The EHR &Nursing:
What, Why & How
Annual Distinguished Alumni Banquet
Jamestown 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.
EMR
1 agency
Electronic Medical Record
CPOE
eMar
All healthcare providers documentation
Lab
Radiology
Financial
Admitting
In short: Any area in the organization where
information is created, stored, or retrieved.
Definitions
Electronic Health Record
An electronic record of health-related information
on an individual that conforms to nationally recognized
interoperability standards and that can be created,
managed, and consulted by authorized clinicians
and staff across more than one health care organization.
EHR
EMR
EMR
EMR
EMR
1 agency
1 agency
1 agency
1 agency
Regional Health Information
Organization (RHIO)
HEALTHeLINK of
Western New York
Personal Health Record
P
H
R
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 being
managed, shared, and
controlled by the
individual.
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 you
record about an IV?
Type of solution, the site,
the rate of flow, the time
it was started etc.
What in this data defines the
practice of nursing?
Would this data convince an administrator, who
is faced with saving $$, that it was necessary
to have RNs on the staff?
W
U N D
B A
G
Terms for a Heart Attack
Myocardial Infarction
MI
Cardiac Infarction
Heart Attack
Standards
Standards 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 Nursing
Terminologies
CCC
SNOMED-CT
LOINC
Data must be in a structured format
Structured Data
Narrative notes…
“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
Time
Started
1015
Solution
Location
Rate
Time
Disc
1815
NS
Rt Wrist
KO
1400
D5W
Lt Arm
38
2200
gtts/min
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
References
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
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
Descargar

The EHR &Nursing: What, Why & How