuadraMed indicators and classification system, saving nurses from having to enter the data twice.
That's one of the areas where nurse informatics can shine, Hebda says. An automated systems that asks nurses to enter the same piece of information numerous times "is clearly a waste of everyone's time," she says. "Nurses are already in short supply, and they know that this is a waste of their valuable time. And if you're already collecting the data once, then the screen capture should bring that information into other programs [and] automatically populate it everywhere."
Acuity data has led to significant staffing changes in several Mission Hospital departments. The surgical unit, for example, used workflow data to make the case for a dedicated discharge nurse who would work peak discharge hours: Monday through Friday from 8 a.m. to 4 p.m.
That allows other nurses to focus on caring for new admissions, Shuford says, and "reduces the chance of error from interruptions." In fact, the surgical unit's readmission rates have decreased from 8.23% to 8.00%, although several initiatives were occurring during this time to reduce readmissions.
In the ED, acuity data was used to make the case for staggered shifts throughout the day with overlap at peaks in volume. Every unit management team has access to the data and can use it to make similar decisions about staffing and other solutions.
Prior to utilizing the acuity data to modify the staffing patterns, the ED provided staffing within the target range only 12.5% of the hours of the day. Since implementation of staggered staffing based on acuity data by hour of day and day of week, they are now providing staffing within the target range 54% of the hours of the day, Shuford says. They are continuing to adjust shift hours to further increase this percentage.
Putting data in plain view
The ability to view alerts and other clinical data in dashboard format also makes it easier for nurses to respond quickly "in a way that we were never able to do in the past," says Oklahoma Heart Hospital's Miller.
The MPages Web-based platform from Kansas City, MO–based Cerner helps keep track of vaccines, stroke indicators, aspirin on arrival, rehabilitation references, venous thromboembolism, restraints, and dietary needs, for example, arranging the information for nurses in an easy-to-read format.
"Most of the data is near real-time in that it is information about patients who are currently in the hospital. It's information about actions that we either have performed or need to perform on those patients," Miller says.
The organization also uses its EMR reports and dashboards to track progress toward goals such as CPOE use and meaningful use readiness.
"We had CPOE; we already had a lot of those meaningful use measures. But we really needed a way to track our percentages and look at that information in much greater detail to ensure we were really meeting the meaningful use standards," Miller says.
"I looked at all these meaningful use measures and I said, 'How are we ever going to know that we're doing all this?' I really have confidence when the CEO comes to me and says, 'Are we going to make meaningful use? Are we going to get a little bit of that EMR investment back so we can reinvest in other areas?' And I can say, 'Absolutely.' I know we're doing this and that we're doing the best job for our patients.
"That's why we started this process, but it really led us to this whole better way to consume information that is, we think, really going to revolutionize our area," Miller says. "This ability to build dashboards and to present data in much more than just lists but to be able to show it in dials, to be able to show it with more graphics, to be able to put that not only on a traditional interface, but put that into an iPhone or put that into an iPad—that ability to bring data out and provide that in a much more meaningful way—that's really changed the way we do business."
The data has also changed the way that the organization serves its patients.
"We are beginning to see information so much clearer than we could in the past. That's really been the innovator for us," Miller says. "We're really focused on making information more useable. And so I think for us we have the data and now we have the tools to present it. Really focusing on that usability engineering in everything we do is a big part of our strategy."
And that applies to both clinical information and business information. "Being able to use that more effectively to run our business is going to be very core to the future," Miller says. "The challenges of healthcare are so large … the ability to use data and information to help us chart the way and become more efficient, to find out ways to improve the cost or the value that we're delivering to that patient, is absolutely paramount."
This article appears in the February 2012 issue of HealthLeaders magazine.