Suzi Birz, principal, HiQ Analytics, LLC
Banner Estrella Medical Center in Phoenix, Arizona, opened in January 2005 with no paper charts. The 172-bed hospital opened as a fully electronic full-service acute care hospital with a five-story medical office building. More than two years later, the hospital still has no paper—no charts and no cardex.
“Four and half years ago, Banner decided to build the ‘facility of the future’ that would serve as the franchise model for Banner Health,” said Diane Drexler, RN, MBA, chief nursing officer at Banner Estrella.
With the help of visionaries, essential components were identified: effective information technology; flexible, culture of service excellence for patients and associates; healing environment for mind, body and spirit; and a connected but separate medical office building.
“To achieve these components, we chartered eight teams to create the transformation of care,” explained Drexler.
Drexler led one of these teams. “The Clinical Documentation Team was multidisciplinary including nursing, respiratory, physical therapy, occupational therapy, spiritual therapy and nutrition,” said Drexler. “We created the clinical documentation charting that is in use today.”
There were several ways for staff nurses to be involved in the development of the information technology. Staff nurses have stayed involved in the activities at Banner Estrella and are playing key roles in the roll out to other Banner facilities.
Staff Nurse Super Users
“During the development, staff nurses with an interest in information technology were hired as Super Users,” said Drexler. Super Users continue as practicing staff nurses.
“Super Users conducted integration testing,” noted Drexler. “This is scenario-based testing of the electronic medical record that resulted in recommendations that went to the development team.”
“These same Super Users are implementing clinical documentation in three more Banner hospitals,” added Drexler.
At Banner Estrella, the command center continues to forward issues to the Super Users. “Super Users are constantly looking at maximizing the use and function of the electronic medical record,” noted Drexler.
Bedside Nurses Tend to the Workflow
Incorporating information technology into an acute care setting always impacts the workflow. “The workflow must be examined ahead of implementing the technology,” emphasized Drexler. “The people at the bedside helped us lay the electronic medical record (EMR) on top of the workflow for each specialty.”
Drexler described the exercises, “With teddy bear patients, nurses tried the electronic medical record processes and provided feedback.” “After teddy bears, the nurses tested the workflow with staff role-playing as patients, followed by real patients.”
A Need for Nurse Informaticists
“After nine months and 69 live information technology applications, Banner recognized the need for a change to the infrastructure in the form of nurse informaticists,” explained Drexler. “Bedside nurses with an interest in information technology have stepped out of their nursing duties for these roles.”
Drexler continued, “These nurses round on units, resolve issues, investigate the effect of regulatory and Joint Commission rules, serve as clinical educators and conduct the information technology training for all new hires.”
The impact to daily nursing is an impact to patient safety. “Our goal is to provide better care and minimize risks,” explained Drexler.
Nurses have an array of information to remember with respect to actions (fill out a fall risk score) and reactions (high or low body mass triggers a nutritional consult). “The EMR has built in rules and alerts to aid the nurse,” said Drexler.
Nurses at Banner Estrella chart in the EMR nearly real-time. As events and tests happen, the information is entered. “Nurses, physicians, surgical teams and ancillary services have the latest nurse documentation including vitals, I/O, hemodynamics available when they arrive to care for the patient,” explained Drexler. “Decisions are more efficient.”
Like most changes, the effect of the changes coinciding with the EMR causes some to leave and some to join. “There was a lack of understanding of what it meant to document electronically,” said Drexler. “The shift to no paper and no cardex can be difficult.”
“Now, we are getting more feedback that the nurses can do without many things, but ‘don’t take away the EMR’,” added Drexler.
“To ease entrance to an electronic work environment for the non-licensed care-givers, we are working with the community colleges to create a familiarity with the idea of an electronic medical record,” said Drexler.
All of Banner Estrella’s technology are used in recruitment efforts. “In addition to the electronic medical record, we have wireless communication devices and nurse locators and we use all these tools in our recruitment pitches.”
Drexler summaries the impact, “This is a tool nurses can use with more confidence; all of the information is at their fingertips for all their interactions with patients, families and the rest of the care team.” “Nurses must recognize that they can make this work for them if they see it as a tool to deliver efficient care with the latest information and creates better relationships with patients and physicians.”
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