This chapter presents the current trends, issues, obstacles, and opportunities facing the nursing profession with regard to utilization of HCIT. The focus was on leading HCIT vendors that provide organizationwide, hospital-centric information systems, and address nursing applications in context of a patient-centric EMR. The response of these vendors to the demand by nursing for improved information systems was discussed. In addition, the demand for delivery of standard-based nursing or clinical data sets with the software application and how leading vendors are responding to this demand were presented.

Current Trends Toward Prime Vendors, EHRs, and Systems Integration
                There are a wide variety of software products offered by an array of diverse vendors that nurses use to plan, document, manage, and evaluate patient care.

·         “NICHE” applications focus on a discrete set of nursing functions such as care planning.

·         “DEPARTMENTAL” systems address a more comprehensive set of functions. This is either of the three: for a single point of service such as labor and delivery; or department such as cardiology; or closely aligned group of departments such as the perioperative suite. These departmental systems are more targeted and robust than comparable modules of EHR solutions since departmental systems focus on one or a few specialties and points of service. Thus, Departmental Systems continue to be sought by many organizations, particularly in academic medical centers and for high acuity, specialized care departments.

The current trend is to limit niche and departmental systems in order to create an HER via well-integrated applications with a common database, tools, and technologies. Although the HCIT environment is by nature heterogeneous, healthcare organizations (HCOs) increasingly seek a primary clinical vendor who, to the degree possible, delivers a single system or suite of tightly coupled solutions that spans all points of service, automates core clinical processes of physicians and all care providers, and creates a multidisciplinary, longitudinal, and patient-centric record.

HCIT vendors do not only offer products that facilitate patient care, but also create products that support quality management, staff scheduling, supply management, and other patient-care-related nursing activities. These applications and comparable capabilities within EHRs are increasing in importance as virtually every HCO faces quality of care, care management, and fiscal challenges on which nursing can have a significant positive impact, using IT as a tool.

New Technologies

New and emerging hardware and software technologies such as handheld devices are increasingly being incorporated in nursing applications. Key goals are to improve quality of care, mobility of caregivers and collaboration among the care team. Currently, strong emphasis is being placed on delivering technology at the point of care via bedside terminals and wireless devices such as PDAs and Laptops. These bedside terminal accesses can facilitate real-time charting, increase nursing time at the bedside, and eliminate “batch” end of shift charting.

Historical Perspective

Historically, nurse executives have not widely embraced it as a strategic business tool. The nursing profession has been largely underserved by HCIT vendors, even though Nursing is one large beneficiaries of IT.  There are a variety of reasons why Nursing is not highly provided by these vendors. In most national and local healthcare debates, nursing has been essentially invisible, partly because this is the only profession that does not charge for services rendered. However, currently there is a new breed of registered nurses that are engaging into the field of informatics.

Current Situation

Today, the majority of nursing-related patient care applications are acquired as part of EHR decisions. But some of the products released are poorly designed and user-unfriendly for nurses, basically because of the following factors:
·         Nursing is an untapped and underserved resource in provider organizations.

·         Workflow inefficiencies are not well addressed by existing solutions

·         Automation is not highly priority for nursing in their organizations

·         Vendors are out of sync with nursing needs

·         Some new tools and technologies have complicated rather than simplified nursing practice, at times decreasing productivity and introducing an element of increased risk to patients.

Root causes of poorly designed nursing applications include:
·         Vendor product design processes driven by non-nurse professionals

·         Insufficient nursing representatives on vendor executive and development teams

·         Then HCIT industry’s overall woeful lack of adequate requirements definition, functional specifications, and process analysis

·         Early focus on automation of the paper chart without a full understanding of underlying nursing process, workflows, anf ergonomic challenges

In response to patient safety concerns, vendors and provider organizations have focused on two primary HCIT initiatives; (1) Computerized Physician Order Entry [CPOE] and (2) Bar-Code Medication Administration [BCMA].

The ability of nurses to clearly articulate and promote the value of HCIT for themselves, their patients, and their organizations could be a crucial factor in accelerating widespread adoption of advanced nursing applications.

Vendor Response

In response to market demand, HCIT vendors are delivering more robust and tightly integrated clinical solutions that better address the needs of all health care providers for more coordinated, streamlined patient care delivery. While some vendors offer clearly superior nursing applications, no solutions; each has different strengths and limitations.

Care Flow Diagram

The care flow diagram is a conceptual model that represents a patient-centric, interdisciplinary, inpatient-oriented view of a clinical information system that supports a fully integrated HER. The model assumes direct physician use of the HER and represents a multidisciplinary team approach reflecting emerging care delivery models.

 Key Clinical System Nursing and Multidisciplinary Care Concepts

Patient Access
                The patient record is initiated in the admission, discharge and transfer [ADT] system or administrative portion of EHR.

Admission assessments
                Nurses and allied health professionals perform initial patient assessment and intakes.

                The concept of “Nursing Diagnosis” has been somewhat controversial.
                A “Problem list” is a common set of patient specific problems that are maintained by the MD and care team.

Nursing and Multidisciplinary Orders and Plans of Care
                Physicians can enter medical orders directly online (CPOE) or via authorized designees such as RNs and Clerks.

Integrated Plans of Care
               An Integrated Plan of Care includes all orders for all services to be provided for a patient, including physician, nursing, ang multidisciplinary pathways, and orders and patient care plans.

                A Kardex is patient management tools used by nurses to collect, organize, and display summary patient information.

Workplans – Tasklists
               EHRs support generation of work plans, known as task lists, as an automatic byproduct of orders and plans of care. These task list help nurses organize, document, and manage patient care activities for individual or groups of assigned patients.

                In an HER, Results data (e.g Laboratory values, chest x-rays) can be viewed overtime in tabular formats and graphed for display of trends.

Clinical Documentation
                Physicians and all care providers document care in progress notes and ongoing assessments. This is the major method by which diverse care providers collaborate across multiple points of service.

Discharge summaries
                 The discharge summary is an increasingly important component of care with inpatient stays shortening and postdischarge care often provided by diverse providers in multiple venues of care across the community.

Summary Reports
                    Patient summaries can be support rounding, initial patient assessment by consulting physicians, end of shift reporting by nurses, and other patient-care-related activities.

Outcome Variance Reports
                    Virtually all HCOs are focused on improving patient safety and quality care. For organizations to thrive, clinicians must be committed to continual performance improvement.
                    As standards of care and clinical pathways are more rapidly adopted, more vigorous analysis of care patterns can occur.
                    Unexplained variances are tracked by the system and available for management reporting. These variance reports can be used to identify practice “outliers”, compare performance across providers, and when appropriate, update the pathway to reflect more effective practices.

 StandardTerminology Provided with Clinical Applications

 Expectation of the marketplace
Despite the lack of a national consensus regarding one standard nursing terminology or data set, HCOs expect their HER vendor to deliver a Standards-based set of nursing content for charting and planning care.

Current Status
Responding to this market demand, most of the major HCIT vendors now deliver at least basic starter set of terminology. An increase number of these vendors are including standards-based terminology with their clinical documentation application as well as evidence-based standards of care with their care planning and clinical pathway applications, and some are using standard terminologies that map tp SNOMED[Systematized Nomenclature of Medicine].