The vast majority of hospitals and health systems have implemented electronic health records. It is now time to shift our attention to optimization with a focus on improving our clinical systems to enhance the delivery of efficient, high-quality, and safe patient care. Establishing and utilizing a clinically led governance structure to select and prioritize optimization projects are crucial. Following project management and change management principles will greatly enhance the probability of a successful initiative. The Nurse Informaticist plays a key role in all parts of the optimization process, and the value of this role should not be overlooked. According to the Office of the National Coordinator (2017), 96% of all nonfederal acute-care hospitals possess certified electronic health records. This indicates an important need for informaticians to shift their focus from implementation to optimization. Electronic medical records (EMRs) must be enhanced and adapted to the needs of the users to minimize challenges to clinicians and ensure best care practices for patients (Shaha et al., 2015). Optimization refers to the continuous improvement of processes that help to enhance patient care, improve outcomes, and create efficiency. In other words, optimization refers to all changes to the EMR except for those made to fix something that is not working as designed, also known as break-fix. EMRs must be continuously improved to align with healthcare’s ever-changing care processes and treatment options (Shaha et al., 2015). Optimization requests can be overwhelming to many organizations, especially those without defined processes and systems in place to manage them. Requests come from all directions. Leadership may mandate top-down changes often as a response to new or changed strategic requirements or business needs. An example of a top-down change might be implementing a new nursedriven protocol such as sepsis screening or urinary catheter removal. Implementing a new technology to prevent patient falls would be another example. Clinical nurses at the bedside request enhancements, often based on personal preferences and challenging workflows. These are referred to as bottom-up requests. Establishing a structure that facilitates getting ideas and input from bedside nurses is encouraged. They are the ones who spend the most time using the system and their voice needs to be heard. The Institute of Medicine (now the National Academy of Medicine) emphasizes the importance of nursing’s role in healthcare transformation and as such believes nurses must help drive the changes that affect them the most (Rojas & Seckman, 2014). Optimization requests also come from external forces. Regulatory agencies and vendors frequently contribute to these requests. These may come in the form of small tweaks to an existing workflow to very large impactful system upgrades. It is not uncommon for a vendor-mandated change or system update to have unintended consequences for the end user. It is important for the Nurse Informaticist to be involved to detect and, hopefully, avoid these consequences. An example of a regulatory change is a new standard of care for managing a patient in restraints. Figure 29.1 demonstrates the complexity of managing requests from these multiple sources when they are all depending on the same informatics, training, build, and configuration resources. • FIGURE 29.1. Competing Priorities. It is imperative that hospitals and health systems have solid governance structures in place to help triage and prioritize all of the requests. Organizations must carefully consider how to best allocate its limited resources when triaging requests because the number of suggestions will almost always outweigh the resources and time available (Bresnick, 2018). Governance structures typically consist of a variety of hierarchical levels to ensure that the right change is reviewed by the right individuals. Ensuring that the decisions regarding what to optimize and how to optimize should be made as close to the impacted business unit as possible. This ensures that the users of the system, those most familiar with the workflows, are the individuals making the decisions that impact their practice. Ideally, an executive level group would only make decisions for very high profile, very costly, or systemwide decisions. For example, an executive group might make decisions on when a major system upgrade will be scheduled or approving the purchase of a new laboratory information system. If a requested change impacts many or all nurses, this decision may be reviewed by a midlevel, multidisciplinary advisory committee. Advisory committee membership may include the Chief Medical Officer, and nursing and ancillary leadership. Deciding if barcode medication administration will be mandatory for all nurses is an example of a decision that an advisory group might make. Conversely, if a requested change only impacts intensive care unit (ICU) nurses, the decision should be made by a workgroup consisting of ICU nurses and their related nursing leaders. The Emergency Department workgroup would make decisions on how the nurse triage tools would be set up and how they will document their assessments. Many workgroups are needed long-term such as a workgroup to prioritize nursing requests, while others are initiative-specific and are disbanded after an initiative is implemented and stabilized. Examples of short-term workgroups include optimizing handover reports and optimizing the nursing admission assessment. Figure 29.2 shows that the majority of decisions are made at the workgroup level. • FIGURE 29.2. Governance Level and Decision-Making. According to Kropf (2015), “Information technology (IT) governance’s role is to assure that benefits are defined and measured, the accountability is made explicit, and that actual performance is measured and reviewed.” Flowcharts or diagrams showing the relationship between the various governance groups are valuable tools and should be available to frontline staff. All users of the EMR should know the process to submit and get approval for enhancement requests. This sort of transparency goes a long way toward developing a trusting relationship between end users and the informatics teams. Some health systems use scoring tools that help guide decision-making and prioritization. Elements often evaluated in these scoring tools include whether there is a financial return on investment, if it would improve patient safety, if it would improve provider efficiency, or if it would have a positive impact on patient satisfaction. Scoring tools often include a requirement to confirm available budget, if applicable. Another important consideration is whether the change is aligned with the strategic plan of the organization. Lastly, tools may evaluate if the request reflects the mission, vision, and values of the organization. Governance committees often rely on this information to guide their decision-making. When first establishing a governance structure, it can be very helpful to develop guiding principles. This can secure alignment throughout an organization when making decisions. Since resources to implement changes are often limited and expensive, it is necessary to ensure that approved changes are the highest priority to the organization. The following are examples of guiding principles focused on EMR implementation and optimization. • Decisions will be made based upon the best interest of the patients. • Standardization to drive consistent outcomes will prioritize enterprise-wide objectives versus individual-, unit-, or department-specific objectives. • Focus will be on the best approach for the health system, while considering and balancing the needs of individual departments. Probably the most important success factor in establishing an IT governance structure is ensuring that it is clinically led. This means that IT staff can and should provide support to the committees, but it is highly recommended that the voting members and the Chair of the committee all represent clinical operations, not IT. This ensures that decisions and priorities are set by operations, the users of the technology. Operations should clearly understand that they own the clinical systems and they have authority and control over what changes are implemented and when they will be made. Decisions can be presented to governance groups in a variety of ways. It can be helpful to the governance committee members if decisions are presented in a uniform way, utilizing a standardized format. This allows committee members to become familiar with how initiatives are presented and ensures they will be provided the details necessary to make sound decisions. It also helps the presenter by providing them with a standard format. Key considerations, applicable guiding principles, background information, and a detailed recommendation are important elements to include. Figure 29.3 is a sample decision document. • FIGURE 29.1. Trauma Name Changes Sample Decision Document. Depending on the size of the initiative and the organization, an official proposal consisting of a charter document, a workflow assessment, and resource estimates may be required prior to presenting the requested enhancement to a governance committee for review and decision. Charter documents can vary, but the elements typically included are described below. First, identify a sponsor. The sponsor is often the individual submitting the request or the person who represents the users who will be impacted by this request. The sponsor plays a key role and is crucial to the project success. If their commitment is low, the team needs to develop strategies to resolve this before moving forward (MacPhee, 2007). Define scope. Scope can be referred to as the boundaries used to define the extent of the project. Clearly and precisely describe what is included in the project. In order to avoid misunderstandings and scope-creep, it is recommended to also document what is out of scope. Scope-creep can happen when requirements are not clearly defined and additional requests come in after the project scope has been approved and confirmed. Allowing additional scope at this time can easily cause confusion to the project team and adds risk to the project timeline and overall success. Documenting clear objectives and deliverables helps to prevent this from occurring. List and describe potential risks and limitations. Establish metrics which will be used to evaluate the effectiveness of the change. The metrics should be measurable and aligned with the project goals. Indicate the desired timeframe to complete the work. If there is a hard deadline that the project team needs to be aware of, be sure to include that. Include cost estimates, as applicable, for new software, hardware, or other related expenses. Identify what governance groups will provide oversight and have the authority to approve the requested changes. A detailed workflow assessment is a critical piece of the proposal. Developing workflow diagrams will clarify what is new, what will be changing, and helps to uncover potential pitfalls or obstacles. Remember to include new reporting requirements or changes to existing reports as these are often overlooked during the planning stages. Having a Nurse Informaticist who is familiar with the associated workflows complete this assessment will be beneficial and can add great value. Taking the time to validate the proposed changes with frontline staff is a critical success factor. Clearly, the nurses who use the system day in and day out are best to provide critical feedback. Understanding resource requirements is another key piece of the proposal. The proposal should include all applicable IT teams involved and an estimated number of hours per team, per month. This should include informaticians, training resources, infrastructure teams, and EMR build resources. Without understanding how many hours of work will be required, the governance committees cannot appropriately approve and prioritize the request. Figure 29.4 is a sample resource assessment for an upgrade to a paging system requiring over 1300 hours. • FIGURE 29.4. Resource Assessment. Determining the implementation strategy is an important step—for example, determining if the change should be completed in phases or as a big-bang. There are pros and cons to each approach which should be considered. An advantage of implementing in phases is that it allows time for evaluation and revisions on a smaller scale. It can also provide time for staff to adjust to incremental changes rather than having to adjust to numerous changes at once. The disadvantages include having to support dual processes during the transition and the extended time it takes to complete the change. Implementing as a big-bang has the advantage of being completed on a faster timeline, and ensures everyone is using a consistent workflow. It provides for more focused training and the project team can move on to other initiatives. The disadvantages of a big-bang approach may include a challenging learning curve and confusion for staff during the initial implementation period. According to MacPhee (2007), change is easier to adapt to when it is simple and complicated initiatives need to be phased in to be manageable. Regardless of which approach you use, it is important to select an appropriate day and time to implement the new features. If possible, avoid selecting a day when other changes are scheduled or when there are other competing priorities. Busy clinicians can only absorb and tolerate a limited amount of change and disruption. Discuss timing with nursing leadership to avoid implementing when there are competing priorities and other changes occurring. Schedule the change early in the week, allowing time to stabilize before the weekend when IT support staff are less available. Confirm availability of key players such as operational leaders, the sponsor, and the most knowledgeable technical staff. Select a time of day when workload is usually lower, typically at night or very early in the morning. Large organizations often have Project Management Offices (PMO) which can help organize requests and prepare them for governance review. Smaller institutions typically have one or more Project Managers (PM) who can assist. These resources can help provide visibility into both available and constrained resources. The PMO or PM may help to ensure the completeness of the charter document, track governance decisions, and oversee approved projects from activation through closure. The PM will create and maintain the project plan and complete and distribute status reports. Status reports ensure that the project team is made aware of the current state, risks, challenges, and milestones achieved. A visible display of the project plan, with designated accountability for each action item, enhances accountability (MacPhee, 2007). The benefits realized when an experienced Nurse Informaticist guides and supports the optimization process can be substantial. The Nurse Informaticist has many opportunities to add value throughout the process. Initially, the Nurse Informaticist should take the time to research the evidence and search for best practices during the planning stage. It is common for hospitals and health systems to be working on initiatives that others have already optimized. There is no need to reinvent the wheel at every institution. Networking with colleagues, asking the vendor for advice, and searching the literature are all valuable resources. Certain initiatives can be controversial and may require consensus building. The nurse informaticist can be key to successfully driving this process. Working to get approval from both formal and informal leaders can be challenging. It often helps to preview proposals with key individuals before the formal meetings; this may be referred to as the meeting before the meeting. This helps the sponsor understand what questions to anticipate, which can then be added to the proposal or the charter document. The project sponsor may need support from informaticist to help direct them in this process. Understanding potential political challenges is crucial and will help ensure project success. At times, the Nurse Informaticist acts as a Customer Relationship Manager (CRM) through the optimization process. The CRM stays involved throughout the project and is responsible for managing the relationship with the sponsor and ensuring their satisfaction. Often the Nurse Informaticist most familiar with the associated business unit will serve as the CRM, maintaining an already established trusting relationship. They will develop the charter, estimate resources, support the sponsor through the governance approval process, and be the primary contact throughout the project. Assigning a CRM often leads to greater sponsor satisfaction since the CRM knows who his or her go-to person is, which can be particularly challenging in large, complex IT organizations. The CRM plays an important role in balancing customer expectations and ensuring the technical teams stay on track and understand the relevant clinical implications. The CRM will also work closely with the assigned PM to help reduce risk and resolve issues and challenges. The CRM plays a vital role as he or she is typically the face of the IT organization and has accountability for maintaining sponsor satisfaction. The Nurse Informaticist may lead an IT optimization review council to evaluate the requests before developing a formal plan. This is especially beneficial in large complex organizations because it helps ensure the IT resources are aligned and supportive of the proposed solution. A review council can also help to uncover and prevent unintended consequences that can easily occur in an integrated system, especially when silos exist between various teams or departments. An example of this is if the emergency department requests to change their documentation without realizing it is a shared flowsheet row impacting all adult medical and surgical units and ICUs. This group may uncover that what the user is requesting already exists. EMRs are very broad and complex and often a tool or workflow may be available and the user is simply unaware. They may determine that the request is not technically possible at this time due to system limitations. In this case, the Nurse Informaticist could submit an enhancement request to the vendor on behalf of the user. The Nurse Informaticist may consult with the requester to better understand what they are trying to achieve and then share this information with the council. Knowing this information is extremely valuable to the IT team who may propose an alternative solution, while still helping the user to achieve their desired outcome. The optimization council should review all wide-reaching clinical initiatives. Suggested membership includes Nurse Informaticists, Physician Informaticists, IT trainers, and applicable application analysts or builders. It is important to remember that an IT optimization council is not an official governance group. They should not make decisions that impact end users, but rather focus on keeping IT in alignment and strategizing collaboratively. The Nurse Informaticist is in a unique position to conduct the workflow analysis. Critically reviewing clinical workflows provides the opportunity to thoughtfully examine practices, and Nurse Informaticists are skilled in facilitating and guiding clinicians as they unravel complex processes embedded in clinical workflow (McLane & Turley, 2011). The Nurse Informaticist has a unique combination of clinical and informatics knowledge, enabling them to focus on the best way to support patient care through integrating people, systems, processes, and technology (McLane & Turley, 2011). The other members of the IT team will rely on their clinical insights and the valuable information they provide to the team. A workflow analysis consists of documenting how work is accomplished. It is helpful to produce a diagram of the workflow from start to finish, with swim lanes for each user role. This is important to identify gaps, areas that need further exploration, or decisions that need to be made. Figure 29.5 is an example of a workflow diagram created when implementing barcode medication administration in the ambulatory setting. • FIGURE 29.5. Ambulatory Barcode Medication Administration. Many healthcare facilities have dedicated testing teams, but an experienced Nurse Informaticist can be a valuable resource during the testing period. A Nurse Informaticist who is familiar with the workflow can help develop testing scenarios as well as perform testing functions from a clinician’s perspective. Having someone familiar with how nurses practice and participate in testing can often find issues that even skilled testers might miss. Working closely with and developing super-users is another function that can be enhanced with Nurse Informaticist direction and oversight. Super-users provide boots on the ground perspectives and help promote twoway communication between end users and IT. The Nurse Informaticist can foster the development of these relationships and effectively translate between the two groups. Keeping super-users engaged and energized on an ongoing basis allows for bidirectional communication between clinical and technology teams (Gocsik, 2014).Depending on the initiative being implemented, they can be critical to the success. Developing a process to keep super-users informed about upcoming system enhancements while also allowing time for them to share feedback from their colleagues is strongly recommended. Once the project is activated and work is underway, it is time for the Nurse Informaticist to shift his or her attention to implementation planning. During this phase of any project it is crucial to remember that how you implement a change is just as important as what you are implementing. If significant attention is not given to focus on change management, even the best optimization project could easily fail. Although it is technically possible for IT to implement optimization initiatives without partnering with operations, it is not recommended. The best case scenario is a solid partnership between IT and operations. Scheduling time to strategize the preferred approach for training, communication, ensuring buy-in, as well as the role of super-users are all important. The goals for training include ensuring clinicians understand the change that is coming and to provide engagement opportunities to promote adoption. There are many ways to train effectively, and the format should be selected based on how impactful the change will be. If a change is minor and the new workflow is intuitive and low risk, a tip-sheet might be sufficient. For example, a tip-sheet would probably be sufficient when adding flowsheet rows with new choice lists. For a change that is high risk or one that involves a complicated workflow, classroom training might be required. Implementing electronic code documentation is an example of a change that might require hands-on classroom training. Another training option to consider includes creating elearnings that can be optional or mandatory, depending on the situation. Having nurses rounding throughout the hospital, informing their colleagues of an upcoming change, showing them what is changing, and allowing them time to ask questions can also be valuable to ensuring adoption. Table 29.1 outlines other considerations to evaluate prior to determining the training strategy. Figure 29.6 can be used as a guide when determining the training approach and the support plan for an optimization initiative. TABLE 29.1.
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Beyond EMR Implementation: Optimize and Enhance
ABSTRACT
INTRODUCTION
GOVERNANCE AND PRIORITIZATION
CREATING A PROPOSAL
ROLE OF THE NURSE INFORMATICIST
IMPLEMENTING THE CHANGE
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