By Joe Vanden Plas, July 28, 2008 – Electronic medical records have been designed to assist physicians, radiologists, and labs, but a partnership between two Milwaukee institutions and a medical software developer is shifting some of that focus to decision support for nurses.

The partnership of Aurora Health Care, the University of Wisconsin-Milwaukee College of Nursing, and Cerner Corp. has reached the go-live phase of an evidence-based nursing initiative. The objective is not only to improve health outcomes by reducing variation in nursing care, but make the nursing profession more attractive at a time of personnel shortages and possibly help Aurora respond to federal action to eliminate payments for avoidable health events.

“Across the country, very few companies and very few places were able to really focus on nurses and nursing care, and yet nurses are the ones that are most involved with data and data management,” said Norma Lang, a professor and former dean of the University of Wisconsin-Milwaukee College of Nursing, and a professor in the University of Pennsylvania School of Nursing. “When you think about the amount of data that nurses have to handle today, it’s pretty awesome.”

Evidence-based nursing

According to project leaders, stakeholder alignment was not difficult to achieve because each entity stands to benefit. The UWM School of Nursing conducted most of the research into actionable evidence-based practices, which have been built into the workflows of Aurora nurses via Cerner software and could, according to Lang, serve as the basis for curriculum development.

As the technology partner, Cerner will be able to share the evidence-based findings with clients, and feed the data into a clinical data repository from which business intelligence can be extracted.

Aurora, which has a longstanding relationship with Cerner, serves as the laboratory for the project and will use the evidence-based information and business intelligence to drive continuous improvement and give its nurses more time to care for patients.

As the project began several years ago, there was a considerable amount of evidence-based research, but it wasn’t in actionable form or in a form necessary for building software. “The thinking was that we could advance the work faster together than if we were trying to do it alone,” Lang said.

The project reached the deployment phase with a July 21 launch of evidence-based protocols at two Aurora St. Luke’s Medical Center nursing units. The protocols are for fall risk, prevention, and management, plus medication adherence and activity intolerance.

Upon admission, nurses conduct a bedside assessment of patients, and the assessment drives care interventions that show up on a computer screen as task lists. For example, if a patient used a cane or walks with a gait, they are at a higher risk for falls. If they have brittle bones or use blood thinners, they run the risk of serious injury or excessive bleeding as a result of falls. The nurses can refer to the software for evidence-based practices that help prevent falls.

“The whole point of documenting electronically was not just to replace paper, it was to provide information to the frontline person,” said Karlene Kerfoot, vice president and chief clinical officer for Aurora Health Care.

Business considerations

Starting this year, the Centers for Medicare and Medicaid Services will not reimburse hospitals for certain preventable medical errors, including certain types of falls, pressure ulcers, and catheter-associated urinary tract infections. The list is likely to grow each year. Several more avoidable events are under consideration for 2009.

These events represent considerable cost. In a study of people 72 and older, the average healthcare cost of a fall injury was $19,440, according to the Centers for Disease Control and Prevention.

Lang believes pay-for-performance considerations are a motivating factor. Kerfoot, however, said CMS reimbursement decisions are not necessarily a business driver for Aurora, but they could be. “We didn’t necessarily align it with pay-for-performance, but in the future we certainly can,” she said, noting that eventually CMS might not pay for any hospital-acquired complication.

In the past, Kerfoot said, nurses have entered data into EMRs but got nothing out of it. Electronic records placed the additional burden of data entry upon nurses and took time away from patient care.

While the jury is still out on whether the system adds more time for care, nurses already see benefits. Jan Mills, a registered nurse for 25 years, said Aurora nurses have been developing care plans on computers for a while, but with this system, care plans can be mapped to the best health outcome for individual patients, and if the patient assessment changes, new alerts are fired off to provide additional decision support.

The alerts come into play throughout hospital care. “Without the technology and the alerting piece embedded into the workflow, you can’t retain a high-reliability organization,” said Ellen Harper, an RN and healthcare executive director for Cerner. “It’s not intended to remove the critical thinking skills of the clinicians; it’s to augment them.”

“Patients that are informed of their risk factors become involved in their care,” Mills said, “so you’re really partnering with that patient.”

Laura Burke, an RN and director of system nursing research and scientific support for Aurora, said the system already is helping nurses more quickly identify potential problems. “A lot of nursing is about prevention, not actually treating things,” she noted.

Once a nurse chooses an intervention, this information goes into the data repository, which already is being populated by Cerner. With the help of business intelligence software from Business Objects, that data repository eventually will produce operational information that drives continuous improvement in clinical processes.

Eventually, participants hope to learn enough to remove unnecessary, time-consuming steps in nursing workflows. “Everybody knows in the quality world that if you do it right the first time, it’s the most cost effective way to do it,” Lang noted. “So we’re interested in putting in the right steps, the right processes of what we call nursing action.”

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