The EHR &Nursing:What, Why & How
Annual Distinguished Alumni BanquetJamestown Community College
May 5, 2010
Linda Q. Thede, PhD, RN-BC
© Linda Q. Thede, 2010
Healthcare Informatics is:• Intersection of
– Information Science– Computer Science– Healthcare
• Addresses healthcare information in terms of its:– Acquisition– Storage– Retrieval– Use
Healthcare Informatics
Definitions
Electronic Medical Record
An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization.
1 agency
EMR
Electronic Medical Record
CPOE eMar
All healthcare providers documentation
Radiology
Lab
Admitting
Financial
In short: Any area in the organization whereinformation is created, stored, or retrieved.
Definitions
Electronic Health RecordAn electronic record of health-related informationon an individual that conforms to nationally recognizedinteroperability standards and that can be created,managed, and consulted by authorized cliniciansand staff across more than one health care organization.
1 agency
EMR
1 agency
EMR
1 agency
EMR
1 agency
EMR
EHR
Regional Health Information Organization (RHIO)
HEALTHeLINK of Western New York
An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while beingmanaged, shared, and controlled by the individual.
Personal Health Record
PHR
What Data?
Structure?
Protocols?
Access?
Meaningful Use
Nursing
What Data for Documentation??
• Purposes of a healthcare record– Communication– Permanent, record of a patient's care: a legal
document– Provide best care– Secondary data use
• What data would best serve each of the above uses?
Data...
Data is objective
Data is objective
Data is objective
Data is objective
Data is objective
EXCEPT that what is collected…
Is subjective…
And determines what conclusions are made…
Nursing Data...What data do yourecord about an IV?
Type of solution, the site, the rate of flow, the time it was started etc.
Would this data convince an administrator, whois faced with saving $$, that it was necessaryto have RNs on the staff?
What in this data defines the practice of nursing?
What term
inology to use to
document our d
ata?
W U N D
B GA
Terms for a Heart Attack
Myocardial Infarction
MI
Heart Attack
Cardiac Infarction
StandardsStandards are an agreed upon way to record and exchange data within and across information systems.Standardized terminologies are content standards that represent a focus of concern.
A nursing standardized terminology represents content that is a focus in nursing.
Standardized NursingTerminologies
NANDA, NIC, & NOC Omaha SystemCCC
PNDSICNP
SNOMED-CT LOINC
Data must be in a structured format
Structured Data
Narrative notes…
Time Started
Solution Location Rate Time Disc
1015 NS Rt Wrist KO 1815
1400 D5W Lt Arm 38 gtts/min
2200
“IV of normal saline started at 10:15 in the right wrist at a keep open rate.”
“Discontinued at 18:15 IV in right wrist of normal saline that was at a keep open rate and started at 10:15”
Same data in a structured format
Benefits of Electronic Documentation
• Less documentation time, more accuracy, patient safety, etc.
• No looking for a chart
• Ability to search and extract information
• Real time information
• Backup of information
• Data only needs to be entered once
Why does my agency need to be concerned?
• Remuneration is going to decrease • Reimbursement is going to be tied not to units
of care, but quality and outcomes and readmission rates
• To improve quality an agency needs “actionable” data
• Best way to provide “point of care” information – including patient care guidelines
It is impossible to achieve these tasks without technology! And in our case this means an Electronic Medical Record.
Moving Forward(Outside the Agency)
• Network!!!– HIMSS/AMIA
– ANIA-CARING/Rutgers/SINI
– Listservs /Journal Articles/Web
– College courses/Degrees
– Certification
Moving Forward(Inside the Agency)
• eMAR– Does it make your life easier?– How could it be made better?
• CPOE– What role will you play?
• Nursing Documentation– Has this even been talked about?– How should it work?
Working Together
• Gain support from the “C” suite• Work with the IT department• Form a clinical informatics group
– Broad representation– Everyone a stakeholder– Focus on usability
• Delegate at least one nurse to be a nurse informatician and help her/him to gain the education needed
Have Fun
On
The Journey
National Alliance for Health Information Technology. (2008, April 28). Defining Key Health Information Technology Terms. Retrieved January 21, 2010, from http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_10741_848133_0_0_18/10_2_hit_terms.pdf
References
http://dlthede.net/Informatics/Informatics.html
Note, feel free to use any of these slides, but please acknowledge the source.
Thede, L. Q. The Electronic Health Record and Nursing Keynote Jamestown Community College, Jamestown, NY, May 5, 2010