As health systems gear up to comply with requirements of the HITECH portion of the American Recovery and Reinvestment Act (ARRA), savvy nurse executives are taking notice. They intuitively understand that as the regulations are clarified and rules are written, nursing will play a key role in determining their organization’s compliance. The reason is simple: Nurses generate the majority of the documentation that makes up a patient’s medical record. These data will be the source for measuring compliance with the law’s quality reporting requirements, helping an organization to qualify for federal incentive monies or avoid future penalties. Nurse executives who do not yet have ARRA or HITECH on their radar screens still have time to get engaged.

At the University of North Carolina Health System (UNCH), a four-hospital integrated health system based in Chapel Hill, nursing has long played a key role in determining how information technology (IT) can enhance the process of care. Carolyn Viall Donohue, RN, MSN, associate vice president and associate chief nursing officer at UNCH, serves on the IT Advisory Council headed by the chief information officer.

“Because I am a member of the IT Advisory Council, I have considerable input into what we’re doing and the implications that it has on our patient care environment, both in the inpatient and outpatient areas and on our providers,” Donohue explained.

The IT Advisory Council existed long before ARRA was even conceived, but since the act was signed into law in February 2009, it has provided guidance and justification to UNCH for re-prioritizing and accelerating certain projects, such as the move to an electronic medication administration record. The council developed a grid of the Meaningful Use criteria as defined in the Notice of Proposed Rule Making that was published in the Federal Register in January 2010. It also conducted a gap analysis of where the health system is compared to where it needs to be to qualify for ARRA incentives. To date, Donohue believes that UNCH is between 60-70 percent of the way to meeting the anticipated quality reporting requirements, largely because the data are already being captured electronically by nurses in the ordinary course of patient care.

Using the Siemens Soarian® healthcare IT solution, UNCH documents almost all of its clinical care processes electronically. Nurses are becoming more engaged in identifying ways in which healthcare IT can help to support the management and delivery of clinical practice. For example, nurses document key clinical data that are used for measuring and monitoring quality as part of their evidence-based approach to clinical practice. Use of Soarian’s clinical summary provides a snapshot of patient information, which helps maintain continuity of care as shifts change and patients move through the care process.

UNCH nurses also use Soarian to help meet current regulatory requirements. Information technology can be an effective communication tool in clinical decision-making and coordination of care. The discharge assessment, for example, includes a smoking cessation workflow that notifies the nurse when patient education is warranted and then helps to easily document the fact that the education has occurred. Patients at risk for pneumonia are also identified as part of the discharge assessment. Those identified as needing a vaccine are immunized before leaving the hospital, helping the organization to ensure compliance with key quality metrics (figure 1).

Figure 1: Discharge Assessment

Donohue’s role on the Council also includes serving as liaison to other disciplines. In one example, she cites the adoption of Soarian by the Food and Nutrition Services department as its mechanism for documenting a patient’s care relative to diet.

“Maybe it has nothing to do with Meaningful Use right now, but in the end, when you are talking about quality of care, patient involvement and the consumerism of patients, the documentation by a dietician is very relevant not only to the patient’s acute episodic care, but their long-term care as well,” Donohue argues.

As a result, dieticians are getting involved with the Soarian care plans and documenting dietary issues in the patient’s problem list.

An important byproduct of electronic clinical documentation is the ability to analyze and aggregate the data for quality purposes. As documentation is completed at UNCH, the data moves to a data warehouse where it is available for quality analysis and performance measures (figure 2). This helps make it easier for UNCH to meet Joint Commission standards and CMS Core Measures, and to follow recommendations from organizations such as the Institute for Healthcare Improvement (IHI). For example, IHI recommendations include quality measures regarding ventilator-associated pneumonia and central-line infections in the neonatal and pediatric intensive care units. These two quality studies underway at UNCH are greatly aided by the ability to collect the necessary culture and patient-specific data and to make it available to the quality department and analysts applying Six Sigma strategies. This is the primary reason that UNCH believes it is well-positioned to meet the Meaningful Use criteria.

Figure 2:



Regardless of ARRA requirements, Donohue’s advice to fellow nurse executives is to get engaged in IT so they can represent nursing’s voice in the IT initiatives. As a result, they will be better equipped to make decisions about what tools will be used and how those tools will integrate into clinical practice. Donohue recommends five basic steps for gaining that control, as listed in the table below.

Action Steps for Nurse Executives

1. Become an active member of the IT initiative and assist with developing, monitoring, and adjusting the IT road map as necessary.

2. Understand what resources are needed for initial design, implementation, training, and ongoing process improvement.

3. Support the culture change and recognize it as a collaborative effort.

4. Develop a communication plan to ensure that all disciplines understand the organization’s strategic objectives and their roles in seeing them addressed successfully.

5. Encourage bedside nurses to get engaged and provide venues for them to give input.

Whether nurse executives have chosen not to get engaged in healthcare IT or have not yet been invited to the table by their organization, the time to get involved is now. “As organizations evaluate ARRA, it is very clear that nursing needs to have an active role in contributing to the design of the IT road map,” says Donohue. Nurses play a big role in ARRA and HITECH, and the savvy nurse executive knows it.

The outcomes achieved by the Siemens customers described herein were achieved in the customer's unique setting. Since there is no "typical" hospital and many variables exist (e.g., hospital size, case mix, level of IT adoption), there can be no guarantee that others will achieve the same results.

An early spring day in March 2010 proved to be an "Aha!" moment for Pamela Crawford, RN, MSN, PhD, and vice president of nursing and social services at MedCentral Health System. A surprise audit from a surveyor with the Ohio Department of Health resulted in a smooth visit and passing grade for meeting clinical documentation requirements. "It was really rewarding to me," said Crawford, "to see we are beginning to reap the benefits of some of the safety drivers we are doing."

MedCentral, the largest medical provider between Cleveland and Columbus, uses Soarian^® Clinicals Suite to incorporate electronic clinical documentation into the nurses’ workflow. “What I came away with after one day with this individual is that Soarian has helped put us in a great position to meet regulatory requirements and address safety initiatives,” said Crawford. The technology has supported MedCentral’s ability to monitor performance indicators such as the Joint Commission National Patient Safety Goals. It is also a useful tool for evaluating nursing performance relative to patient outcomes through the National Database of Nursing Quality Indicators and for helping to prevent hospital-acquired conditions as identified by the Centers for Medicare and Medicaid Services.

Tina Eldridge, RN and nursing information technology liaison, explained that MedCentral is always looking for ways to balance the documentation requirements with high-quality bedside care. This is critical, given the findings of a national study indicating that nurses spend an average of 25 percent of their time on documentation. In Eldridge’s view, information technology serves as a sort of personal assistant for clinicians. “I don’t want to see IT as my input system only. Technology is a tool that I use to support my work and to make me work more efficiently,” she explained.

Information technology supports MedCentral’s nurses in their day-to-day clinical practice. Soarian Clinicals includes Healthcare Process Management (HPM), which provides the flexibility to design, synchronize, analyze, and adapt processes. HPM provides innovative workflow management technology that helps organizations consistently drive and direct care processes. MedCentral has successfully leveraged HPM capabilities to support a number of their clinical processes. The organization has achieved impressive results with their Siemens solutions and team efforts.

Several key clinical areas of recent focus include:
1. Fall Prevention. The fall precaution process and intervention workflow requires nurses to document a fall risk assessment every eight hours with the frequency of interventions increasing based on the level of a patient’s risk. The system helps clinicians identify potential risks and fall precautions, supporting their efforts to minimize the occurrence of falls. MedCentral has reduced the patient fall rate by 70 percent over the past year by combining technology and process improvement.

2. Pressure Ulcer Prevention. An electronic worklist notification helps nurses to ensure that patients at risk for pressure ulcers are repositioned every two hours and that the completion of the task is properly documented. Additionally, a wound care screening notification is sent for high-risk patients, triggering a more in-depth assessment by a wound care specialist who then prescribes patient-specific interventions or prevention methods. Since July 2009, documentation compliance has improved to 90 percent and the overall pressure ulcer incidence rate is below the six-percent national average as identified by the National Pressure Ulcer Advisory Panel.

3. Patient Education. Patient Education workflows help nurses ensure compliance with patient education needs. For example, patient response to smoking habits during admission triggers an order to respiratory therapy to initiate smoker cessation education, resulting in 100 percent compliance with the requirement. The first time a patient is ordered Warfarin, a reminder appears on the nurse’s assessment list to provide the necessary education on dietary considerations, contraindications, etc. Warfarin education compliance has increased by 60 percent.

4. Hospital Acquired Infection Prevention. The workflow triggers a notification regarding a patient with a history of methicillin-resistant Staphylococcus aureus (MRSA) infection, prompting a nurse in turn to notify the infection control team and to implement isolation precautions. Also, as IV site checks are documented, the system checks to see if the insertion site has been changed in the last 72 hours and, if not, triggers a notification for the nurse to either change the site or document the outliers. This type of surveillance and notification is being applied to other time-sensitive procedures such as Foley catheter and central line insertions. Incorporating notifications and reminders into nursing workflow has also helped Infection Control perform active surveillance of infection prevention methods. It’s an example of how the use of heathcare IT, combined with vigilant process measures, supports MedCentral patient safety initiatives.

MedCentral’s mission includes a focus on teamwork, quality, innovation, and customer service, using information technology as an important tool. To that end, Eldridge created the Innovation Inputters, a formal process to enhance communications between nurses and the information technology department. Floor nurses meet monthly with nurse analysts to review IT initiatives, identify end-user requirements, assess process and workflow implications, and evaluate equipment the IT department is considering.

The Bright Ideas program encourages experienced staff to propose and share process improvement ideas that have had an impact on productivity as well as on MedCentral’s patient care initiatives. More than fifty ideas regarding technology have been implemented from the nursing staff over the last twelve months through this program.

While much of the care delivery processes have been streamlined with the help of IT, work remains. Crawford articulates a simple vision whereby the administrative side of patient care is seamlessly integrated into the care process itself: “It is my personal vision to fully incorporate documentation at the bedside, involving the patient and family so they perceive you are spending more time with them and, ultimately, helping nurses manage their time more efficiently.” MedCentral continues its work incorporating information technology into clinical practice process improvements, building upon a solid foundation that has already had a measurable impact on the health system’s efforts to maintain high levels of quality and safety for its patients and community.

The outcomes achieved by the Siemens customers described herein were achieved in the customer's unique setting. Since there is no "typical" hospital and many variables exist (e.g., hospital size, case mix, level of IT adoption) there can be no guarantee that others will achieve the same results.

Nacogdoches is the oldest town in Texas and reputedly the origin of the independent and tenacious character that makes Texas such a great state. It’s no wonder then that Nacogdoches Memorial Hospital has found a way to create such a solid footprint in its community. Prominent community presence, combined with its forward-thinking application of information technology, has helped the hospital to attract the best nurses in the region. A 200-bed, county-owned community hospital in this small college town of 30,000 people, Nacogdoches Memorial uses Siemens MedSeries4® as its health information system.

“Our number one challenge is recruitment and retention of good nurses, and one thing that does help us recruit is our medication bar-coding solution, Siemens Med Administration Check,” explained Beth Knight, MBA, BSN, RN, chief nursing officer. Med Administration Check helps clinicians at every step verify that the right drug is administered to the right patient at the right time. “When we visit nursing schools and talk about how our point-of-care bar-coding solution helps support our patient safety initiatives, the student nurses understand the benefit of this technology and it does help us with recruitment,” Knight said. Knight acknowledges that her local competitors use information technology to some degree, but the feedback she gets from the student nurses as they rotate through the different hospitals is that the user friendliness of the Siemens MedSeries4® solution and its ability to support patient safety sets Nacogdoches apart.

It’s not just Med Administration Check that makes the system attractive to nurses. Knight and her team built the system to help them guide the nurse’s workflow. “We have our nurses focus their care delivery and documentation on the patient care plan,” explained Knight, who noted the role care plans have in supporting compliance with Joint Commission accreditation requirements. She also noted that the nurses follow charting-by-exception guidelines while documenting care, which streamlines the documentation process efficiently and accurately.

Linda Lawson, RN, BSN, director of Women and Children Services and a member of the original design team, admits that it was a challenge coming from a paper-based world to an electronic documentation process, so it was important to her that the system was easy to use. “We kept that thought in mind with everything we built, to provide a logical guide as to what’s next,” said Lawson. The clinician’s workflow is intuitive and easy to follow. Documenting assessments, interventions, and goals all revolve around the patient care plan. As a result, the clinical documentation process at Nacogdoches Memorial provides a kind of “one-stop-shopping” experience for its nurses and other clinicians, making both the act of charting and chart review easier. “The system guides our clinicians through the documentation process so things are not missed and overlooked. It provides all the information they need to keep care delivery on track. With the support of technology, Nacogdoches' compliance with completing required documentation is between 95 and 100%,” says Patrick Brazil, BBA, RN clinical analyst.

Figure 1: View of Patient Care Management Profile



At times, managing nursing overtime has been a challenge. The standard process before the introduction of electronic clinical documentation was usually for nurses to wait until the end of their shifts to make sure all the documentation was completed and in order. Now they document as they go, and because the process is more structured, nurses can avoid writing out long narratives. Ann Scott, PhD, MSM, RN, director of Medical Critical Care, estimates that overtime due to charting has been cut in half. “I did have one nurse in particular that was averaging three hours of overtime per shift just related to charting. Within a month after we automated documentation, that amount decreased by 75 percent,” said Scott.

Figure 2: Documenting Risk for Skin Breakdown

Documentation is entered once and available throughout the system. Information captured while documenting medication administration, such as vital signs, is available within the shift assessment, providing complete access to all necessary patient information. Integrating documentation from Med Administration Check with the assessment flowsheet provides the additional benefit of enabling users to see trending over time, making it easier to identify changes in patient condition in a timely manner. With the implementation of technology, the organization has been able to more effectively manage the collection and monitoring of clinical data required to address CMS core measures as well as industry performance measures. As clinicians complete their documentation, they also collect and review the information needed to monitor specific measures, helping to ensure that they are providing evidence-based care efficiently and effectively.

Nacogdoches has seen a reduction in pressure ulcers over the last two years. Technology aids clinicians in documenting and monitoring progress with pressure ulcers, which is a key clinical metric for all organizations today. In addition, with MS4 custom reporting capabilities they are able to review an up-to-the-minute status of each patient and the degree to which their care has been documented according to all core measures. This report has helped Nacogdoches Memorial achieve near-perfect compliance with requirements for pain reassessment, critical lab values, smoking cessation education, pneumovax compliance and others. “Additionally, reporting capabilities are flexible enough that the nurse managers can create reports for their own units to support them in monitoring quality performance and clinical outcomes,” explained Brazil.

Figure 3: Reduction in Pressure Ulcers at Nacogdoches Memorial Hospital



The secret to Nacogdoches Memorial’s success seems to be tied to its collaborative approach, developing a system by nurses for nurses. MedSeries4 supports that approach. “The common thread throughout our site visits to evaluate information systems was an assumption that you cannot change it, that it is what it is. We didn’t want that. We wanted something that was going to fit into our hospital and support our care delivery processes,” said Lawson. As a result, she concluded, “Our nurses bought into it because it was built by nurses.”

Nursing leadership also did not want to just transfer what was on paper to the computer system. To that end, the chief nursing officer set up processes to incorporate end-user feedback. “They see this as their system,” said Knight, “because when they can suggest a change and it’s there the next day, it really gives them the wow factor.”

Knight’s closing advice to fellow nurse executives who have yet to embark on information technology is to get involved and stay involved. “You’ve got to have leadership engagement. If I was not actively involved and did not have several of my key nursing managers doing this, the rest of the staff would not buy into it,” she admitted. Nacogdoches has embraced a team approach that considers the input of all members of the care delivery team. As members of a community-based hospital, the staff has learned to work together to make its vision a reality. This approach has had a tremendous impact on their ability to achieve such widespread adoption of information technology. IT truly is a tool that supports nursing practice, and Nacogdoches is demonstrating that fact every day.

The outcomes achieved by the Siemens customers described herein were achieved in the customer's unique setting. Since there is no "typical" hospital and many variables exist (e.g., hospital size, case mix, level of IT adoption), there can be no guarantee that others will achieve the same results.

Every day in the United States some 55,000 patients are treated in critical care units, presenting unique documentation challenges to the nurses caring for them¹. The heightented complexities in this clinical environment magnify the need for ready access to legible patient information at the bedside and they multiply in difficulty when trying to complete up-to-date accurate documentation.

Riverside Health System, an award-winning, five-hospital community health system in eastern Virginia, has found that Soarian^® Critical Care is an important tool in its critical care management strategy. Prior to implementing Soarian and the Soarian Critical Care solution , the Riverside critical care teams were challenged by the need to manually document notes and assessments, transcribe patient data onto a multi-page FlowSheet, and search for paper charts. Clinicians needed complete patient information available at their fingertips. The complexity and pace of the critical care environment increased the opportunity for human error and its related consequences. Additionally, the manual documentation process was also time-consuming. It was perceived that some nurses were spending up to three hours of a 12-hour shift on documentation alone. Research from Hendrich and Chow in 2008 validates this perception. The results indicated that nurses in the study spent more than three quarters of their time in nursing practice with 35.3% spent on nursing documentation. The researchers recommended three main areas for improving the efficiency of the bedside nurse: documentation, medication adminstration, and care coordination. The study also noted that technology could provide valuable assistance in supporting these areas of clinical practice².

One of the biggest impacts electronic documentation has had in critical care is enabling clinicians to put together a complete, hour-by-hour clinical picture of the patient. Now, almost all documentation is done electronically, assisted by medication adminstration with bar-code technology. Clinicians are able to quickly review the critical care FlowSheet and assess subtle changes in the patient’s condition that warrant their immediate attention. "Technology is a tool that supports clinical practice and will continue to evolve. We recognize the value it brings and how it has helped our clinicians to deliver safe, high-quality, efficient care,” said Gwen Hartzog, RN, MSN, MSHA, VP Patient Care Services, CNO, Riverside Regional Medical Center.

Technology has helped increase a clinician’s confidence in his or her care delivery by providing up-to-date patient information whenever or wherever it is needed. Patient clinical information such as vital signs are transferred electronically from critical care monitoring devices to the electronic medical record upon verification by the clinician, thus reducing the potential for human error that can occur when relying on transcription. “You can keep your eye on your patient and their vital signs and all you have to do is validate them, which really streamlines the process,” explained Susan Donston, RN, BSN, MSA, CCRN Nurse Manager, ICU & CCU. Measuring fluid intake and output has also been streamlined with the help of electronic documentation. “You may have a patient who has five different IV drip medications that are being changed and titrated, as well as multiple drainage outputs, so it really helps us keep it all straight and is a huge time saver,” said John Waite, RN, BSN at Riverside.

Critical Care FlowSheet

One specific area of focus for critical care has been preventing ventilator-associated pneumonia, or VAP. According to the Institute for Healthcare Improvement (IHI), VAP is the leading cause of death among hospital-acquired infections in the United States, exceeding the mortality rate of central line infections, severe sepsis, and respiratory tract infections in non-intubated patients³. The IHI developed an organized process called the Ventilator Bundle, which enables early recognition of pneumonia and includes evidence-based best practices that are designed to be implemented together.

Riverside now documents and monitors the usage of the IHI Ventilator Bundle in Soarian Critical Care and according to Connie Hebert, RN, BSN, CCRN and nursing informatics specialist at Riverside, “We just celebrated our one-year anniversary without a VAP in our ICU.”

Copyright 2010, Riverside Regioanl Medical Center

Clinicians are able to select interventions such as head-of-bed elevation and venous thromboembolism (VTE) prophylaxis. In the case of VTE prophylaxis screening, Riverside uses Soarian Critical Care to track interventions such as sequential compression devices or a medication order. If interventions are not found, the nurse is notified via his or her unique Soarian worklist and can then initiate the organization’s predefined protocol, thereby enhancing compliance to the organization’s protocols and supporting optimized patient outcomes. The organization has been able to use technology to more closely monitor quality performance, helping clinicians follow evidence-based practices and addressing industry and regulatory patient safety and quality initiatives. In the future, Riverside will include its sepsis bundle protocol in Soarian Critical Care, whereby clinicians will be notified when a patient is identified as being at risk for sepsis.

Today, all clinical documentation is completed in near real time and is more standardized, concise, and usable. The added benefit of being able to access the patient record electronically has enhanced efficiency compared to the days of completing manual documentation or searching for the paper record in a busy critical care environment. Donston has heard very positive feedback from nurses on her unit. “I encountered one nurse in particular doing her documentation while I was taking an applicant on a tour. She was overwhelmingly positive about how easy her charting was, how it was able to collectively help her form her thoughts, and how efficient it was,” Donston recalled.

Interdisciplinary teams including physicians at Riverside utilize technology as they complete their rounds. All members of the care team can access and refer to the patient’s vital signs, lab results, and medications, identifying trends as they discuss modifications to patient treatment. Physicians at Riverside are using computerized physician order entry while making rounds. As a result, they can quickly enter new orders streamlining the care delivery process. Technology has not only enhanced the rounding process but also supports more efficient communication in patient hand-offs, in keeping with The Joint Commission’s requirements related to effective communication processes for care providers.

Like many organizations today, Riverside sees information technology as a tool to support clinical practice. Riverside’s success with information technology (IT) is founded on a collaborative process that involves all members of the patient care team. With the support of nursing leadership, clinicians from across the organization participated with IT in the Soarian implementation. This included critical care as well as other areas of the health system. The organization clearly recognized the effort as a clinical initiative. It was driven by clinicians who collaborated on worklows and processes that support care delivery. With this focus in mind, Riverside has been able to implement an IT solution that supports its care delivery process and assists it in meeting the many quality and regulatory requirements all organizations face today. Delivering quality care is truly at the center of what Riverside does – as its mission states: “Empowering caring people to save lives, to improve health and to enhance well-being.”

¹Society of Critical Care Medicine," Critical Care Statistics in the United States" www.sccm.org, 2006.
²Hendrich, A., Chow, M., et al., A 36-Hospital Time in motion Study: How do Medical-Surgical Nurses Spend Their Time? The Permanente Journal, Summer 2008/Volume 12 No. 3.
³Ibrahim EH, Tracy L, Hill C, et al. The occurrence of ventilator-associated pneumonia in a community hospital: risk factors and clinical outcomes. Chest. 2001;20(2):555-561.

The outcomes achieved by the Siemens customers described herein were achieved in the customer's unique setting. Since there is no "typical" hospital and many variables exist (e.g., hospital size, case mix, level of IT adoption), there can be no guarantee that others will achieve the same results.