The Impact of Emerging Technology on Nursing Care: Warp Speed Ahead
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Technology is changing the world at warp speed and nowhere is this more evident than in healthcare settings.
Emerging Technologies That Will Change the Practice of Nursing
Carol Huston, MSN, DPA, FAAN
While myriad forces are changing the face of contemporary healthcare, one could argue that nothing will change the way nursing is practiced more than current advances in technology. Indeed, technology is changing the world at warp speed and nowhere is this more evident than in healthcare settings. This article identifies seven emerging technologies that will change the practice of nursing; three skill sets nurses will need to develop to acquire, use, and integrate these emerging technologies; and four challenges nurse leaders will face in integrating this new technology.
Citation: Huston, C., (May 31, 2013) "The Impact of Emerging Technology on Nursing Care: Warp Speed Ahead" OJIN: The Online Journal of Issues in Nursing Vol. 18, No. 2, Manuscript 1.
Key words: Change, future, technology, genetics, genomics, Human Genome, 3-D printing, robotics, nanomedicine, nanotechnology, biomechatronics, Kansei, biometrics, electronic healthcare records, computerized physician/provider order entry, clinical decision support, nursing leadership, informatics, training, education
While myriad forces are changing the face of contemporary healthcare, one could argue that nothing will change the way nursing is practiced more than current advances in technology. Technology is changing the world at warp speed and nowhere is this more evident than in healthcare settings. This article identifies seven emerging technologies that will change the practice of nursing; three skill sets nurses will need to develop to acquire, use, and integrate these emerging technologies; and four challenges nurse leaders will face in integrating this new technology.
There are many emerging technologies that will change the practice of nursing in the coming decade. Seven are discussed here; genetics and genomics; less invasive and more accurate tools for diagnosis and treatment; 3-D printing; robotics; biometrics; electronic health records; and computerized physician/provider order entry and clinical decision support (See Table 1 for a discussion of the benefits and challenges of each).
Table 1. Seven Emerging Technologies that Are Changing the Practice of Nursing
Technology Benefits Challenges
Genetics and Genomics The majority of disease risk, health conditions and the therapies used to
Many nurses currently in practice know little about genetics and genomics
treat those conditions have a genetic and/or genomic element influenced by environmental, lifestyle, and other factors therefore impacting the entire nursing profession (Calzone et. al, 2010).
and lack the competence needed to effectively counsel and teach patients in this regard.
Less Invasive and More Accurate Tools for Diagnostics and Treatment
Non-invasive and minimally invasive tools for diagnostics and treatment generally result in lower patient risk and cost.
The rate at which noninvasive and minimally invasive tools are being introduced makes ongoing competency regarding their use a challenge for nurses.
3-D Printing Bioprinters, using a "bio- ink" made of living cell mixtures can build a 3D structure of cells, layer by layer, to form human tissue and eventually human organs for replacement (Thompson, 2012).
Healthcare is just beginning to explore the limits of this technology. There are limits to the materials which can be used for printing and materials science is a laggard in 3D printing (Nusca, 2012).
Robotics Robotics can provide improved diagnostic abilities; a less invasive and more comfortable experience for the patient; and the ability to do smaller and more precise interventions (Newell, n.d). In addition, robots can be used as adjunct care providers for some physical and mental health care provision.
More research is needed on comparative effectiveness of robotics and human care providers. Many healthcare providers have expressed concern about the lack of emotion in robots, suggesting that this is the element that will never replace human caregivers.
Biometrics Biometrics increase the security of confidential healthcare information and eliminate the costs of managing lost passwords.
The measurement of biometric markers may occur in less than ideal situations in healthcare settings and in a rapidly changing workforce, cost may become an issue.
Electronic Healthcare Records (EHR) Healthcare providers have
access to critical patient information from multiple providers, literally 24 hours a day, 7 days a week, allowing for better coordinated care.
Implementation costs, getting computers to talk to each other and debates about who “owns” the data in the EHR continue to challenge its required implementation.
Genetic advances are likely to eliminate the need for organ transplants since new organs will be able to be grown from a patient’s own tissues.
Health care professionals already encounter patients who arrive for diagnosis or treatment with their genotyping or genetic sequencing in hand.
Computerized Physician/Provider Order; Entry (CPOE) and Clinical Decision Support
CPOE and clinical decision support fundamentally change the ordering process resulting in lower costs, reduced medical errors, and more interventions based on evidence and best practices.
The introduction of CPOE and clinical decision support requires providers to alter their practice. Resistance is common due to the time spent on order entry. Implementation and training costs are often significant.
Genetics and Genomics
The American Cancer Society (2011) suggests that genetic testing is already being used for many reasons. Some of these reasons include:
its predictive value (identification of gene mutations that might put a person at risk of developing a disease such as cancer, cystic fibrosis, sickle-cell anemia, or Tay-Sachs disease) its ability to determine carrier status or whether a person has a gene mutation which could be passed on to a child prenatal screening to diagnose some conditions in utero newborn screening (to determine the existence of a variety of inherited conditions such as phenylketonuria [PKU], cystic fibrosis, or sickle cell disease) as a means for checking cancer cells to determine prognosis or potential benefits of certain types of treatment.
Future applications of genetics and genomics will transform the health care system even further. Carroll (2011) suggests that by the year 2020 the healthcare system will have transitioned from one which “fix[ed] people after they were sick” (para. 1) to one of preventive, diagnostic, genomic-based medicine where patients will be treated for conditions we know they are likely to develop.
Health care professionals already encounter patients who arrive for diagnosis or treatment with their genotyping or genetic sequencing in hand. With websites such as 23andMe (2012), patients can send in a saliva sample and receive a comprehensive genotyping (DNA analyzed by genetic variants) with periodic updates on the latest biomedical literature for less than $100. Clearly, having genetic data can ultimately lead to better care and patient empowerment. But of concern are the ethical dilemmas associated with safeguarding such personal information and potential emotional consequences of uncovering unknown medical data without the guaranteed support of a primary care provider. Dilemmas such as these, and others we may not yet imagine, will pose significant challenges for all healthcare professionals, including nurses.
Despite these concerns, there is no doubt that genotyping and genetic sequencing will continue to significantly improve diagnostic and interventional medicine. Gene therapy is expected to make significant inroads in curing cancer and preventing birth defects within the next two decades (American Association for Cancer Research, 2012; Manchester University Scientists, 2013; Pearson & Flake, 2013, Pelletier, n.d.).
Genetic advances are also likely to eliminate the need for organ transplants since new organs will be able to be grown from a patient’s own tissues. Researchers are already beginning to grow individual tissues, tendons, and cartilages from stem cells and several years ago, a kidney-like organ was grown from scratch in the lab and used successfully in animals (Coghlan, 2012). In January 2013, Japanese researchers announced that they had succeeded in growing human kidney tissue from stem cells for the first time; a potential breakthrough for millions with damaged organs who depend on dialysis (Japanese Researchers Grow, 2013). Similarly, thyroid cells can now be grown in the lab, a new ear has been grown in the skin of a woman’s arm, and cells are being reprogrammed so that they can turn into a variety of cell types. Leading scientists suggest that there may be no limit to the kinds of organs and body parts that can be grown from stem cells (Complex Body Parts, 2012). This ability to grow major organs and body parts will eliminate the need for external donors, and since organs are genetically matched to the patient, the chance of rejection should become minimal or non-existent.
Stem cells and new biologic treatments will also impact the future of joint repair. Rath (2012) suggests that stem cells will be used to generate replacement cartilage tissue to repair damaged joints, especially for osteoarthritis patients. The process of autologous chondrocyte implantation (ACI) involves removing a small piece of healthy cartilage from the knee and growing millions of new cartilage cells (chrondrocytes) in a lab, before reinjecting them back into the knee. ACI will help people aged 15 to 50 with single cartilage defects no larger than 10 centimeters. Similarly autologous cartilage tissue implants, which use a combination of cell therapy and tissue
Less invasive and more accurate tools for diagnostics and treatment will also change nursing practice in the future.
Tattoos have been developed that can monitor blood glucose without a finger prick, a huge advancement for the 26 million Americans with diabetes.
engineering techniques, will be the next logical step in tissue regeneration. Such experimental implants are already in clinical trials (Rath, 2012).
The ability to clone teeth is also expected in the near future. Experts suggest that “dentures are the past, dental implants are the present, and teeth grown from stem cells could be the future” (Cloning Teeth, 2012, para 2). Clinical trials are already underway in Europe, where a fully functional and living tooth can be re-grown in around two months. In addition, Onion (2012) notes that scientists hope that by locating the right biological triggers people may one day be able to grow several sets of teeth instead of just two — much like the way sharks, rodents or stingrays grow several generations of teeth to replace teeth that are worn out or damaged.
Less Invasive and More Accurate Tools for Diagnosis and Treatment
Less invasive and more accurate tools for diagnostics and treatment will also change nursing practice in the future. For example, heart disease is likely to be diagnosed by a new blood test that eliminates the need for risky diagnostic angiograms. A new 23-gene blood test checks for certain blood proteins linked to heart disease (Howard, 2011). In a recent trial, the blood test was 85% accurate in detecting potentially harmful blockages among patients.
Tattoos have been developed that can monitor blood glucose without a finger prick, a huge advancement for the 26 million Americans with diabetes (Howard, 2011). The miniature tattoo, which is only a few millimeters in size, is made up of nanosensors that contain a yellow-orange dye. The dye lights up when glucose levels are high and becomes darker when the levels drop. The tattoos are applied once a week and are being piloted at Northeastern University in Boston (Tattoos That Improve Health, 2010).
Magnets are also increasingly likely to be used as a treatment for major depression (Howard, 2011). Cleared by the FDA in 2008, small electromagnets are now placed on the scalp behind the left forehead as a therapeutic intervention for depression. These magnets deliver a tiny electric current to the part of the brain linked to depression. It seems to work, although the mechanism for action is not fully understood. In fact, a large study found these magnets were three times more effective than a placebo and most importantly, they had no serious side effects (Howard, 2011).
Scanning technology is predicted to improve to the point that images of soft and hard tissues in the body will be so clear that exploratory surgery and invasive procedures will virtually be eliminated within a few decades. The Nuclear Energy Institute (n.d.) notes several current examples of state of the art nuclear medicine. Myocardial perfusion imaging maps blood flow to the heart, allowing doctors to diagnose heart disease and determine the most effective course of treatment. Today’s bone scans can detect the spread of cancer six to 18 months before X- ray imaging.
Researchers are also making strides to develop vaccines for some types of cancer. For example, Howard (2011) notes that researchers are using the same technology used to create childhood vaccines to develop a prostate
cancer vaccine known as Provenge®. Doctors remove some of a patient’s white blood cells, expose them to a protein found in prostate cancer, and then inject the cells back into the body, where they prime the immune
system to attack the cancer. So while Provenge® doesn't cure prostate cancer, it does reduce a patient’s overall risk of death by 24% in a three year period. The drug was approved in 2010 for use with patients with metastatic prostate cancer which had stopped responding to hormone treatments (Howard, 2011).
3-Dimensional (3D) Printing
3D printing, also known as additive manufacturing, "is a method of building objects layer by microscopic layer, fusing each cross section of molecules until a complete object is formed" (Pellet, 2013, para. 2). Typically, this requires scanning an existing object with a 3D scanner which gathers the data necessary to print on a 3D bioprinter. The bioprinter prints the object by adding layer after layer of materials such as plastics, glass, metal, or ceramics. Thus, three dimensional solid objects can be created from a digital model (Thompson, 2012).
The application of 3D printing in healthcare literally makes the body into a system of interchangeable parts (Banham, 2013). For example, in February 2013, doctors and engineers in the Netherlands collaborated on the 3D printing of a prosthetic lower jaw, which was subsequently implanted into an 83-year-old woman who suffered
The application of 3D printing in healthcare literally makes the body into a system of interchangeable parts
Growth in robotics is expected due to workforce shortages, a growing elder population, and a call for higher quality care not subject to human limitations.
Theoretically, nanobot technology could become the effective end of aging...
from chronic bone infection. The printer produced the prosthetic jaw from 33 layers of titanium powder that were heated, fused together, and then coated with bioceramic artificial bone (Banham, 2013). Artificial limbs can be created by the same technology, as can custom hearing aids and dental fixtures (Thompson, 2012).
In February 2013, Scientists at Cornell University used 3D printing to create an ear remarkably similar to a natural one. Using 3D images of a human ear, they printed a mold to be injected with gel containing collagen from rat tails and then added cartilage from cow ears. It took half a day to design the mold, about a day to print it, 30 minutes to inject the gel, and the ear was removed 15 minutes later (Cantor, 2013).
In addition, human organs can be “bioprinted” for transplant by 3D printing. This technology involves the creation of replacement tissues and organs that are printed layer-by-layer into a 3-dimensional structure. The parts are made from the organ recipient's own genetic matter, and precisely match the tissue or organ they replace (Banham, 2013). To date, 3D printers are able to print simpler tissues like skin, heart muscle patches, and blood vessels, although the printing of solid organs like hearts and livers is expected within a generation (Banham, 2013). Thompson (2012) agrees, noting that “printing off a kidney or another human organ may sound like something out of a science fiction novel, but with the advancements in 3D printing technology, the idea may not be so far-fetched” (para. 1).
Robotics, as an emerging field in healthcare, will also greatly impact how nursing is practiced in the future. Growth in robotics is expected due to workforce shortages, a growing elder population, and a call for higher quality care not subject to human limitations. Areas of projected robotic growth include nanomedicine, biomechatronics, and the use of robots as direct care providers.
Nanomedicine, which is the application of nanotechnology (the engineering of tiny machines or robotic devices) to the prevention and treatment of disease in the human body, is an evolving discipline has the potential to dramatically change medical science (Whatis.com, n.d.). Nanomedicine should be commonplace in another 2 to 3 decades, with engineered nanodevices, or nanomachines, repairing damage accumulated as a result of metabolism (being alive) by performing nanorobotic therapeutic procedures on each of the ~75 trillion cells that comprise the
human body (Healthcare in the 21st Century, n.d.). Microbots and nanodevices, which will circulate in the bloodstream, should be able to identify and repair systems early in disease processes to greatly reduce or eliminate the risk of cancer.
By the early 2020s, molecular manufacturing will enable the first nanobots to be inexpensively produced for use in medicine. Once in common clinical use, nanobots will have an enormous positive impact on the lives of billions of people
(Healthcare in the 21st Century). Theoretically, nanobot technology could become the effective end of aging as well as the reversal of one's current biological age to any new age that is desired.
There will also be more mergers of humans and machines through biomechatronics, which means creating machines which replicate or mimic how the body works. For example, it’s likely by 2020 that pancreas pacemakers for diabetics, mentally controlled electronic muscle stimulators for stroke and accident survivors, as well as miniature cameras and microphones that can be wired into the brain, will exist, allowing blind people to see and deaf people to hear (Huston, 2014).
Electroencephalography (EEG) technology already exists that uses mathematical algorithims to read minds, restore brain-controlled ambulation to the paralyzed, move experimental wheelchairs by brainwaves alone, and
It’s the use of robots as direct service providers, however, that may most impact nursing in the future
Experts suggest that biometric signatures will
explore game control without a joystick (Isaacson, 2012; Anderson, 2012). Philip Low, the mathematician and biology student cited as being the inventor of this EEG technology, plans to introduce Low's "iBrain 3" as the first FDA-approved EEG device in 2013. This device, the size of a U.S. quarter, can be used for medical as well as recreational purposes and is expected to possibly sell for less than $100 (Isaacson, 2012).
The first prototype of a bionic eye should be available by 2013 (Howard, 2011). The bionic eye works by having a tiny camera is mounted on a person’s glasses. The camera sends signals to an implant on the retina, which sends impulses to the brain, which are perceived as images. About 30 individuals have received artificial retinas so far and the technology continues to improve. Future adaptations of this eye have the potential to change lives for people with macular degeneration, a disease that impacts 1.75 million Americans (Howard, 2011).
We expect to see many more robotics, and they will have developed to the point that the differences between what these life forms and humans can do will be smaller than ever. For example, more robots will be used in surgical procedures, since already they are more accurate and steadier than human caregivers (Huston, 2014) Robots will also increasingly be used to provide direct patient care. Service robots are being developed for use as caregivers in Japan, particularly for the elderly. These robots help with tasks such as washing or carrying elderly patients, although they are still not yet developed for commercialization. In July 2012, iRobot Corp unveiled its most humanlike device yet: a 5-foot, 4-inch tall mobile robot which allowed doctors to examine diagnostic data in real time and interact with patients anywhere in the world (Seiffert, 2012). The robot features a flat-screen on top which pivots like a human neck, showing the physician's face and allowing him to look around the room and talk to patients, family members, and other healthcare professionals. It includes sensors for mapping and navigation and even carries a stethoscope.
It’s the use of robots as direct service providers, however, that may most impact nursing in the future (Huston, 2014). Currently, prototypes of physical care robots are in development, but commercial production may still take some time. Mental service robots are already here and in use as therapeutic adjuncts in mental health care.
One such mental service robot is Paro, the seal. Paro is fitted with sensors beneath its fur and whiskers and it responds to petting by opening and closing its eyes and moving its flippers. Paro is used in Japanese nursing homes and by autistic and handicapped children as a therapeutic robot. It retails for about $6,000 and several thousand have been produced since 2004. Paro was used to provide comfort and reduce stress in nursing home residents located near the tsunami- crippled nuclear power plant leaking radiation in Fukushima (Kyung-hoon, 2011). Residents named two of the Paro robots “Love” and “Peace” and treated them more like real animals than robots.
Many healthcare providers have expressed concern about the lack of emotion in robots, suggesting that this is the element that will never replace human caregivers. New technology in Japan, however, has resulted in a kind of robot intelligence known as “kansei,” (KEN-ZI), which literally means “emotion or feeling.” Kansei robots monitor human expressions, gestures, and body language and listen to people. They also sense human emotion through sensors that monitor pulse rate and perspiration. When Ken-zi hears a word, it searches through its database of more than 500,000 words and then it displays one of 36 expressions it thinks matches the word (Huston, 2014).
Robots will also increasingly be used as couriers. Robot couriers find and deliver medications, supplies, equipment, and other goods so that scarce, valuable human resources do not have to leave the patient care area.
There will continue to be more high fidelity, robotic simulation used in nursing education to supplement clinical nursing experiences. The newest simulation robots sweat, cry, turn cyanotic, and speak. But as with other robotics, nurse leaders will be challenged to figure out how much simulation may be too much. Perhaps by 2020, simulation will be so highly developed that most of student’s clinical learning can be done in a simulation laboratory. It would certainly be safer for patients and could eliminate the scramble to find enough clinical facilities. The nursing leadership challenge, however, is to determine the degree of real human interaction needed for students to develop the art of professional nursing.
The healthcare environment will also continue to be rapidly transformed by new technology as a result of the need to provide confidentiality and security of patient data, i.e., to comply with the Health Insurance Portability and
Accountability Act of 1996 (HIPAA) (Huston, 2014). HIPAA calls for a tiered approach to data access in which staff members have access to only the information that they need to know to perform their jobs. To that end, developers of new technology must assure that access is both targeted and appropriate. Biometrics, or the science of identifying people through physical characteristics
Clinical Decision Support will likely be commonplace within a decade...
become common place in most healthcare organizations since they will provide the needed security for medical records
such as fingerprints, handprints, retinal scans, palm vein prints, voice recognition, facial structure, and dynamic signatures, is often suggested as a solution to the information access problem. Experts suggest that biometric signatures will become common place in most healthcare organizations since they will provide the needed security for medical records (Krawczyk & Jain, n.d.).
Fingerprint biometrics is still the most common type of biometrics in healthcare, primarily because of its ease of use, small size, and affordable price. Detection of facial geometry through facial landmarks such as approach angles; eyebrow and mouth contours; skin texture analysis; and hairstyles, however, is also beginning to make inroads into healthcare as a biometric measure (Huston, 2014).
Electronic Health Records
Even health records continue to evolve as a result of technology. Any changes in documentation of care have a significant impact on nursing practice. The electronic health record (EHR) is a digital record of a patient’s health history that may be made up of records from many locations and/or sources, such as hospitals, providers, clinics, and public health agencies (Huston, 2014). The EHR is available 24 hours a day, 7 days a week and has built-in safeguards to assure patient health information confidentiality and security. In January 2004, President George Bush set a goal that most Americans would have an EHR by 2014. This goal was endorsed by President Barack Obama and supported financially with $30 billion in stimulus funds to support hospital implementation over the next several years. As a result, this optional improvement has become a near-mandatory initiative (Haughom, Kriz, & McMillan, 2011).
Many federal programs currently exist to support EHR adoption, including those around meaningful use (capturing the right data that can improve patient outcomes); the implementation of electronic information exchange; consumer e-health; and workforce training (Centers for Medicare and Medicaid Services, 2010; Take 5 with a Nurse Leader, 2012). Challenges continue to exist in understanding and demonstrating meaningful use; capturing the relevant data electronically as part of clinical workflows; and not having the appropriate certified technology (Miliard, 2012). In addition, most hospitals and health systems continue to doubt their ability to meet new mandated EHR standards, with only 48% of healthcare leaders in a recent survey feeling confident in their organization’s readiness to meet Stage 1 meaningful use requirements (Miliard, 2012). Thirty-nine percent said they were somewhat confident; three percent said they were not confident at all; and 10 percent indicated that they did not know their level of readiness. Even with these concerns, nearly three-quarters (71 percent) of hospital and health system leaders said they are more than 50 percent of the way to completing EHR system adoption (Miliard, 2012).
Computerized Physician/Provider Order Entry and Clinical Decision Support
Computerized physician/provider order entry (CPOE) is a rapidly growing technology as a result of its designation as one of three key patient safety initiatives by the Leapfrog Group, a conglomeration of non–health care Fortune 500 company leaders committed to modernizing the current health care system (Huston, 2014; The Leapfrog Group, 2013). In addition, the Institute of Medicine (IOM, 1999) study To Err Is Human recommended the use of CPOE to address medical errors.
CPOE is a clinical software application designed specifically for providers to write patient orders electronically rather than on paper. With CPOE, providers produce clearly typed orders, reducing medication errors based on inaccurate transcription. CPOE also gives providers vital clinical decision support (CDS) via access to information tools that support a health care provider in decisions related to diagnosis, therapy, and care planning of individual patients. Clinical decision support is defined broadly as “a process for enhancing health-related decisions and actions with pertinent, organized clinical knowledge and patient information …
Health Information Technology, Patient Safety, and Professional Nursing Care Documentation in Acute Care Settings
...the EHR [is] seen by nurses as both a benefit and a source of considerable frustration.
Mary Ann Lavin, ScD, APRN, ANP-BC, FNI, FAAN Ellen Harper, DNP, RN-BC, MBA, FAAN
Nancy Barr, MSN, RN
The electronic health record (EHR) is a documentation tool that yields data useful in enhancing patient safety, evaluating care quality, maximizing efficiency, and measuring staffing needs. Although nurses applaud the EHR, they also indicate dissatisfaction with its design and cumbersome electronic processes. This article describes the views of nurses shared by members of the Nursing Practice Committee of the Missouri Nurses Association; it encourages nurses to share their EHR concerns with Information Technology (IT) staff and vendors and to take their place at the table when nursing-related IT decisions are made. In this article, we describe the experiential-reflective reasoning and action model used to understand staff nurses’ perspectives, share committee reflections and recommendations for improving both documentation and documentation technology, and conclude by encouraging nurses to develop their documentation and informatics skills. Nursing issues include medication safety, documentation and standards of practice, and EHR efficiency. IT concerns include interoperability, vendors, innovation, nursing voice, education, and collaboration.
Citation: Lavin, M., Harper, E., Barr, N., (April 14, 2015) "Health Information Technology, Patient Safety, and Professional Nursing Care Documentation in Acute Care Settings" OJIN: The Online Journal of Issues in Nursing Vol. 20 No. 2.
Keywords: Experiential-reflective reasoning, electronic health record, informatics, informaticists, nursing practice, health information technology, standards, documentation, quality, safety, patient responses, patient outcomes
The electronic health record (EHR) is a documentation tool that yields data useful in enhancing patient safety, evaluating care quality, maximizing efficiency, and measuring staffing needs (Beck et al., 2013; Harper, 2012a; Towsley, 2013). Although nurses indicate dissatisfaction with the EHR design and cumbersome electronic processes (Sockolow, Liao, Chittams, & Bowles, 2012; Stevenson, Nilsson, Petersson, & Johansson, 2010), they view the EHR and the data generated as an opportunity to improve care, safety, quality, and coordination (Cipriano et al., 2013), as well as a tool to study appropriate nurse staffing and to gauge or predict staffing needs (Beck et al., 2013; Harper, 2012b).
The work of the Nursing Practice Committee (NPC) of the Missouri Nurses Association (MONA) included identifying areas of interest to direct care nurses. One identified interest area was the EHR, which was seen by nurses as both a benefit and a source of considerable frustration. Furthermore, nurses were challenged to articulate their concerns due, in part, to the fact that there was no available taxonomy to describe EHR-related difficulties. This article begins to articulate EHR concerns of Missouri nurses. Realizing that these concerns transcend state boundaries, the MONA NPC decided to share their recommendations with a broader nursing audience with the hope that they would increase participation of all direct care nurses in EHR, vendor, and Health Information Technology (HIT) department decisions and problem solving. In this
...nurses were challenged to articulate their concerns due, in part, to the fact that there was no available taxonomy to describe EHR- related difficulties. The Model
Direct care nurses, at their core, are risk managers. They attach meaning to what is and anticipate ‘what might be.’
HIT and the electronic documentation of nursing care directly influence patient safety.
Committee Reflections and Recommendations for Improving Documentation
The investigation of EHR-associated medication administration
article, we share the reflections and recommendations of MONA nurses with direct care nurses and HIT communities across the nation and around the world.
The goals of this article are to add to the EHR literature by categorizing views of nurses as expressed by members of the MONA NPC and to enhance the computer vocabulary of all nurses, empowering them to voice their EHR concerns to IT staff and vendors and to take their places at the table when health and nursing-related IT decisions are being made. In this article, we will describe the experiential- reflective reasoning and action model used to accomplish these objectives; share committee reflections and recommendations for improving both documentation and documentation technology; and conclude by encouraging nurses to consider how they can develop their documentation and informatics skills.
We used an experiential-reflective reasoning model, one that leads to action, to accomplish our purpose. This model includes consideration of participants’ context, experience, reflection, action and evaluation. This experiential-reflective reasoning model has been incorporated into Jesuit pedagogy for more than 450 years. Within nursing, the Jesuit model has been used as a basis for transformative change (Pennington, Crewell, Snedden, Mulhall, & Ellison, 2013). It is analogous to the learning theory and the change/action research methods identified by Kurt Lewin (Atherton, 2013; Smith, 2001). We used this model to categorize the experiences of the members of the MONA Nursing Practice Committee related to their use of the EHR, to reflect upon these experiences, and to draw up a set of recommended actions.
We reflected and articulated direct care nurses’ concerns regarding the EHR. We involved direct care nurses in this initiative because they plan care used to address the clinical judgments/diagnoses flowing from a nursing assessment and provide care to individuals and/or families. The care itself is designed, through this planning process, to achieve the desired outcomes (American Nurses Association [ANA], 2010; Shake, n.d.).
Direct care nurses are bedside nurses; they include generalists, advanced practice registered nurses, care coordinators, visiting nurses, public health nurses, camp nurses, and school nurses. In brief, they are found in any and every setting where nurses practice. Direct care nurses, at their core, are risk managers. They attach meaning to what is and anticipate ‘what might be’ (Meyer & Lavin, 2005). When they anticipate risk, they conduct surveillance, intervene when necessary, and document not only their risk prevention findings/observations, but their reasoning and clinical judgments, interventions, patient responses and outcomes.
HIT and the electronic documentation of nursing care directly influence patient safety. This is because nursing documentation facilitates real-time communication among all healthcare providers and because electronic documentation allows for its study in proportions never before attempted. If patient safety is to be optimized through EHR use, effective collaboration between nurses and HIT staff is needed, along with greater clarity of the patient safety perspective that direct care nurses offer.
The reflections and recommendations described in this section are not research findings, but rather reports of the experiential/reflective thinking of the committee, categorized under the headings of both medication safety, and direct care nursing documentation and standards of practice. It is from these reflections that recommendations flow.
NPC members focused primarily on medication safety, with special attention to the prevention of errors and adverse events. They approached the discussion by following the four categories used to organize medication error prevention strategies in the Agency for Healthcare Research and Quality (2012) report. The Nursing Practice Committee felt that the system, as implemented within the EHR, is weighted toward maximizing the safety of the prescribing, transcribing, and
errors is a ripe area for nursing research and/or nurse-led quality improvement studies.
In each of these examples, the data were already contained within the EHR; they simply needed to be connected in a nurse-and-patient- safety-sensitive manner.
dispensing categories (see Table 1). The table indicates that, of the citations retrieved, only 35 were devoted to medication administration. Of these, only two included the word nurse or nursing in the title (Debono et al., 2013; Yuan, Finley, Long, Mills, & Johnson, 2013). There were no nurses as first authors among the 35 citations dealing with medication administration, nor were there any citations from nursing journals. The investigation of EHR-associated medication administration errors is a ripe area for nursing research and/or nurse-led quality improvement studies.
Table 1. Distribution of Citations Retrieved from PubMed Central Database on September 28, 2014
Search string: EHR AND prevention AND
medication error AND…
Number of citations retrieved
More recent and last citation publication
Prescribing 201 2004 - 2014
Transcribing 9 2010 - 2014
Dispensing 69 2005 - 2014
Administering 35 2005 - 2014
Total number of citations and overall range
2005 - 2014
The NPC further recommended that all four categories of prescribing, transcribing, dispensing, and administering (thus including the nursing-sensitive medication administration category) be digitalized and synchronized in the EHR. Such an action would combine bar code medication administration technology at the point of care with real- time medication surveillance of therapeutic goal attainment, enhanced adverse drug-event alerts, and adverse event-surveillance information. In other words, if bar code data could be used to do more than identify the patient and report medication administration doses, the additional synchronization of information would broaden the scope of the medication-administration patient safety zone. This would give nurses more efficient access to information which the nurse actually uses when administering medications. Additional information, triggered by the bar code, might help the nurse to:
Identify and evaluate the appropriateness of the drug dose and route, given the drug’s specific therapeutic goal Respond to an enhanced, real-time medication contraindication/drug interaction check with the EHR, by linking the drug on the same screen with the most recent, clinically relevant laboratory values
For example, if a low serum potassium value were to appear, it would prompt the nurse to request a supplement for the patient receiving a thiazide. It is important to note that the nurse currently takes these steps manually in a time-consuming process, searching for the potassium values while preparing the drug for administration. The electronic process being recommended is both more efficient and safer.
Electronic medication records (eMARs) should also include trending of medications along with clinically relevant laboratory values. Insulin administration in the eMAR should be trended with the most recent plasma glucose and serum potassium levels in a single view, so as to keep busy nurses from having to retrieve the labs from another flow sheet in the EHR.
In each of these examples, the data were already contained within the EHR; they simply needed to be connected in a nurse-and-patient-safety-sensitive manner. Programming of drug administration processes at the point of patient contact, with strategically placed tips and alerts, might lessen medication errors significantly. We authors support informatics research that moves in this direction. We also offer the following additional medication safety recommendations:
Improve user friendliness (screen size, font size, adequate LED lighting for use in darkened rooms) of handheld devices used to bar code scan medications Build in efficient and timely access to laboratory results for all medication providers (physicians, advanced practice registered nurses [APRN], pharmacists, and other direct care nurses).
Use of non- standard materials will cause documentation to appear as if nurses are not meeting patient education/health promotion standards.
...it is imperative that specialty- specific nurses become involved in the selection and updating of computer- generated, patient- education materials to ensure the evidence base and the appropriateness of all materials.
...the electronic health record should allow providers to manually order or sort the problem list.
Finally, we encourage careful consideration of policies governing the use of pharmacy technicians in dispensing medications without direct pharmacist supervision. Boards of Nursing and Pharmacy may want to take up this consideration from a regulatory or statutory viewpoint. EHRs need to reflect the credentials of the person dispensing and administrating the medications to compare medication error rates between and among licensed and unlicensed personnel.
Direct Care Nursing Documentation and Standards of Practice
Appropriate quality care comparisons among and between providers and practices can only be made when standardized processes and products are used. This section will explore three aspects of the patient safety implications of direct care nursing documentation and its unique characteristics from three aspects, including standardization of evidence-based care processes, transparency of the nursing process, and development of an electronic workflow tool to standardize and improve communication.
Standardization of evidence-based care processes. The NPC recommended standardization of evidence-based care processes, including patient educational materials and actions plans, within and eventually across the care setting. Appropriate quality care comparisons can only be made when such standardized processes and products are used. The operational phrase is ‘when standardized processes and products are used.’ If nurses or nurse practitioners use their own materials and do not use, for example, the EHR-generated patient education materials, then they are at a disadvantage when electronic comparisons within and between institutions are made. Use of non-standard materials will cause documentation to appear as if nurses are not meeting patient education/health promotion standards.
Registered nurses, including APRNs, may defend themselves by saying that their own personal materials are the most current and most evidence-based. If this is so, then it is imperative that specialty-specific nurses become involved in the selection and updating of computer-generated, patient-education materials to ensure the evidence base and the appropriateness of all materials. In addition, documents generated by the EHR must be written clearly and simply, in keeping with sound health-literacy and evidence-based patient education strategies and tools Harvard School of Public Health (n.d.). Nurses may also voice concerns about newer electronic documentation methods interrupting workflow, in which case they need to become personally involved in workflow design with vendors or with IT department personnel.
Some may object to the notion of ‘standardized’ care processes, incorrectly thinking it eliminates individualized care. In contrast to this misperception, it is important to recognize that evidence-based practices and standardization of care processes help to assure that the quality of care is optimized for each individual patient. The premises underlying evidence-based practice and standardized care do not negate, but rather heighten, individualization of care, including consideration of personal beliefs, values, and individual preferences. In brief, evidence-based practice and the standardization of care processes enhance the trust patients have in nurses to consistently function on behalf of their best interest.
Prioritization of diagnoses and transparency of the nursing process. The Nursing Practice Committee recommended that nurses make the nursing process more transparent in the EHR for each patient problem requiring nursing care. The Committee also recommended that nurses properly prioritize patient problems in their documentation.
Proper prioritization of diagnoses and a more transparent process are two methods of evaluating nursing documentation. The American Health Information Management Association indicates the electronic health record should allow providers to manually order or sort the problem list (AHIMA Workgroup, 2011). Analogously, nurses need to have the ability to manually order or sort by priority the diagnoses that drive their interventions.
When documentation is poor it is likely that both human and technologic improvements are needed.
Transparency refers to the clarity of the record for its users. Transparency, in more recent times, has come to mean the open sharing of information. For purposes here, we define electronic health record transparency as clear and open sharing of information among providers and with patients. While providers using the EHR have access to information inserted by interdisciplinary team members, access to this information is not always intuitive, nor is its presentation always clear. Systems today do provide patients with electronic access to limited information in their EHRs. However, it is possible that even greater information sharing in the future will further improve the quality of care (Delbanco et al., 2010; Delbanco, et al., 2012).
Development of an electronic workflow to standardize and improve communication. Additionally, the Nursing Practice Committee recommended that the nursing process steps be researched and developed into an abbreviated communication tool, one that would describe and prioritize each individual patient problem for use during handoff at change of shift and also when documenting planning of care during admission, transfers, and discharges. The NPC suggested that nurses apply ANA nursing practice and documentation standards within the EHR using the nursing process model illustrated in the Figure.
Figure. Assessment, Diagnosis, Outcome Identification, Planning, Implementation, and Evaluation Model
A simple, electronic workflow helps standardize and improve communication of direct care in keeping with the ANA documentation standards (2010), as in the following focused-care example.
Assessment: Data provide information for nurses to arrive at specific clinical judgments (diagnoses/problems). Diagnoses/Problems/Clinical Judgments: Appropriate outcome identification, planning, and implementation of interventions are not random actions, but are actions that are assessment-and-diagnostic-specific. Outcome Identification and Planning: In these two standards, nurses specify the intervention(s) to be used to achieve the desired outcomes, both process outcomes and clinical outcomes. Implementation: Engage the individual/family/community/population in care planning and on the implementation of interventions. Conduct on-going vigilance and act to prevent or to reverse movement toward outcomes that are undesired. Initiate rescue, as needed. Evaluation: Document patient outcomes and make summative statement/analysis, e.g., condition stabilizing/worsening. Continue to modify plan to achieve desired process and clinical outcomes.
The purpose of nursing documentation is to record nursing care provided and patient responses. The old adage, ‘If it wasn’t charted, it wasn’t done,’ still holds today. Because the current standard of care is the nursing process, the steps in the nursing process need to be evident in nursing documentation. If the process is documented, then the practice standard will be judged as ‘met.’ If the process is not documented, then the practice standard will be considered ‘not met.’ This standard holds true for registered nurses at all levels, whether nurses are documenting in EHR or on paper health records.
We authors find human-machine interaction to be interesting. When there is an issue with documentation, those closest to the world of informatics are quick to exculpate the EHR by saying it was never intended to fill a gap in practice. On the other hand, those closest to the clinical world are quick to exculpate themselves by blaming one or more technical features of the EHR. Reality most likely lies somewhere in the middle. When documentation is poor it is likely that both human and technologic improvements are needed.
It may be that standardization of care processes, including clinical decision-support processes, becomes more fully appreciated as the number of Doctor of Nursing Practice (DNP) graduates increase. These graduates are prepared to use new quality improvement technologies; organize and analyze the evidence that flows from their own practice; and compare their practice parameters against those of others. The following paragraph provides an overview of DNP clinical projects designed to improve patient outcomes or reduce patient risk by improving care processes.
Examples of DNP projects that incorporated clinical decision-support processes include: a) establishing criteria for evaluating provider compliance with amiodarone guidelines in primary care (Dixon, Thanavaro, Thais, & Lavin, 2013); b) addressing therapeutic or clinical inertia in the management of patients with diabetes (Apsey et al., 2013; Mackey et al., 2014); and (c) decreasing HbA1C by building confidence in patient ability to select correct portion sizes and complete weekly exercise plans (Beckerle & Lavin, 2013). APRNs, and especially DNP graduates,
Clinical decision support (CDS) information depends on real time data.
Committee Reflections and Recommendations for Improving Documentation Technology
...structured, electronic documentation is more closely associated with quality patient outcomes in primary care than free text or dictated documentation.
know that the ability to take advantage of EHR data to improve patient care first requires the proper entry of process and outcome data in the record.
Appropriate timing of nursing documentation, both real time/synchronous and late charting/asynchronous documentation, requires that nurses have access to and use the EHR at the point of care. Nurses use both synchronous and asynchronous methods to document care . Perhaps when voice activated, natural language processing methods are further developed and better integrated into the EHR, all nursing documentation will be synchronous.
Clinical decision support (CDS) information depends on real time data. Triggering an alert for sepsis is only beneficial if the alert comes as soon as the system inflammatory response system (SIRS) criteria are met. If the vital signs are written on paper and entered later, the alert is delayed and patient safety is impaired.
Continued research is needed in basic nursing care of the ill patient and its documentation (Englebright, Aldrich, & Taylor, 2014; Van Achterberg, 2014). Documentation studies indicate that factors to promote diagnostic reasoning and accuracy have been identified. These factors include use of problem, etiology, and signs/symptoms (PES) structure; computerized aids (e.g. diagnostic specific scales); and standardized care plans (Müller-Staub & Paans, 2011; Paans, Nieweg, van der Schans, & Sermeus, 2011; Paans, Sermeus, Nieweg, Krijnen, & Schans, 2012).
Other methods to improve documentation include nursing documentation audits, use of safety checklists in surgery, and nursing diagnostic-specific checklists (Mykkänen, Saranto, & Miettinen, 2012; Treadwell, Lucas, & Tsou, 2014). Researchers should work closely with EHR vendors and terminology developers to be assured that tools with known validity and reliability are correctly incorporated into the clinical workflow. These scales not only meet nursing and hospital system standards but are increasingly being incorporated into big data and population- health management.
Comparisons of physician documentation suggest that structured, electronic documentation is more closely associated with quality patient outcomes in primary care than free text or dictated documentation (Linder, Schnipper, & Middleton, 2012). On the other hand, unintended consequences may flow from what a clinical ethicist calls EHR quality and documentation pitfalls. Examples include “copying and pasting data from day to day without proper evidence of verification, authorship ambiguities, inadvertent inclusion of un-obtained data in templated notes, ambiguous history and physical examination findings, failure to review prepopulated data, inadequate discharge summaries” (Bernat, 2013, p.1057).
Each of these issues may be prevented or addressed by discussion and exchange of information between the provider, whether physician or nurse, and the vendor and/or IT department. Most vendors provide software with a variety of options for each assessment parameter (e.g., yes, no [not present], no [NA], or deferred). Yet, well- intended but clinically inappropriate IT decisions may be made. For example, in an attempt to save electronic memory/space, a system may be designed to include ‘only’ a single yes/no option for each assessment parameter. In such cases, the EHR nurse/physician on the next shift -- or much later when a case is presented in court -- does not know if a recorded ‘no’ means that the parameter was assessed and found to be negative, or was not assessed because it was not applicable, or was deferred.
When clinicians identify problems, such as ambiguous yes or no options, they are encouraged to correct them by explaining clinical and legal consequences of such decision-making to IT department staff or to healthcare system executives. Other technology issues may also need to be voiced to vendors.
In the paragraphs below, we will first consider efficiency and EHR technology concerns. Then we will offer HIT and nursing practice recommendation.
Efficiency Concerns Related to the Use of EHR Technology
A time and motion study addressing nurses’ work in the acute care setting found that collecting, entering, and accessing data used a large portion of nurses’ time.
...a well- constructed EHR also reflects accurately how nurses think (assess), arrive at clinical judgments (diagnose), identify outcomes, plan, intervene and evaluate care.
Efficiency in the delivery of healthcare is defined as “avoiding waste, including waste of equipment, supplies, and ideas” (Institute of Medicine, 2001, pg 6). Several studies have documented the lack of efficiency in current EHR documentation practice.
A time-and-motion study of resident physicians' note-writing practices using an EHR revealed high fragmentation in clinical work (Mamykina, Vawdrey, Stetson, Zheng, & Hripcsak, 2013). Activities that interrupted documentation included: phone calls, patient requests, and frequent transitions between various types of documentation modalities. Researchers suggested that physicians rely on synthesis rather than composition to write progress notes. Newer technologies that support synthesis are exemplified by highlighting and thus capturing single words or phrases from the chart to construct a new note descriptive of the patient at the current point in time. Another technology would be use of the ‘ready selection of clinically relevant trend lines’ to indicate the patient's current clinical status. Research is needed to compare the quality of such charting and to determine if it is less vulnerable to fragmentation than current charting methods. This research needs to include study of the documentation by both direct care nurses and physicians.
A time and motion study addressing nurses’ work in the acute care setting found that collecting, entering, and accessing data used a large portion of nurses’ time. This resulted in in considerably less nursing time available for patient care (Hendrich, Chow, Skierczynski, & Lu, 2008).
A recent hospital-based study by Englebright et al. (2014) developed a definition of basic nursing care documentation for the adult patient and integrated it into an EHR. The researchers concluded that this newer method minimized or eliminated documentation that did not directly support patient care. These investigators recommended use of alternative options for recording non-patient-care-related information and use of EHR technology to help nurses document and communicate basic care elements.
The Nursing Practice Committee of the Missouri Nurses Association is committed to efficiency in the provision of care. These nurses recognize that efficiency, including efficient capture of meaningful data, helps to translate information and to communicate nursing-based knowledge to other members of the healthcare team, thus improving patient safety and care quality. The MONA Nursing Practice Committee has recommended:
Ease of access and availability to computer devices in patient rooms. Emphasis should be on positioning of the computer to augment the engagement of the nurse and the patient as partners in care. Because no single device will work in all care areas, nurses should consider multiple types of computer device options. The number of devices available should be contingent upon the number needed to cover high volume times of day. High reliability/consistency when accessing/using computers on wheels. Variables to consider include quality of the …
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Opportunities for Improving Patient Care Through Lateral Integration: The Clinical Nurse Leader Begun, James W;Tornabeni, Jolene;White, Kenneth R Journal of Healthcare Management; Jan/Feb 2006; 51, 1; ProQuest Central pg. 19
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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
NUR 650 Module Six Short Paper Guidelines and Rubric Using what you have learned from the assigned readings for this module, analyze current and proposed uses of patient care technologies, including health information technology (HIT), in the collection, analysis, and dissemination of data to design and deliver cost-effective care. Identify a coordination activity and associated HIT example from the AHRQ Mechanisms for Achieving Care Coordination (Domains) table (Care Coordination: The Game Changer, Table 1, pp. 156). Discuss the impact of the activity/example on care coordination and the lateral integration of patient care within, across, and among healthcare providers in various healthcare settings. You must incorporate a minimum of one scholarly resource into the discussion beyond the text and required readings to support your short paper. Specifically, the following critical elements must be addressed:
Patient Care Technologies: Analyze current and proposed uses of patient care technologies, including HIT, in the collection, analysis, and dissemination of data to design and deliver cost-effective care.
Coordination Activity: Identify a coordination activity and associated HIT example from the AHRQ Mechanisms for Achieving Care Coordination (Domains) table (Care Coordination: The Game Changer, Table 1, pp. 156).
Activity Impact: Discuss the impact of the activity/example on care coordination and the lateral integration of patient care within, across, and among healthcare providers in various healthcare settings.
Scholarly Resource: Incorporate a minimum of one scholarly resource beyond the text and required readings to support your short paper. Guidelines for Submission: Your paper should be submitted as a 2- to 3-page Microsoft Word document with double spacing, 12-point Times New Roman font, one-inch margins, and at least one piece of resource material cited in APA format.
Critical Elements Exemplary (100%) Proficient (90%) Needs Improvement (70%) Not Evident (0%) Value
Patient Care Technologies
Meets “Proficient” criteria and demonstrates a strong understanding of patient care technologies and their application
Analyzes current and proposed uses of patient care technologies, including HIT, in the collection, analysis, and dissemination of data to design and deliver cost-effective care
Analyzes current and proposed uses of patient care technologies, but does not include HIT in the collection, analysis, and dissemination of data to design and deliver cost- effective care
Does not analyze current and proposed uses of patient care technologies
Meets “Proficient” criteria and demonstrates a strong understanding of the AHRQ mechanisms for achieving care coordination
Identifies a coordination activity and associated HIT example from the AHRQ Mechanisms for Achieving Care Coordination (Domains) table
Identifies a coordination activity from the AHRQ Mechanisms for Achieving Care Coordination (Domains) table, but does not
Does not identify a coordination activity
provide an associated HIT example
Activity Impact Meets “Proficient” criteria and demonstrates a firm grasp of the impact of care coordination activities on patient care
Discusses the impact of the activity/example on care coordination and the lateral integration of patient care within, across, and among healthcare providers in various healthcare settings
Discusses the impact of the activity/example on care coordination, but does not discuss the lateral integration of patient care within, across, and among healthcare providers in various healthcare settings
Does not discuss the impact of the activity/example on care coordination
Meets “Proficient” criteria and strongly supports paper with existing scholarly literature
Incorporates a minimum of one scholarly resource beyond the text and required readings to support short paper
Incorporates a minimum of one scholarly resource beyond the text and required readings, but the chosen resource does not support the paper
Does not incorporate a minimum of one scholarly resource beyond the text
Articulation of Response
Submission is free of errors related to citations, grammar, spelling, syntax, and organization and is presented in a professional and easy-to-read format
Submission has no major errors related to citations, grammar, spelling, syntax, or organization
Submission has major errors related to citations, grammar, spelling, syntax, or organization that negatively impact readability and articulation of main ideas
Submission has critical errors related to citations, grammar, spelling, syntax, or organization that prevent understanding of ideas