In September 2009, the OR at Hartford (Conn.) Hospital began to implement intraoperative documentation with the Eclipsys Sunrise Clinical Manager software, an electronic health record system that offers information solutions to hospitals and health systems. With the system expected to be fully implemented by June, Rosemary Aiello, RN, CNOR, nurse manager, says OR staff members like it now, but its a big change from doing things on paper.
Instrumental in helping staff become acclimated to the new system, Aiello says one of the best features is the required fails for surgical timeouts. Since the system has been implemented, Aiello says The Joint Commission said Hartfords timeout is one of the best that it has seen. Patient case turnover time and on-time starts also increased.
Hartford Hospital implemented Eclipsys in October 2001. The softwares many options, integrated unit by unit over time, allows healthcare staff to enter patient information into computers on carts stored in hallways near outlets and patient rooms. Computerized physician order entry and the electronic medication administration record were the first phase of the EHR to go live in October 2002.
With CPOE and medication management 100% implemented, the information services team began to work this April at implementing the interdisciplinary clinical documentation module throughout the hospital. The ICD module documents pre-admission history and risk screening, such as immunizations, pain and domestic violence; patient assessment and intervention flow sheet; patient plan of care; education sheet; and goals and outcomes flow sheet. All clinical disciplines use the ICD documents, and some even have customized flow sheets and notes, such as pharmacy, rehabilitation and social work, says Susan Marino, RN, director of nursing informatics.
As a super user of the Eclipsys system, Dianne Bronkie, RN, CNRN, CCRN, C91 neurosurgical intensive care staff nurse, says the implementation team conducted biweekly meetings with representatives from all departments to discuss what care needs would include before starting the project. In these meetings, each staff member brought up how the system and its processes would need to be tailored to achieve quality patient care. [We] needed nursing input for timing of patient meds, etc., Bronkie says, and which medications and classes of drugs nurses would always want to check that needed alerts.
One of the first challenges the meetings addressed was the scale for steroid tapers, Marino says. Nurses also were given the ability to reschedule a medication during the meetings because of nursings input, Marino adds.
The goal is to keep the patient at the center of the design of the work process to improve quality and safety. The biggest challenge for staff is to learn how to integrate this change in workflow with the delivery of patient care, says Linda Berger Spivack, RN, MSN, vice president of patient care services at Hartford Hospital. You have to make sure you dont lose sight to care for the patient instead of caring for the computer.
Over time, the health information management process has been tweaked and improved. To make sure patient data is as complete as possible, required fields were built into some of the documentation tools to ensure completion of patient records, Marino says. When using CPOE, providers receive an alert that requires them to sign orders before they can move forward with other elements of the record. When nurses use the electronic medication administration system, they receive color-coded reminders to complete tasks on the work list. This becomes especially important when patients are transferred to another unit. All charts and medication administration times must be completed before a user can sign off the system.
These deadstops make patient care communication more efficient and eliminates trying to correctly fill in the blanks after shift change. Staff see the system as value added, Spivack says, because it eliminates penmanship issues, increases accuracy and timeliness, allows more bedside patient care and works more efficiently. Data also can be extrapolated from the system to better analyze outcomes and trends.
Getting Staff Up to SpeedHartford (Conn.) Hospital clinical consulting analysts, from left, Julie Michaelson, RN; Patty Kaehrie, RN, MSN; and Laura McKiernan, RN, interact with the electronic health record system Eclipsys Sunrise Clinical Manager Software in an employee training room.
Nurses and other healthcare staff are trained on the system in a classroom environment led by analysts employed in the information services department of Hartford Hospital. Analysts work on the workflow, design, training and implementation of the Eclipsys system, Marino says. Staff then are trained in a simulation environment to make sure everyone is on the same page before using the system with real patients, specifically in the OR.
There are 11 RNs in roles supporting development of the EHR, Marino says. There are two RNs on the nursing informatics team, six RNs on the EHR team, two RNs on the ED team and one RN on the perioperative team. The team continues to grow as technology is implemented, says Julie Michaelson, RN, clinical consulting analyst. Nurses who ask about informatics positions and have a good understanding of the flow of a unit are good candidates for analyst positions. The hardest part is picking the right person, Michaelson says.
In addition to training by analysts, expert RNs on each unit serve as preceptors to work with new hires and new graduate nurses to orient them to the specifics of needed clinical competencies, policies and procedures in a specific specialty, Marino says.
After training, a preceptor works with staff members on their unit to get everyone up to speed, troubleshoot glitches and offer one-on-one training if necessary, Michaelson says. The preceptors also have helped with nursing buy-in, Marino adds.
Success of implementation often depends on how staff members adapt to change. Those who adapt quickly often serve as unit resources and preceptors, says Laura McKiernan, RN, clinical consulting analyst.
Most nurses on the information services team are from the bedside. Before joining the team, Michaelson worked as a bedside nurse at Hartford for a few years. I love clinical documentation so I got picked [for the team], she says.
Each analyst covers different clinical areas, usually covering the units they practiced in at the bedside. Such collaboration helps the analysts get close to the providers and build healthy communication to effectively tailor the system to each unit.
The information services team was purposely selected to have a nurse or other staff member from each unit on its team to address unit-specific concerns. This created respect between the analysts, preceptors and staff members regarding the units needs and made the implementation period smoother because staff were comfortable with one another. We created internal experts on the team so they could teach each other in any of the disciplines, Spivack says.
The EHR team moves along quickly and aggressively to keep up with policy and patient care. Team members are alerted about new practice guidelines every six months by Elsevier, a leading publisher of science and health information. The guidelines are then reviewed by the speciality staff affected to decide if and how it should be implemented. This process keeps clinical care guidelines up-to-date and keeps patient care running smoothly, Marino says.
All staff are involved to make it flow, Aiello says. If it doesnt work for them, it will fail.
Informatics HurdlesHartford Information Services staff, from left, Patty Kaehrie, RN, MSN, clinical consulting analyst; Julie Michaelson, RN, clinical consulting analyst; Laura McKiernan, RN, clinical consulting analyst; and Susan Marino, RN, director of nursing informatics.
Slowness in system performance while accessing patient information and the littering of computer carts in the hallways have been the teams biggest challenges, Marino says.
To address speed, the system is maintained monthly. During that time, the system goes offline and clinicians use a printed version of patients latest charts. Despite the downtime, clinicians never lose anything from the point of being down, Marino says. Included in the printed chart is the most recent version of the most critical elements, Marino says.
To address the cart issue, Marino says Hartford is looking into different types of batteries that wouldnt require the carts to stay by an electric outlet. With better batteries it would be possible to move the carts into alcoves or patient rooms.
Marino says Hartford also is looking into the use of wireless and wired devices, as well as tablets and PDAs for use by clinicians.
Its hard to sell new systems to staff by saying the equipment or program is faster and easier, Marino says. You have to sell on you can get [patient records] anywhere [in the healthcare system], she says.
Editors note: For a photo gallery from Hartford Hospital, visit www.Nurse.com/gallery/Hartford.