Record Time
Nurses play a vital role in the implementation and success
of digital medical records
By John Leighty
January 10, 2005
Nurses at the Palo Alto Medical Foundation are test-driving a patient-accessible electronic health records (EHR) system about to be deployed to 5,000 physicians and 27 hospitals in Sutter Health’s Northern California region.
At Kaiser Permanente’s clinic-based Colorado provider network, nurses are being wired for wellness with an upgraded EHR platform that places a strong emphasis on promoting preventive care.
In an accelerating trend toward paperless, data-driven health care systems, nurses are taking key roles in the testing, tutoring, and tweaking of complex technology tools that will radically change the way they work and interact with patients. With the Veterans Health Administration (VHA) hospital network paving the way nationally, inpatient and ambulatory facilities throughout the country are getting onboard the digital express.
The VHA was an early pioneer in computerizing patient records in 1985. In the mid-1990s, the Mayo Clinic and some larger networks launched more modern-style EHRs. While a new generation of Web-based applications is speeding the trend, there’s still a long way to go. A government survey earlier this year showed only 13% of hospitals and 14% to 28% of physicians’ practices used EHRs in 2002, citing cost, technical compatibility problems, and privacy and confidentiality issues.
“Nurses are embracing the electronic health records technology and making it work,” says Charlotte Mitchell, RN, MPA, who helped launch and enhance the $154 million system that Sutter is implementing throughout its provider network by the end of 2006. “It raises the bar for quality and gives us more patient information. The medical records are more complete, the patient literature is more complete, and the problem lists are more complete.”
However, the technology can be daunting, and there was a “bell curve” learning experience for nurses — ranging from the computer-savvy to those who had never used a keyboard, Mitchell says. “They all got there. It isn’t hard to learn, but it’s a different way of processing when you’re dealing with a computer instead of paper.”
Mitchell says a unique feature for the 40,000 clinic patients is the ability to access portions of their medical records from home or work to view their health histories, request prescription renewals, schedule medical appointments, or even question their physicians about health concerns via e-mail and receive a prompt reply.
At your fingertips
Jeffrey Emrich, RN, assistant nurse manager of the ICU at the San Francisco VA Medical Center, recalls having to rush to a folder-filled chart room to pull a patient’s X-ray or health history. Now, the records room is gone, and instead of shuffling through a paper trail, Emrich can instantly access specific patient data without leaving his busy 18-bed unit.
Through the VHA’s advanced computerized patient record system (CPRS), nurses throughout the 120-bed hospital can go to any computer station and check on a patient’s medications, lab results, clinical reminders, or physician notes on a diagnosis. In intensive care, getting such information quickly can provide an edge in patient safety.
“With CPRS, we can scan through all kinds of documents related to a patient, and the faster we get information, the better care we can give,” Emrich says. For example, he can click an onscreen tab that pulls up a menu of a patient’s medical images, including X-rays, pathology slides, video views, scanned documents, cardiology exam results, wound photos, dental details, or endoscopies.
In Colorado, clinics serving thousands of Kaiser patients in the Denver, Boulder, and Colorado Springs areas were upgraded to an advanced EHR system called KP HealthConnect. It’s a $3 billion network that will eventually integrate 8.2 million patient records in nine states and the District of Columbia. While the Kaiser rollout is gradual in most regions, the Epic Systems-powered technology was implemented in four weeks in the Rocky Mountain state.
“We’ve been using an older clinical information system for years, but the new computerized medical chart is amazing,” says Sherrie Epperson, RN, MSN, NP, charge nurse at Kaiser’s Skyline Internal Medicine Clinic in Denver. “It really lets nurses navigate around health care information in a very timely manner and allows for accuracy and clarity that I don’t think ever existed in a paper chart.”
With the transition, nurses can access physician orders, track medications, and create graphs of a patient’s vital signs, such as blood pressure readings. The system also incorporates Kaiser’s strong emphasis on wellness and preventive care with alerts on patients who would benefit from disease management, weight control, or diet and fitness programs.
Also, patients in Colorado will be able to log in and view portions of their medical records from their home computers in mid-2005, an enhancement Epperson says would further engage patients in managing their own health.
At Colorado’s Poudre Valley Health System in Fort Collins, some 1,000 nurses are participating in 18-hour training sessions for the integration of an electronics medical records platform with a busy emergency department, inpatient facilities, and some outpatient clinics.
“The greatest impact is the positive effects it will have on nursing practices,” says Craig Luzinski, RN, MSN, chief nursing officer and head of the technology project. “It’s not about computers. It’s more about process change. The electronic medical record technology allows us to gather and share information in a consistent manner that adds to the quality of care we give patients. We hope to heavily populate the database with better processes.”
While electronic nursing documentation of patient records goes “live” in February at Poudre, other key elements — such as having physician prescription orders available online, scanning and bar coding of medications and radiology/lab data — won’t be fully functional until late 2005.
Catch the wave
The growth of EHRs is evident. In Nevada, North Vista Hospital recently became the seventh of 11 hospitals in Las Vegas to launch an EHR as part of a $40 million rollout to 15 hospitals in five states by IASIS Healthcare. Spokane, Wash.-based Inland Northwest Health Services, meanwhile, manages EHR and ancillary services such as physician orders entry for 2.6 million patients at 32 hospitals in Washington and Idaho.
The VHA hospital network launched its CPRS in 1999 to provide a single interface to integrate EHR information in a health data repository. The system, called VistA, was designed for clinicians to review and update medical charts and to place and track orders for prescription drugs, lab tests, and special procedures. Since November 2003, the system has allowed veterans Internet access to portions of their medical charts to view medication use, test results, and allergies. In early 2005, veterans will be able to refill prescriptions and make medical appointments online.
Emrich says the EHR infrastructure makes it possible for a bedside workstation to use a software program to continually monitor and record a critical care patient’s vital signs — heart rate, temperature, blood pressure, cardiac indexes — and download the minute-by-minute data to the patient’s files for clinician review.
“In the past, nurses had to stay with a patient and write every figure on a big spreadsheet,” Emrich says. “The compatible monitoring technology frees up nurses to be with other patients.”
With President George Bush pushing for a national electronic medical records network by 2014, the open-source software of the VHA’s inpatient and ambulatory VistA technology is being touted by the agency as a “low-cost building block” toward reaching that goal.
The VistA platform contains dozens of applications, including a nursing component with modules for a variety of functions. For administration, it can track staff information, generate management reports on employees, accumulate daily statistics on the number of patients treated, and provide miscellaneous patient acuity reports. A clinical module generates patient classification reports by bed section and unit. It also helps nurses to generate a patient care plan based on national standards and identified needs, and lets users enter a patient’s vital signs, height, and weight.
Emrich says the VistA technology also is improving the way medical researchers gather patient data, study diseases, and seek cures.
Kaiser, Sutter Health, and other large providers will have networkwide EHR systems in place long before the 2014 federal deadline. However, there are formidable barriers involving technology standards and security issues to overcome before reaching one milestone for patient safety — 24-7 access to a patient’s complete electronic medical record at any health care facility in any section in the country.
At the regional level, Sutter Chief Information Officer John Hummel credited nurses with helping to implement the critical clinical and workflow processes necessary for a state-of-the-art digital records network.
“The ultimate goal is to integrate community-based medical records with hospital records so that patients can access the information and become more empowered to manage their health care needs.”