How Nurse Informaticians Are Transforming Clinical Care
No one “gets it” better than a nurse.
By Robert P. Carlson, MHA
In 1992, Microsoft released Windows 3.1, Johnny Carson made his final appearance as host of The Tonight Show, Bill Clinton was elected president, and the American Nursing Informatics Association (ANIA) was founded.
Actually, nurses had been active in informatics at least a decade before 1992, but it was official recognition by American Nurses Association (ANA) and other nursing informatics organizations of informatics as a nursing specialty that put nursing informatics on the map.
The Capital Area Roundtable on Informatics in Nursing (CARING) and ANIA merged in 2010 and two years later decided to shorten the name of the new organization from American Nursing Informatics Association-CARING to American Nursing Informatics Association, “Where caring and technology meet.”
According to a news release for the ANIA 2013 Annual Conference in San Antonio, “Nursing informatics is a high-level specialty that blends the science of information technology with nursing practice, education, administration, and research. Nurses who work in this arena are project managers, administrators, leaders, directors, consultants, and more.”
The three-day ANIA conference program included presentations that left no doubt about nurse informaticians’ determination to transform clinical care.
In a 2011 blog, Healthcare Information and Management Systems Society (HIMSS) Vice President of Informatics Joyce Sensmeier, RN-BC, MS, CPHIMS, FHIMSS, FAAN, wrote “while numerous healthcare organizations have been advancing clinical transformation initiatives for several years, to date there is no widely adopted, standard definition.”
The term “clinical transformation” is not unique to nursing informatics, but the idea of transforming clinical care is a recurrent theme in conversations with nurse informaticians.
Online Bedside Information Portal
“When we started doing research on fall prevention interventions back in 2007, there were no known protocols for reducing falls in inpatient hospitals, even though it had been studied for 40 years,” recalls Patricia Dykes, PhD, RN, FAAN, FACMI, senior nurse scientist, program director of the Center for Patient Safety Research and Practice and of the Center for Nursing Excellence at Brigham & Women’s Hospital in Boston. “So we did a lot of focus groups with patients who had fallen in the hospital, with their family members, with nurses, with other professional and paraprofessional providers, and we learned that falls are really a communication problem.”
Dykes explains that the results of nursing fall risk assessments and plans to reduce falls were not consistently communicated to patients, to families, and to other members of the care team. These communication gaps turned out to be the root cause of patients falling.
Funded by a Robert Wood Johnson Foundation grant, the Fall Prevention Toolkit was deployed in 2009 for inpatients at Partners HealthCare system hospitals in Boston. Nurses use the Toolkit with the patient to periodically assess a patient’s risk of falling and select patient-specific interventions recommended by the software. The Toolkit then generates a customized fall prevention plan, a patient/family educational handout, and a bedside poster that uses icons to alert caregivers and visitors. In a randomized, controlled trial for which Dykes was the PI, the Fall Prevention Toolkit reduced falls by 22% in acute care hospitals.
The Fall Prevention Toolkit led to another transformative project—an online information portal at the bedside for clinicians and patients.
“We learned from this fall prevention study that you need a core set of information at the bedside for patients to participate in their care plan and for the team to safely care for the patient,” says Dykes. “That’s how we got to this web portal.”
Funded by the Gordon and Betty Moore Foundation, the “Promoting Respect and Ongoing Safety through Patient-centeredness, Engagement, Communication, and Technology” (PROSPECT) project is a web-based communication platform now being implemented on ICU and oncology units at Brigham & Women’s Hospital. David Bates, MD, MSc, senior vice president for quality and safety and chief quality officer for Brigham & Women’s Hospital, is the PI.
For patients, the PROSPECT portal provides information about their diagnosis, their recovery plan, the names of everyone on their care team, their medications and medication administration schedule, their lab values, and the ability to communicate directly with their care team—all accessible bedside.
The plan is to eventually make the PROSPECT portal available to all inpatients throughout the Partners system. “By showing that this can be done, we’re hoping that it’ll become the new standard of care,” says Dykes.
Clinician-to-Clinician Texting
Patient falls is just one safety measure for which nurses are responsible. But a patient’s risk of falling can vary from hour to hour, and nursing assessments of that risk are based on data entered on a patient flow sheet. That means an avoidable patient fall may occur if these data are not entered and acted on in real time.
“A huge priority that is going to revolutionize nursing in terms of contributing to quality and safety is moving to real-time information at the point of care,” says Ann O’Brien, RN, MSN, senior director of clinical informatics at Kaiser Permanente in Oakland, California.
Kaiser Permanente nurses and physicians have already made that move with real-time clinical care dashboards available on the same devices they use to access the patient electronic health record (EHR), such as a wireless laptop on a mobile cart, a wired workstation, or a tablet.
Real-time documentation is just one initiative in the Kaiser Permanente Smart Care strategy. To minimize the time spent logging into patient EHRs 80 to 120 times in a shift, nurses and other clinicians will soon be able to authenticate their access at the beginning of a shift and then use a secure sign-on tag to instantly tap in and tap out of the EHR. O’Brien notes that rapid sign-in also increases the likelihood that clinical data will be entered in real time.
In addition to their ID badge, most nurses also carry a Spectralink phone, a pager, a second pager if on call to the code nurse, and a personal mobile phone. That’s way too many communication devices, according to O’Brien, who sees advantages to texting with a unified communication device like the Apple iPhone.
“We’ve learned from some of the pioneers who are already doing clinician-to-clinician texting that it speeds the ability to get questions answered,” she adds. “Clinician-to-clinician texting changes the whole culture. It speeds communication and enhances safety because it improves the coordination of care.”
End-User Acceptance
Changing from a paper-based system to an EHR is an expensive, labor-intensive undertaking that involves everyone in a hospital. It’s a multi-year project implemented in bite-size pieces, usually with several projects running concurrently.
Vicki Vallejos, RN-BC, is manager of clinical informatics at Clark Memorial Hospital, a 241-bed community hospital in Jeffersonville, Indiana, just across the Ohio River from Louisville. She anticipates that computerized physician order entry (CPOE) and progress notes will “go live” for physicians house-wide at Clark Memorial in the first quarter of 2014. A pilot group of emergency department physicians has been doing CPOE since October 2013.
EHR vendor Allscripts provides consultants, but it’s up to Vallejos and her team to get feedback from clinicians affected by the activation of a new EHR module, make necessary changes, train the “super users” who train the end users, and prepare to “go live.” An IT help desk is available 24/7 and Vallejos and her team staff a 24-hour command center that receives all calls on “go live” day as well as during the following week.
“Just about any organization can put electronic clinical documentation in place,” says Vallejos. “How well that is accepted goes back to who has input into that documentation.”
Vallejos, immediate past-president of ANIA, is biased in favor of integrated steering committees with input from representatives of all hospital units. It’s a strategy that has served her well, starting with EHR vendor selection in 2005 and extending to getting input on the sequence of data fields on new electronic documents. Customizing Allscripts forms for the way they do things at Clark Memorial pays off in a high percentage of end user acceptance.
Barcoded medication administration (BCMA) went live in January 2013, and clinical documentation for nursing, nursing assistants, dieticians, PTs, OTs, SLPs, and RTs was scheduled to go live in October 2013, but was postponed until November 2013. Instead, their Allscripts system needed an upgrade to better support clinical analytics for generating reports that are required under the Medicare and Medicaid EHR Incentive Programs known as Meaningful Use.
The reports required for the first stage of Meaningful Use provided unexpected insights into opportunities for improvement. An additional informatics nurse was hired to create and generate these reports, which are making “a huge difference for us,” according to Vallejos, who is finishing her master’s degree in informatics.
“I like the idea that we are being pushed to start clinical documentation, that we are being pushed to use better care plans, that we are being pushed to look more at our outcomes, because that’s what it should all be about, is patient outcomes.”
Why Nurse Informaticians?
Nurse informaticians aren’t the only ones doing clinical informatics, and ANIA isn’t the only professional organization of healthcare informaticians.
The American Medical Informatics Association (AMIA) was formed in 1988 by the merger of the American Association for Medical Systems and Informatics (AAMSI), the American College of Medical Informatics (ACMI), and the Symposium on Computer Applications in Medical Care (SCAMC).
Founded in 1961, the Hospital Management Systems Society changed its name to the Healthcare Information and Management Systems Society (HIMSS) in 1986. Today HIMSS is the largest association in the United States dedicated to transforming healthcare through the use of IT and management systems.
It’s not unusual for a member of one informatics organization to also belong to one or more of the others. For example, HIMSS Vice President of Informatics Joyce Sensmeier, RN-BC, MS, CPHIMS, FHIMSS, FAAN, is also a member of AMIA. In fact, nurses are the largest professional group in HIMSS and the second-largest group in AMIA.
“Clinical informatics is a team sport,” O’Brien declares. “We cannot do this alone as nurses. It has to be everyone you’re bringing together as an interdisciplinary team. We need our physician partners, we need our pharmacy partners, we need our IT techie people who are on the build side.”
Still, you are likely to find clinical informaticians with an RN after their names in positions like Dykes’s, O’Brien’s or Vallejos’s. There are good reasons why nurses make good clinical informaticians.
“The unique skill set of the nurse informatician is that we understand the workflows of the hospital, and that understanding of workflows and hospital operations is key if we want to improve care,” O’Brien explains.
Immediate past AMIA President and CEO Kevin Fickenscher, MD, who was a keynote speaker at the 2013 ANIA conference, agrees:
In my experience as a physician, I would say that nurses are much more knowledgeable, much more expert on how work gets done in the healthcare environment,” says Fickenscher. “Nurses are much more involved in the care process and how to engage patients than physicians, and as a result I think nurses really do need to take the lead on issues that relate to care delivery.
While a large percentage of clinical informaticians are nurses, less than one percent of U.S. nurses are informaticans. According to Sensmeier, about 8,000 of the 3.2 million RNs in the U.S. are full-time informaticians. The absolute number of physicians who are full-time informaticians is smaller, but the number of medical informaticians relative to the 875,000 US physicians is also less than one percent.
“There is no formal Department of Labor category for ‘informaticians,’ so it’s anyone’s guess,” Fickenscher says. “If we base it on AMIA membership, there are more than 3,000. An additional cadre of CMIOs or CNIOs who may not be members of AMIA could be categorized as informaticians.”
Clinical informatics is booming not just because it can make care safer, improve patient outcomes, and reduce overall costs, but also because new informatics applications keep expanding the scope of the possible. Fickenscher recalls a recent conversation with a small start-up that has developed an app to analyze pathology slides and provide a preliminary diagnosis. Another company claims to be able to identify certain pathologies by analyzing videos of patients.
“It just blows my mind,” Fickenscher confesses. “You can sense my excitement about the field of informatics. It’s going to require the involvement of lots of clinicians.”
Sensmeier believes that nurse informaticians will lead those clinicians because nurses understand the potential pitfalls of automated systems, they know how to mitigate error and make sure patient care is not compromised.
“No one gets it better than a nurse,” Sensmeier says.
Bob Carlson writes exclusively about healthcare. He lives near Zionsville, Indiana, and may be contacted at bcarlson@indy.net.
Carlson, R. (2014). How nurse informaticians are transforming clinical care. Patient Safety & Quality Healthcare, 11(2), 28–30.