Computers are predictable. Not so a nurse's workday.
Getting computers and nurses' work to flow together for the good of patients is part of the art of informatics. As hospitals rely increasingly upon electronic records for everything about patient conditions and outcomes, a workable blend of informatics and practical bedside experience is vital.
"Getting a new software system is only the beginning," said Mercedes Fleming, manager of nursing systems and support at Catholic Medical Center in Manchester, N.H. The system has to be user-friendly and adaptable when clinicians identify practical concerns.
"Nurses are very busy, and one constant of their work is constant distraction. If a (computer) system doesn't meet the needs of the clinicians, the ones who suffer are the patients," Fleming said.
Fleming is a registered nurse with 33 years of experience, including work in intensive care units and as a supervisor. Since the medical center created her informatics position five years ago, she has been immersed in such things as software systems and computer devices, and involved in training sessions, both as a student and as a trainer for colleagues at Catholic Medical Center.
In a Feb. 21 article in HealthLeaders Media, Fleming said the hospital relies on its nursing staff to do frontline training when it deploys clinical technology. For instance, when it implemented a computerized physician order entry system, the hospital built nursing expertise and the nurses helped private practice physicians learn the software.
Clinical tool
Broadly put, informatics blends computer science, information technology, and expertise in clinical care and medical procedures in a manner intended to support clinical decision making, care quality and patient safety.
Fleming works with information technology specialists, doctors, nurses and other medical professionals in the hospital to find ways to improve the system's usability and functionality. For instance, Catholic Medical Center tried providing nurses with portable computer tablets, but found out quickly that didn't work.
"Nurses' hands are full. They carry dressings and all sorts of things," Fleming said.
The solution was to install at least one fixed computer screen in each patient room and put more on easily accessible portable carts. In the intensive care units, all computer screens are on carts.
"Computers need to be available when nurses interact with patients, and patients aren't always conveniently in a bed," she said.
Bob Duhaime, chief nursing executive at Catholic Medical Center, said the hospital created Fleming's position to assist the nurses during installation of the system, train the staff in its operation and provide ongoing support. Duhaime said he appointed Fleming primarily because of her knowledge of hospital nursing, not computers. Fleming was interested in computers and wanted to make a career change after years as a nursing director.
"Having this knowledge allows Mercedes to understand (nurses') concerns and why they ask the questions they do," he said. "I believe it's less difficult to learn the (information systems) world than having an IT person learn the clinical world."
Fleming is working on a master's of science in nursing, with specialization in leadership, and has spent much time at the headquarters of software design companies learning the workings of computers. But she said her kind of job need not, and perhaps shouldn't, be all about computers.
"You need to understand these systems, but first you need to be a knowledgeable clinician, someone who understands what nurses do," she said. "Much of a nurse's work is filled with crazy situations. The stuff you can anticipate is easy. What's needed are systems to help when things go wrong."
Experience preferred
Vicki Vallejos, president of the American Nursing Informatics Association in Sewell, N.J., said most of the nation's hospitals have nursing informatics administrators, or an equivalent position. "Clinical experience and ability for critical thinking is what makes them valuable in this role." She said the field has grown quickly in the past decade, spurred on by the federal mandate for electronic health records. Vallejos said more than 40 universities now offer master's degrees in nursing with emphasis upon informatics.
Continuous improvement
Duhaime said ongoing evaluation of hospital work flows is essential to making sure caregivers have timely access to information that allows them to begin treatments sooner and more efficiently.
He said the computer-record system used by Catholic Medical Center includes results of all laboratory and radiology tests, and it is programmed to warn nurses when an action might be necessary to prevent an untoward result.
For example, the hospital's system requires a clinician to log the insertion and removal of all Foley catheters. The result, Fleming said, has been the reliable compilation of much more complete information on the hospital's compliance with clinical protocols for Foley catheter use and the ability for supervisors to monitor in real time the number of hospital patients with Foley catheters and how long the device has been in use in each patient.
Duhaime said the program warns nurses when it's time to remove a patient's indwelling catheter to reduce the risk of infection. He said a nurse or other provider can keep the catheter in place, but must write an explanation in the computer record to deactivate the warning.
Fleming said: "The outcome has been excellent in terms of getting catheters out of patients at the proper times." And, according to Duhaime, it "has had a positive effect on our catheter-infection rate."
Fleming said nurses also have become more thorough in completing patient profiles through a combination of training and question prompts built into the software. This greatly reduces omissions on such matters as the medications a patient is taking, and dosing. The program also prompts nurses to ask nonclinical questions of patients, such as their religion, to allow for a better tailoring of an individual's care.
More complete information also has reduced lost billable charges in the hospital's emergency room by more accurately accounting for all services rendered, she said.
Fleming coleads the hospital's Electronic Practice Advisory Council, which meets at least monthly to discuss issues and ideas for improvements. The council includes nurses from all departments and representatives of other departments as needed. The council recently worked through upgrades in the program software to make sure it best fits Catholic Medical Center.
"We involved (nurses) in the design phase so they can tell us what their needs are," Fleming said. "We strive to provide tools to develop a comprehensive and real-time picture of a patient — the patient's story — so we can make the best decisions with them."
Fleming said the electronic records system used by the nurses and other caregivers also allows supervisors to monitor patient-care performance and allows nurses and others to evaluate themselves. "We follow a just culture. We try hard not to be judgmental, but to understand why something goes wrong. With individual feedback, we can have a positive impact with our nurses and other caregivers," Fleming said.
Copyright © 2013 by the Catholic Health Association of the United States
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