The Nursing Shortage: Can Technology Help? Prepared by First Consulting Group June 2002 The Nursing Shortage: Can Technology Help? Prepared for: CALIFORNIA HEALTHCARE FOUNDATION Prepared by: First Consulting Group Authors: Joanna Case Mychelle Mowry, R.N., M.N. Emily Welebob, R.N., M.S. Acknowledgments First Consulting Group is a leading provider of consulting, tech- nology and outsourcing services for health care, pharmaceutical and other life sciences organizations in North America and Europe. More information about FCG is available at www.fcg.com. The authors would like to thank the following people associated with First Consulting Group for their time and input: Erica Drazen, Katy Gladysheva, Judy Joy, Linda Lockwood, Keith MacDonald, Jane Metzger, Debbie Slye, Dona Stablein, Steven Vowels, Shelli Williamson and the Scottsdale Institute. In addition, the following individuals were helpful in providing input and generating contacts: Elaine Batchlor, M.D., California HealthCare Foundation; Susan Fletcher, Pyxis Corporation; John Haughom, M.D., PeaceHealth; Linda Miller, Johns Hopkins Bayview Medical Center; Marcy Mishiwiec, CliniComp Interna- tional; Matthew Morgan, M.D., and Angela Jenkins, Per-Se Technologies; Marge Pike, Sigma Theta Tau; Harris Stutman M.D., Eclipsys Corporation; Amy Vance, VasTech, Inc.; and Robert B. Zaleski and Mary S. Zeringue, Alaris Medical Systems. Thanks also to reviewers Kathleen Charters, Therese Morley, and Jean Ann Seago, as well as Elaine Batchlor, Sam Karp, and Tom Lee of the California HealthCare Foundation. The California HealthCare Foundation (CHCF) is an indepen- dent philanthropy committed to improving California’s health care delivery and financing systems. Our goal is to ensure that all Cali- fornians have access to affordable, quality health care. CHCF’s work focuses on informing health policy decisions, advancing efficient business practices, improving the quality and efficiency of care delivery, and promoting informed health care and coverage decisions. The iHealth Reports series focuses on emerging technology trends and applications and related policy and regulatory developments. Additional copies of this report and other publications in the iHealth Report series can be obtained by calling the California HealthCare Foundation’s publications line at 1-888-430-2423 or visiting us online at www.chcf.org. ISBN 1-932064-00-1 Copyright © 2002 California HealthCare Foundation Contents 5 I. Why This Research Was Conducted The Nursing Shortage: Setting the Context Shortages May Compromise Patient Safety The Benefits of Successful Technology Implementations 9 II. Systems to Support Nurses Administration: Staff Scheduling Communication Clinical Decision Support Medication Management Documentation Access to Information 21 III. Technology and Financial Considerations 23 IV. Insights from the Front Lines 26 V. Conclusions: Implications for Recruitment and Retention 28 Appendices Appendix A: Interviews Appendix B: Vendor references Appendix C: Glossary 34 Endnotes I. Why This Research Was Conducted Q TODAY’S HOSPITAL ENVIRONMENT IS MARKED by rising patient acuity, staffing difficulties, and burdensome Throughout this report, paperwork—all factors that contribute to the stress often cited nurses and industry by nurses as their reason for leaving the inpatient setting. experts respond to the With a worsening shortage of nurses, health care organizations must seek out a variety of solutions, including technology question, “How can systems, to enhance nurse efficiency and satisfaction. technology best be used The California HealthCare Foundation (CHCF) commis- to support nurses?” sioned First Consulting Group (FCG) to explore how tech- nology solutions can, and do, support nurses. FCG employed A industry, client, and vendor contacts to connect with nurses, as well as clinical and IT staff at hospitals where technologies “With many experienced baby have been deployed. In all, 26 interviews were conducted, boomer nurses leaving front representing 19 hospitals and health systems, two experts from line clinical care and more nursing schools, two experts from nursing associations, and one state senator. The interviews consisted primarily of open- traveler and younger nurses ended questions to assess the impact, benefits, and challenges joining staffs, it becomes these systems posed for nurses and organizations. especially important to goof- proof the health care system The Nursing Shortage: Setting the Context and systematize different Current estimates of the nursing shortage suggest that average processes.” hospital vacancy rates are well over the 10-percent mark: In 2001, a major survey found national vacancy rates of 13.0 per- —Nurse, large California Hospital cent for registered nurses, 12.9 percent for licensed practical nurses, and 12.0 percent for nursing assistants.1 This shortage will grow to unprecedented proportions; one expert predicts the national shortfall will reach 500,000 nurses by 2020.2 The state of California—which has the lowest number of registered nurses per capita—will need at least 60,000 (31 percent more) nurses by 2020 to maintain current levels.3, 4 As has been amply described in recent literature, the demand for nurses is increas- ing due to the rise in older and sicker patients and the greater complexity of care, while the supply of nurses is diminishing. The aging nurse population is one factor; by 2010, more than 40 percent of registered nurses will be over the age of 50,5 but as these nurses retire, they are not being replaced with new recruits. In order to mitigate the effects of the shortage on patient care, hospitals must find ways to increase nurse effi- ciency and satisfaction. (For more background on the nursing shortage, see Understanding California’s Nursing Crisis and related links at www.chcf.org/topics/view.cfm?itemID=19638.) The Nursing Shortage: Can Technology Help? | 5 Experts speculate that other reasons for the The growing shortage poses an immediate prob- decreasing supply of nurses include: (1) expanded lem for hospitals, where nurses represent more job opportunities for women; (2) a negative than 23 percent of the full-time workforce.8 In an perception of the nursing profession; (3) the rise attempt to fill vacant positions, hospitals and of managed care and the subsequent layoffs of health care organizations are employing a variety nurses in the face of declining provider reim- of recruitment and retention strategies including: bursement; and (4) increasing frustration with s Increased salaries and benefits; working conditions in hospitals. An industry expert at the UCSF School of Nursing says nurs- s Flexible scheduling, child care, es are dissatisfied with the lack of control they and other employee-friendly options; experience in the workplace; with their inability s Sign-on bonuses; and to make decisions about patient care; and with s Traveling/agency nurses. the lack of recognition of their professional status. Nationally, one study found that 50 per- Although some of these measures provide valu- cent of nurses have considered leaving patient able and sustainable benefits, others do not. care for reasons other than retirement, and more Hospitals recognize that these stopgap measures than half of these cite the desire to have a job are not only costly, but do not provide long-term that is less stressful and less physically demanding solutions. Hospitals and other organizations are as the primary reason.6 Another study indicates involved in a number of initiatives to attract that 40 percent of nurses in the U.S. are dissatis- nurses to the profession, but unless they are able fied with their jobs and one-third of the nurses to improve conditions for these new nurses, under the age of 30 plan to leave their jobs with- they will be unable to meet the growing demand. in one year.7 This research shows the necessity The consequences if hospitals fail to meet this of improving hospital working conditions to demand are significant. Quality of care will be prevent the continued exodus of nurses from the compromised if nurses do not have enough time direct care setting. (A recent CHCF-sponsored to monitor patients and perform safety checks; roundtable on the nursing crisis offers a broad patient access also will be jeopardized as emer- range of approaches to solving the nursing short- gency rooms become overcrowded and hospitals age. See Stakeholder Perspectives on California’s close down beds. If allowed to continue, these Nurse Staffing Crisis at www.chcf.org for more problems will be self-perpetuating as the working information.) environment becomes even more stressful and more nurses leave the direct care setting. 6 | CALIFORNIA HEALTHCARE FOUNDATION Shortages May Compromise The Benefits of Successful Patient Safety Technology Implementations Complicating both the demand and supply Although numerous examples exist of technolo- side are issues of patient safety, which are of gies that have not been beneficial to nurses— enormous concern to nurses. A landmark 1999 or actually made their work more difficult—this Institute of Medicine report estimated that report focuses on implementations considered between 44,000 and 98,000 patients die each to be successful by interviewees. It is not a com- year as a result of medical errors.9 A Chicago prehensive review of nursing technologies; rather Tribune article on nursing errors, published in it provides examples of how technology has been 2000, estimated that the actions or inaction of used to support nurses. Its purpose is to illustrate registered nurses resulted in 1,720 deaths and the possibilities and share practical information 9,584 injuries to patients since 1995. Nurses among nurses and organizations. quoted in the article expressed their anxiety The report cites the experiences of health care about patient care and their awareness that time organizations that have implemented a number constraints might keep them from performing of technologies that benefited nursing in key safety checks and monitoring patients as vigilantly areas, including: as needed.10 As front-line caregivers, nurses must cope with the consequences of medical errors I Nurse scheduling no matter who or what is the cause. I Mobile communication It is not surprising that technology systems I Patient education installed by hospitals as part of a broad quality I Messaging functionality improvement effort were found to provide I Medication administration significant benefits for nurses. According I Clinical decision support functionality to one expert, many of the changes that nurses have sought in technology systems are those I Computerized physician order entry (CPOE) that decrease the likelihood of making a mistake. I Automated nursing documentation Although technology systems that increase I Computerized patient record (CPR)/Clinical patient safety and clinical quality may not always data repository (CDR) increase nurse efficiency, they can relieve anxiety and enable nurses to provide safer, better All of these solutions required changes in work- care—which has a positive impact on job satis- flow and clinical processes, and many required faction, and potentially on nurse recruitment the participation of other clinicians as well and retention. as nurses. Hospitals must be sure to address financial and technical issues as a part of every A technology initiative. Insight provided by inter- viewees can help to guide organizations that “Technology can be used to address the wish to use technology as part of a plan to create nursing shortage by effectively implement- a culture of safety and a supportive environment ing standards and protocols…to impact for nurses. on patient safety and outcomes.” —Nurse Educator The Nursing Shortage: Can Technology Help? | 7 As the shortage gets worse, hospitals will need to use every means possible to support nurses. There are far too many examples in the industry of unsuccessful implementations and poor uses of technology that have created more work for nurses. But when the right technology is success- fully implemented, monitored for effectiveness, and adequately maintained, technology can make a positive difference in the patient care environ- ment. By increasing efficiency and alleviating some of the burden on nurses, technology can free nurses to concentrate on direct care. And, as part of a comprehensive strategy to support nurses within the hospital, it can help make the care environment more rewarding and thus help improve recruitment and retention. 8 | CALIFORNIA HEALTHCARE FOUNDATION II. Systems to Support Nurses A The nursing process, as shown in Figure 1, involves gathering “Since this shortage has limited the appropriate information to assess, diagnose, plan, inter- vene, and evaluate the patient’s condition. Many organizations the number of nurses, nurses have technologies in place to support nurses in various aspects should be gathering data of the process. They cite the benefits of those systems in several through the use of technology, functional areas, including administration, communication, clinical decision support, medication management, documen- making decisions, and then tation, and access to information. Each of these areas presents delegating basic tasks to others.” opportunities for technology improvements that can make —Nursing Administrator, nurses more efficient and their work more satisfying—as well large Eastern teaching hospital as safer for patients. Figure 1. The Nursing Process N U R S I N G P R O C E S S A N D S O M E I L L U S T R AT I V E A C T I V I T I E S Nursing Problem Identification/ Assessment Nursing Diagnosis Planning Intervention Evaluation • Review clinical • Develop appro- • Develop inter- • Preform • Interpret results, history (past priate nursing disiplinary plan precedures evaluate out- and present) diagnosis or of care comes, assess problem list • Coordinate and compliance • Access relevant • Assign appro- oversee diagnos- information • Obtain appropri- priate protocol tic interventions • Intervene for (exams, tests, ate consent or guideline critical values procedures, (clinical pathway) • Medicate as results review) • Use standards indicated • Provide support and precautions • Educate for unexpected • Assess patient patient/family • Provide reassur- outcomes • Communicate ance/support • Document with care team • Communicate • Monitor/teach with care team • Prevent/treat to watch for • Document complications complications • Document • Monitor • Facilitate appropriately follow-up tests • Communicate and treatment with care team • Communicate • Document with care team • Document Based loosely on the five-step nursing process (Doenges ME, et al, 1995) cited in “Building Standard-Based Nursing Information Systems” Pan American Health Organization, 2001. The Nursing Shortage: Can Technology Help? | 9 Administration: Staff Scheduling Scheduling Web site.Executives at St. Peter’s Even small improvements in staff scheduling may Hospital of Albany, New York asked an interest- have a big impact as hospitals struggle to ensure ing question: Could something similar to that they have enough nurses with the appro- Priceline and E-Bay help to solve the hospital’s priate skill levels to provide round-the-clock care nursing shortage? Looking to apply the success every day of the year. Research from the Amer- of these Internet start-ups to their own hospital, ican Nurses Association as well as the Harvard they built a Web site, RNJobs, in which nurses School of Public Health suggests that staffing could bid for vacant shifts. In about two levels may affect patient outcomes of care, high- months, the hospital was ready to begin using lighting the importance of scheduling capabili- the system on the units. They began slowly, by ties.11, 12 Enabling nurses to create schedules to suit rolling out the system to two units in December their lifestyles is an important part of recognizing 2000. Because the system is so easy to use, their professional autonomy, according to one they encountered no major barriers and were expert at UCSF School of Nursing, which in able to continue the rollout. turn can improve nurse recruitment and The Web site allows nurses to go online and retention.13 The following are two examples of view shifts that have not been filled by the nor- staff scheduling systems. mal staffing process. They enter their skill-level Nurse scheduling system. When four units and a bid for an hourly wage (the site lists a merged in the Department of Gynecology and range of likely bids). A nurse manager reviews Obstetrics at Johns Hopkins Hospital in Balti- the bids, decides when to close the bidding, and more, Maryland, three years ago, the complexity which bids to accept. In order to ensure quality, of scheduling shifts and matching skill levels nurses unknown to St. Peter’s Hospital must fill was too cumbersome to do manually. It took 40 out an online application, take a written test, hours each month to get the schedule in place, and participate in orientation before they may and even then it was not always successful. The bid and work a shift. Department of Nursing implemented the Night- Two-thirds of the users are nurses from St. Peter’s ingale scheduling system from VasTech because it Hospital who are bidding for overtime shifts. In was flexible and could meet the needs of multiple this way, nurses can get more work if they want units. The system provides various tools to help it, and nurse managers no longer have to spend manage unit scheduling, credential and certifica- time calling around and posting messages to tion tracking, and time and attendance. bulletin boards to fill vacancies. In addition, the With the Nightingale system, nurses enter their Web site has become a recruiting tool for the preferences for shifts via the Internet. Admin- hospital by attracting new nurses, some of whom istrators enter the requirements for the unit, become permanent staff members. Even tempo- and the system then runs through algorithms to rary nurses say they feel a sense of control and produce the schedule that best meets the needs belonging. The RNJobs system is one part of the of everyone. Producing the schedule now only hospital’s successful strategy to reduce its vacancy takes about 10-12 hours per month.14 In addition, rate of registered nurses. nurses can enter the system through the Internet and schedule at their convenience, and it “remembers” their preferences, which has helped to increase staff satisfaction with the system. The staff is reassured, knowing that nurses with appropriate skills will cover each shift. 10 | CALIFORNIA HEALTHCARE FOUNDATION Communication Patient education. More than half of nurses Nurses are at the center of information coordin- (58 percent) reported in a national survey that ation among patients, physicians, staff, and fami- at least once a week they do not have time for lies. They are extremely busy and highly mobile, patient education and training,15 but at Adventist which can create obstacles to timely communica- Health in California, patient education materials tion. Delays and difficulties in communication are accessible electronically through the Phoenix create frustration for nurses, other clinicians, patient education system. Unlike printed mater- and patients, and may have a negative impact on ials, the electronic patient education materials patient care. A variety of tools, including mobile can be easily modified to meet clinician and phones, patient education systems, and automat- patient needs. Most are available in Spanish as ed messaging and email, are used to facilitate well as English, satisfying patient needs and communication. regulatory requirements. The system tracks which materials were given and by whom, as well as Mobile communications.Wireless phones trans- follow-up comprehension activities. In the acute- mit to antennae in the units for nurses to use care environment, the system links education at Bridgeport Hospital in Connecticut. Each activities and documentation, making the educa- nurse picks up a phone at the beginning of the tion process more structured. The system has shift and has a regular seven-digit number to helped to improve workflow for nurses, enabling receive calls. them to provide the education and support The system was implemented to solve several patients need. problems. First, patients complained about the The Phoenix system has provided greater benefits noise associated with the nurse call system, which than Adventist Health anticipated; it has facili- paged nurses in every room. Second, when nurses tated the transfer of information between the needed to reach physicians or physician offices, acute care and home care facilities, providing they had to leave the bedside to call from the greater continuity and standardization. nurses’ station. Physicians returning calls were inconvenienced by having to wait while someone found the nurse. (This problem was exacerbated if there was a shift change or lunch break.) With the new wireless system, nurses make and receive calls from anywhere on the unit. If a call comes in while the nurse is at the bedside, the phone vibrates, without disturbing patients. In the event of an emergency, the nurse can stay at the bedside and call for ancillary services. Nurses on the unit that piloted the system report great satisfaction with the technology. The Nursing Shortage: Can Technology Help? | 11 Automated messaging.Nurses spend a large Clinical Decision Support portion of their time coordinating patient care Computer-based clinical decision support (CDS) services. Automated messaging—which may be a functionality can provide access to information, feature of clinical documentation, order entry, generate alerts, increase access to and compliance and electronic medical record systems—sends the with standards, and enable greater collaboration. needed information without extensive human CDS can be incorporated into a variety of sys- intervention. Forrest General Hospital in Mis- tems to prevent errors and help caregivers adhere sissippi has found that the automated messaging to standards of care—although it is not meant functionality incorporated into their clinical to override clinical judgment. A system does documentation system has saved nursing time not have to be complicated in order to include by improving the referral process. With the decision support. The international nursing previous manual system, nurses would often have honors society, Sigma Theta Tau, maintains an to spend time following-up on referrals to ensure online library so that nurses can access the latest that they reached the appropriate destination. research; and the order entry system at Vanderbilt Now, when a nurse documents that a patient Medical Center incorporates access to knowledge requires assistance walking, for example, the bases, including a drug database, patient edu- system automatically sends a referral to a physical cation resources, nursing references, and hospital therapist. In this way, the system not only helps monographs. to save nurses’ time coordinating services, but it also helps to ensure that the appropriate referrals The real power of online CDS is its ability to are generated. work in real-time, generating feedback based on the information entered into the system. Email. As computers proliferate on hospital floors, email has become an effective communi- CPOE. Extensive CDS capabilities support cation method for nurses. Because of its asyn- nurses at Alamance Regional Medical Center in chronous nature, nurses can communicate with North Carolina through its computerized physi- one another even when they are not on the same cian order entry (CPOE) system. New orders shift or in the same department. ICU nurses at are flagged, and if a medication order is entered Stanford Medical Center use email to communi- “STAT,” it is automatically sent to the nurse’s cate with each other about problems encountered pager. The system has safety nets at the ready on the weekends, specific patient problems, and when the nurse logs on to verbally enter orders. supply issues. The nurses even send each other If the name of the physician on the order does kudos and feedback. Email also enables managers not match the name of the patient’s physician, to communicate with and solicit feedback from for example, the system generates an alert. many staff members at once. Overall, the one complaint that Alamance has received from the nurses regarding CPOE is that they wish all the physicians would use it. 12 | CALIFORNIA HEALTHCARE FOUNDATION Automated nursing documentation.CDS can Figure 2. The Medication Management Process in the Inpatient Acute Care Setting present information in a way that supports adherence to standards and policies. One of the History Taking reasons that Forrest General Hospital imple- mented the Per-Se Technology’s patient record system with automated nursing documentation Ordering • CPOE was to improve compliance with Joint Commis- sion on Accreditation of Healthcare Organiza- tions (JCAHO) standards. The system provides Pharmacy Management Dispensing automated reminders such as pain assessment • Automated follow-up, and helps ensure that needed infor- Dispensing Administration mation is gathered by requiring certain fields to Systems be complete, such as the documentation required • IV Pumps for use of restraints. Children’s Hospital and • Medication Surveillance Administration Health System in San Diego noted that the ease Systems of incorporating new standards and policies into Based on Kilbridge P. and D. Classen “VHA’s 2001 Research Series: A Process Model of Impatient and Information their CDS system was a great benefit, and also Technology Interventions to Improve Patient Safety.” increased the sense of ownership among the Prepared by First Consulting Group for VHA, Inc., 2001 nurses who suggested changes. CPOE has been proven to help reduce errors, Medication Management but the primary benefit that organizations cite Medication regimens have become more com- for nurses is that it enhances nurse efficiency by plicated, taking up more of nurses’ time and providing them with the information they need contributing to medical errors. Studies indicate in a clear, legible manner. Nurses do not have to that 6 to 10 percent of hospital stays include an engage in lengthy transcription or verification of adverse drug event (ADE).16 According to a orders. Given that nurses often lack the time to 1999 Institute of Medicine report, 7,000 deaths perform safety checks for each administered dose, each year are attributable to medication-related automating such checks at the point of decision errors.17 relieves some of the burden on nurses. (See more on CPOE under “Access to information.”) A variety of systems and technologies can be used to support the medication management process A at the point of care. Their effectiveness varies depending on ease of use and the level of integra- “Anything to do with record keeping and tion with other systems. When successful, these orders, and communication between systems perform safety checks in real-time based doctors and nurses [will help nurses].” on patient data, and are fully incorporated into workflow. Figure 2 shows an overview of the —Nurse Educator medication management process and specific technologies used to improve safety. It highlights the two areas carrying the highest risk: An esti- mated 49 percent of ADEs occur because of an error during ordering, and 26 percent occur during administration.18 The Nursing Shortage: Can Technology Help? | 13 The following are examples of some specific tech- Dispensing devices.For other types of medica- nologies in medication management. tion administration, a dispensing device, such as the Pyxis system, can assist nurses. Standalone “Smart” IV pumps. A “smart” IV pump was systems are used to regulate access to controlled piloted on two units at Vanderbilt Medical substances and provide inventory and charge Center in Nashville, where it is having a “consid- functionality; as such, they have limited safety erable positive impact on nurse job satisfaction.”19 impacts. More advanced systems are most ALARIS Medical Systems has been working with effective when tightly integrated with an order nurses, physicians, and pharmacists there to system, either through the hospital information improve the safety of IV infusion of medications. system or the pharmacy information system, With traditional IV pumps, nurses program the and with software to perform safety checks. A dosage and the rate of administration. Linked to nurse at Catholic Healthcare West compared the safety software, the Alaris Medley pump checks Pyxis dispensing station to an ATM machine— the nurse’s order against a database of drug infor- the nurse requests medications for patients from mation and predetermined limits that can be the cabinet and, before permitting access, the sys- set for different units in the hospital. The pump tem checks that the nurse is administering the alerts the nurse to any potential errors, much in correct medication for that patient at the correct the way that the CPOE generates alerts for time. At Tri-City Medical Center in California, physicians. For increased safety and ease of use, the Pyxis stations have eliminated some of the the Medley pump requires fewer keypunches hassles associated with medication administra- and decisions than traditional pumps. One nurse tion. Nurses do not have to call the pharmacy to at Clarian Health in Indiana notes that “A get the medications they need, and they can programming error is like making a typo”; the access drug information from the station. system doesn’t replace the nurse’s judgment, but guards against such inadvertent errors. (From One hospital, in order to make the system fit a personal communication with Robert Zaleski, existing workflow better, bought medication carts ALARIS Medical Systems, March 2002.) in addition to the dispensing cabinets. Nurses took all the medications they needed for the day at once instead of returning to the dispensing cabinet for each patient. Despite its added con- venience, this system introduces a step that could produce error and diminishes the benefit of the dispensing cabinet to ensure accuracy. 14 | CALIFORNIA HEALTHCARE FOUNDATION Medication administration systems. A more Medication administration systems with bar- comprehensive medication administration system code technology. The Veterans Affairs (VA) is a component of Per-Se Technologies’ Patient1 Health System mandated the use of bar-code computer-based patient record, in use medication administration (BCMA) in 163 of its at St. Francis Hospital in Oklahoma. It provides medical centers in 1998, and went live two years “closed-loop” medication management: Orders later. Tightly integrated with the CPOE and are placed online, routed to the pharmacist for pharmacy systems, the BCMA technology uses a approval and dispensing, and documented by the wireless notebook computer on top of a medica- nurse when administered. Nurses like the system tion cart and a bar-code reader to enable nurses for several reasons. First, orders are legible and to administer medications and document online more timely; the instant an order is entered or at the point of care. The nurse signs onto the changed it is available online. Second, the system BCMA wireless laptop, then uses the bar-code features safety checks; for example, it generates scanner to read the patient’s identification an alert if a nurse attempts to administer a bracelet and bring up the patient’s medication medication too soon. Third, the system integrates record. The nurse then scans the bar code on the the ordering, dispensing, and administration unit dose medication (placed there by the phar- processes. macy); if there are any issues an alert appears. If not, the nurse administers the medication and However, it poses some problems for workflow. enters any necessary notes in the system. Nurses found the use of computers while they were preparing medications for administration The Topeka VA Medical Center measured the disruptive. As a result, the hospital built a med- impact of the system and found that the number ication pre-administration report that the nurses of wrong medications dispensed was reduced by generate twice a shift and use as worksheets to 75 percent, patient mix-ups by 93 percent, and facilitate the process. This solved the immediate dose errors by 62 percent.20 Nurse focus groups problem at St. Francis Hospital, but may not be agreed that BCMA is effective in preventing the recommended solution for other sites. errors and cited specific examples of errors that would not otherwise have been caught. With the system, nurses have what they need at the point of care and do not have to interrupt medication administration. If a medication is missing, for example, they can send a message to the pharma- cy immediately. On the other hand, nurses some- times feel chained to the cart to get through a complete round of medication administration and to maintain security. The Nursing Shortage: Can Technology Help? | 15 At both St. Francis Hospital and the VA Health Nursing Assessment.More than one-third (37 System, implementing the medication adminis- percent) of nurses surveyed nationally say there is tration system involved a great amount of not enough time to assess each patient on each change-organizational, cultural, and workflow. shift.22 Yale-New Haven Hospital was able to “It is hard to explain,” said a nurse at St. Francis, reduce the time required to complete an assessment “but there is a comfort level working with what by half by using a wireless device to complete is known and familiar. Losing the paper MAR documentation. The hospital also streamlined (Medication Administration Record) was disturb- and standardized documentation, eliminating ing to many nurses who had to learn to ‘trust’ unnecessary steps (growing concerns over liability the electronic MAR.” As difficult as the imple- and piecemeal growth of information systems mentation was, however, nurses at St. Francis have resulted in increased redundancy in reported that the medication administration documentation). Nurses on the unit like the system has exceeded their expectations on their system because they know exactly what they are annual IS “report card.” required to document. A Documentation Most organizations agree that documentation “The place where technology can best be and paperwork demand a significant portion leveraged to support nurses is at the of nurses’ time and often take them away from assessment and planning level…We need the bedside. Documentation is a component of every step in the nursing process. One study online decision support tools.” estimates that every hour of patient care gener- —Nurse Administrator, ates another 30 to 60 minutes of paperwork large, multi-state health system for nurses,21 who may spend hours at the end of the shift working overtime to catch up on it. Ideally, nurses would be able to easily record actions, interventions, and patient information in real-time as they provided care. In this way documentation would become a by-product of patient care, rather than a separate task. Auto- mated nursing documentation systems can streamline documentation, ensuring that all the required information is gathered (and gathered only once), and can also improve the quality of patient information collected. 16 | CALIFORNIA HEALTHCARE FOUNDATION Imagine that you are a nurse, working in a hospital in the not-so-distant future … • A message on your data phone indicates that a • You then administer medications using a cart new patient, a diabetic with foot pain, is on his equipped with a laptop and bar code scanner, way to the unit from the emergency department scanning the bar code on your badge and the one (ED). You greet Mr. A as he arrives and complete on the patient’s bracelet. The system confirms his assessment in his room. There you pull up that you are administering the right medication to the nursing assessment from the ED to compare the right patient at the right time. (Any warnings findings and avoid asking for duplicate informa- about contraindications or dangers to the patient tion. Checking Mr. A’s vital signs, physiological were generated at the time of ordering.) You and functional status, you speak into a micro- administer the medication and document it with phone attached to your collar. As you speak, the a single click. information populates the patient chart on the bedside monitor (use of a non-standard term • As you log on to the computer to check your causes a soft beep to sound). worklist, a reminder appears that it is time for Mrs. B to proceed to the operating room. Based Admitting orders for Mr. A’s protective boot and on Mrs. B’s current weight, an automatic page crutches have already been transmitted; just has been sent to patient care technicians who like a FedEx package, you can log in and see that will help transfer Mrs. B. The hospital has issued the materials are on their way. On the bedside a policy for nurses to use other staff resources to monitor, you enter checks next to the “Physical help move patients in an attempt to cut down therapy referral” and “Nutritionist referral” fields on staff injuries. Mrs. B’s chart shows that all the on the chart, and messages are automatically preoperative tests, procedures, educational acti- routed to the appropriate clinicians. As Mr. A vities, and consents have been completed, and recently lost some aspects of his health insur- she appears to be calm as she leaves for surgery. ance, you schedule an appointment with a financial counselor, viewing the available time • Ms. C is scheduled for discharge shortly. In her slots for financial counseling as well as Mr. A’s chart you confirm that Ms. C has been educated schedule. Your admission assessment is com- about her condition and can monitor her own plete (and immediately documented), discharge blood pressure. She does not have a computer at planning has been automatically initiated, which home, so you print out the tailored educational leaves you time to talk with Mr. A about his materials and discharge instructions for her. interests and preferences for care. • At the end of your shift, you are able to leave • In the hallway, you log into the computer with a promptly, all documentation having been com- swipe of your badge to confirm your schedule for pleted as care was provided. It was only a few the coming week (the scheduling system knows years ago, you recall, when you spent an hour your shift preferences) and elect to pick up an at the end of the shift just catching up on paper- extra weekend shift. You then check your email. work. Now you have time to complete all your You are pleased that there is a response from the documentation, to talk with your patients, and committee on improving working conditions and to complete required training and educational regarding your suggestions for how to increase activities. You appreciate working in such a diversity among nurses at the hospital. collegial, patient-centered care environment. The Nursing Shortage: Can Technology Help? | 17 Online charting. The CareVue system in use at the ICU at Stanford Medical Center provides online charting throughout the nursing process. Nurses complete the admission assessment online and then can configure the individual chart to meet the patient’s care plan. If a patient is on A“In the future, nurses could wear equipment that would record data as they speak; the information could be transmitted over a wireless network to complete documen- dialysis or IV infusion, the nurse indicates it in the chart; consequently, all the sections needed tation and be immediately available for documenting care for this intervention appear through the same device.” in the online chart. The system uses “click-and- —Nurse/Clinical Systems Expert, drag” and “pick-list” functionality, which increases large California health system efficiency and standardizes terminology. The pick-lists are updated frequently. A recent strike at a hospital demonstrated the The charting system also supports continuous power of automated charting to standardize patient monitoring. It “speaks” to cardiac moni- documentation across care providers. One unit tors, urine collectors, and the laboratory infor- decided to continue using the electronic system mation system, allowing the data from these during the strike and held training sessions each sources to be captured automatically. To chart, morning for new nurses. Because the system is nurses check the values that have been automa- intuitive, the new nurses were able to get up to tically collected from monitoring devices and speed and maintain high-quality documentation. accept them if correct; nurses can also add explanations if they choose. In this way, nurses Measuring benefits of documentation systems. do not need to enter data; they validate it. A In addition to providing anecdotes such as these, nurse manager of the ICU hopes to continue to a few hospitals have attempted to measure and add other systems, such as ventilators. document the benefits of their automated docu- mentation systems. At Sacred Heart Medical Several institutions are using a particularly valu- Center in Eugene, Oregon, a study found that able feature of online charting that enables nurses overall nursing documentation time (excluding to carry forward notes from one assessment to medication administration) was reduced from the next. Instead of re-writing the entire assess- 24.6 percent to 18.4 percent. (From a personal ment, nurses can copy forward previous notes communication with John L Haughom, M.D., and edit them to document any changes in the Peace Health, April 2002.) A study at Forrest patient’s condition. Children’s Hospital and General Hospital also found improvements in Health System in San Diego found that this not nurse efficiency. Nurses spent three minutes less only saves time, but also establishes an individu- on the nursing admission assessment and five alized baseline for each patient against which minutes less on documenting shift assessment per changes can be measured. However, this feature shift. Nursing overtime was reduced by 1 to 1.5 must be used with caution so that mistakes do hours per shift. Other benefits cited by the study not get carried forward as well. include more rapid and effective use of allied health care referrals; enhanced documentation of patient education; elimination of redundant data entry; and safer and more efficient patient care due to the accurate and up-to-date documenta- 18 | CALIFORNIA HEALTHCARE FOUNDATION A tion of medications and allergies, anesthesia history, and past medical history. Overall, nurses were able to spend more time delivering patient “I think it’s to give clinical outcomes care instead of documenting it. [information] to the staff.” Non-acute care settings are benefiting from —Nurse Manager, mid-sized Eastern hospital nursing documentation systems as well. Aurora Health System’s 200 home care nurses use Interdisciplinary documentation.The time- laptops to document the care they provide. The savings associated with Aurora Health System’s system has resulted in both productivity enhance- clinical documentation system have been ment and increased levels of satisfaction among realized because of faster access to interdisci- the nurses. Each night, the computer uploads the plinary information. Nurses can get information documentation from the day and downloads the when they need it and can document their next day’s assignments and the associated records. activities. They can also track and trend data, Through this system, nurses avoid having to which helps them to assess the significance of the make a trip into a central office. The only draw- data without looking up additional information. back of the system is that the laptops can some- And, when calls come in from clinicians or times be awkward to use in the home; the nurses concerned family members, nurses have infor- are hoping to find a smaller, more portable mation readily available. device that provides the screen resolution they need and is affordable. The pitfall with providing greater access to infor- mation is that more information is not always Similarly, a California home care agency has better. When one organization put new monitors found great success using PDAs—the system cut in an ICU to reduce staffing, the monitors actu- paperwork for its nurses in half. As word of ally increased the need for staff because nurses the system spread, the number of employment had to spend so much time sorting through data. applications rose by 40 percent.23 The data must be presented in a way that is useful to nurses. Access to Information Collaboration on wound management. nfor- I Making timely information available to nurses mation technology can also help clinicians to supports high quality, knowledge-driven care, as collaborate on patient care. In one example, a well as efficiency. Charting systems that lack nurse informatician in Buffalo created a wound interdisciplinary documentation or integrated management program in Microsoft Access that viewing capability require nurses to spend a great provides an interface between the hospital deal of time away from the bedside—ordering information system’s basic patient information charts, calling other clinicians, looking for paper, and the patient’s Braden scores, recorded by or searching through screens online. Systems nurses to document the level of skin breakdown. with clinical documentation functionality The informatician also wrote software enabling and order-entry systems can improve nursing the program to operate on a personal digital efficiency by providing immediate online access assistant (PDA). to patient data and interdisciplinary documen- tation. As one expert put it, “Integration of information at the point of care frees up nurses from being data enterers to being data analyzers.” The Nursing Shortage: Can Technology Help? | 19 The wound management clinician uses the PDA (with updated patient and Braden score data) to see a list of patients at risk for skin breakdown, enabling proactive intervention. The program also provides reports to help the wound management clinicians, nursing adminis- trators, and quality assurance personnel work more effectively. CPOE. Alamance Regional Medical Center has found that with the Eclipsys CPOE system, orders are clear and concise, saving nurses time deciphering handwriting, calling the physician to clarify the order, or manually transcribing it into the system. Nurses also spend less time coordi- nating ancillary services and tracking down patients because the system has expedited deliv- ery of the order to the appropriate department. Organizations have found both positive and negative workflow issues for nurses as a result of having this new access to information. On the positive side, Boston Medical Center reports that nurse efficiency is improved by the increased legibility and correctness of the orders. The use of order sets in the CPOE system also supports nursing interventions. For example, if an order for patient-controlled analgesia is given, the associated requirements and nursing interven- tions are ordered automatically. On the negative side, nurses must now log on to the computer more often to monitor new or changed orders. Nurses have accommodated this change in workflow because the benefits out- weigh the drawbacks. They have less work on the back end to check orders, and they see lab values and overall trends more often as they access information in the computer. 20 | CALIFORNIA HEALTHCARE FOUNDATION III. Technology and Financial Considerations Technolog Regardless of the system that is deployed, organ- y. izations must consider underlying technologies and end user tools to make these systems work in the various patient care areas. Internet technology and mobile computing both enable access to the real-time information critical to nurses and other clinicians. At Cedars-Sinai Health System, nurses benefit from the clinical data repository, accessed by a Web-based front end. The organ- ization chose this option over the complicated (and expensive) process of replacing the existing database, and was able to gain clinician buy-in for further initiatives when they saw how the Web technology made access to information easier. Wireless local access networks also provide infrastructure to support highly mobile direct care nurses. The nursing depart- ment at Yale-New Haven Hospital found that as it promoted its initiative for a mobile nursing assessment tool, it was able to use the mobile technology already in place to support their CliniComp order entry system. Although mobile computing and Web technology have created quite a buzz in the industry, the organizations regard them as enabling technology, similar to a database backbone or an operating system. There is also much debate about the comparative strengths of different end-user devices in the areas of mobility, computing power, and screen resolution. Since no device can meet the needs of all users, bedside monitors, wall-mounted monitors, laptops on carts, tablets, and handheld devices all compete for use with these clinical applications. For example, although Maine Medical Center has had clinical systems in place for decades, they have not yet found one device for all users. The organization piloted a range of devices, including PDAs and bedside monitors. Some nurses are uncomfortable using technology in front of the patient, and others do not want anything more to carry. Today, every unit has about ten fixed devices and five to ten mobile ones, a device for every two to three patients in most units. The Nursing Shortage: Can Technology Help? | 21 Considering the needs and preferences of the end The systems identified in this research range in users is paramount. One organization made a cost from thousands to “millions and millions” large investment in placing a computer at every of dollars. At St. Peter’s Hospital in Albany, the bedside when it implemented an automated Web site on which nurses bid for shifts was documentation system, but has since found that developed in-house and was relatively inexpen- none of the clinicians are comfortable completing sive. The more extensive systems that support their documentation in front of the patient. The complex clinical processes are correspondingly investment was wasted. Overall, when choosing more expensive. However, the cost of not doing an application, organizations must also consider anything may be greater, since anecdotal evidence the technologies needed to make them work suggests that technology can attract nurses to the in the various patient care areas. profession and improve the work environment for nurses who are presently employed. Costs and benefits.The technologies examined in this research represent significant costs to A hospitals, not only for the systems themselves, but also to support the implementations. “Information technology can help transfer Because hospitals’ resources are limited, there is the rich collective wisdom from experi- an increased interest in systems that can demon- strate a return on investment. As one nursing enced nurses to the next generation. expert points out, hospital executives generally do Otherwise, our nation will have to pay not think that technology for nurses will provide a tremendous price in dollars as well a cost savings; the nursing shortage may have to get worse before they will change their minds. as lives lost to keep re-learning the same lessons the hard way.” In making technology decisions, financial con- cerns must be weighed against the benefits of —Nurse, large California hospital technology, such as increased patient safety through medication administration, improved patient care through access to information and standards, and greater efficiency for nurses through automated documentation and easier modes of communication. 22 | CALIFORNIA HEALTHCARE FOUNDATION IV. Insights from the Front Lines AS THE EXAMPLES IN THE PREVIOUS CHAPTER illustrate, technology can help to improve nurse efficiency and the hospital environment in variety of ways, but it also presents challenges. “Remember, it’s not easy,” said one hospital repre- sentative, “If it was, we all would have done it by now.” One nurse offered a first-hand account of the implementation of an automated nursing documentation system: “We thought it was agony switching to it.” Because there were no expert users to help nurses first learn how to use the system and configure it appropriately, it took three to four months to adapt to the online documentation system. During this time, there was an extra nurse on each shift to assist with the documentation. At the end of the period, however, when the system was taken down for a day for upgrades, the nurses found they hated going back to paper. Once they got used to it, the system made documentation faster and easier. Nurses could access vital signs at any time and not have to worry about missing information because it was recorded in the system. The challenges of implementation can be overcome when the right technology is selected and is implemented in as painless and professional a manner as possible with the right resources and methods of communication in place. s Address wor flow issues.If there was a workflow problem k before, it will only be heightened in an electronic environ- ment. It is crucial for organizations to optimize processes as they automate them. This provides the opportunity not only to solve problems, but also to transform clinical processes and incorporate best practices. Marrying technology and workflow is one of the biggest challenges that organizations face, and it is complicated by the fact that systems must adapt to the various models of nursing at a number of sites and times with different inter- pretations of data. One nurse offered this advice: “Our success is 25 percent software and 75 percent process. Make software fit work processes and, at the same time, change work processes to leverage software.” Similarly, Maine Medical Center has found through experience that they should spend 60 percent of their time solving workflow/ process issues to achieve successful implementations. The Nursing Shortage: Can Technology Help? | 23 s Support the staff with training and edu- s Watch for unintended consequences. everyFor cation. Learning a new system is always diffi- successful implementation cited in this report, cult. Front-line clinicians working as “super there are many instances where technology users” can be effective both to provide edu- made nurses’ jobs more difficult. One hospital cation to the staff and to give feedback on how was in the process of implementing a comput- the system is working. At Children’s Hospital erized order entry system but found that is was and Health System, San Diego, an accident not working. From one nurse’s perspective, the led to an effective way to train staff members. system created more paperwork than it saved One nurse injured her hand and was placed because there were not enough computers, and on light duty; she was recruited to work with online charting for medication administration the IS department on the implementation had not yet been implemented. Another of their documentation system and became a difficulty was that the system required several convert to the new system. She is now an screens to complete a medication order, and educator, and more effective than most because there was no screen to review the because “she lived it.” order, residents said they crossed their fingers, hoping they got it right. Knowing this, nurses s Involve all appropriate staff. Beginning with checked the orders for mistakes. Since the the decision-making process, the only way system was not providing the expected safety that organizations are going to be able to meet benefits, the implementation was suspended. their staffs’ needs and have successful implemen- tations is if clinicians have every opportunity If the system does not meet the needs of its to provide feedback and input. Open lines of users, does not realize benefits, and creates communication (with two-way mechanisms) more work than it eliminates, the imple- and interdisciplinary collaboration can help mentation should be suspended until these with the implementation process. Just as problems are resolved. It is crucial to know nurses need to be involved when physician when to persist through a difficult imple- systems go online, other clinicians need to be mentation and when to pull the plug on a involved when implementing nursing systems. system that is not working. The importance of staff involvement cannot be overemphasized. Aurora Health System’s Metro Region hospi- tals have been recognized as Magnet hospitals, or ones that do an exceptional job recruiting and retaining nurses. Although Aurora has not looked to see if there is a direct correlation between automation and nurse recruitment and retention, the two may be related. The shared governance model allows nurses to be involved in system selections, implementa- tions, and ongoing decision-making. Thus, nurses can be confident that the technology will meet their needs. 24 | CALIFORNIA HEALTHCARE FOUNDATION s Have the right technology.mplementing I change will be impossible if the technology is unfit to address the problems it was installed to solve; even the best technology will be useless without an adequate infrastructure. According to one nurse, investing in infra- structure is essential for clinical applications: “One of the reasons that nurses may not trust a new system is because it is not reliable enough to support clinical activities. The system has to work. Hospitals have historically not invested enough in hardware and network redundancy to ensure system reliability and fast response time. Once they do, nurses will trust and use systems for direct clinical care.” s Do a pilot. One nurse manager volunteers her unit to participate in pilot tests. That way she can be sure that the technology will be useful and beneficial for nurses before the hospital makes a large investment or the system is implemented on other patient care units. s Keep it simple One nurse who had been . through the implementation of a medication administration system on all 20 units at once was particularly vehement about this point. All of these pieces of advice speak to the larger issue of creating a culture of safety and support in the hospital. Technology systems are only a part of such a culture. Adequate staffing both to provide care and to support the technology is critical. As a representative from the Massachu- setts Nurses Association noted, without adequate staffing, technology may actually increase the burden on nurses—machines beep and alarms sound for all the wrong reasons, creating even more time away from patient care. The Nursing Shortage: Can Technology Help? | 25 V. Conclusions: Implications for Recruitment and Retention ALTHOUGH AUTOMATION AND THE USE OF A “Empowering nurses with the tools they need and reducing their frustration with paper- work can help to improve technology may not be directly correlated with improved recruitment and retention, it is becoming part of a comprehen- sive strategy to address nursing needs. Aurora Health System has learned through interviews that nurses come to them because of their use of technology. They have heard repeated comments expressing nurses’ satisfaction, such as “I would nursing retention and lessen never leave here,” and “I can’t imagine going back to paper.” the nursing shortage.” A human resources representative claims that there is no one —Nurse, large California hospital predominant factor that helps Cedars-Sinai Health System consistently attract nurses, but “We do have an image of being top in patient care and having the tools to support it; people come to us because of that.” Just as technology is embraced in the home and in schools, it will be increasingly important to nurses entering the field. Industry experts note that upcoming nursing graduates have come to expect a higher level of automation in their work. New nurses may be shocked when they arrive at large medical centers to find that documentation is not automated. Recruit- ment campaigns targeted at high school students are beginning to emphasize the technical aspect of nursing as well as the caring side, hoping to lure more students who are interested in careers in technology. When nursing students from Tulsa University visited St. Francis Hospital, they were shown the Patient1 system and were very excited about it. “I believe that the level and sophistication of automation here will help with our recruiting efforts,” says one nurse; “Looking at the new generation of nurses entering the profession, one can expect these clinicians to be more computer savvy. This is the way the world operates for them. Why should nursing practice be any different? We have already seen the shift start to occur here. Recently we had to show some nurses how to use a paper MAR in the event of a down- time—these nurses had never charted on paper.” 26 | CALIFORNIA HEALTHCARE FOUNDATION A “I can’t imagine pinpointing any one component of the nursing process. Either technology is integrated into the nursing process or it’s not.” —Nurse/Clinical Systems Expert, large mid-Western hospital There is no single solution or “magic bullet” technology that will immediately impact nurse recruitment and retention. The nursing process is complex, and—as the diversity of opinions expressed throughout this paper illustrates—there are many points where technology may be used to assist the nurse in patient care. With the growing adoption and advancement of technology, an increasing need for nurses, and a generation raised with computers reaching employment age, there is no better time for hospitals to explore the wide range of technology that can provide significant benefits for clinicians. This report has only scratched the surface of what is possible. There is hard work still to be done in the auto- mation of clinical processes, but the benefits, glimpsed here, may be tremendous. The Nursing Shortage: Can Technology Help? | 27 Appendix A: Interviews This report would not have been possible if the John Gama, Pharm.D. following people had not volunteered their time Pharmacy Clinical Specialist to participate in the interviews: Tri-City Medical Center Oceanside, California Eric Anderson, R.N. Brian Gugerty, D.N.S., R.N. Director of Clinical Information Systems Assistant Professor Maine Medical Center School of Nursing Portland, Maine Nursing Informatics Department Margaret F. Budnik, R.N., M.A. University of Maryland Faculty-University of Phoenix (Tulsa) Baltimore, Maryland Project Lead, Clinical Applications Karen Hughart, R.N., M.S.N. St. Francis Hospital Director of Systems Support Services Tulsa, Oklahoma Vanderbilt Medical Center Elizabeth Buff Nashville, Tennessee Vice President, Patient Care Services Lynn Jones, R.N., M.S. Medical Center at Princeton Assistant Administrator, Princeton, New Jersey Department of Gynecology and Obstetrics Janice Buhler The Johns Hopkins Hospital Director, Recruitment and Workforce Planning Baltimore, Maryland Cedars-Sinai Health System Linda Kresge Los Angeles, California Chief Nurse Executive Richard Chady Catholic Healthcare West Public Relations Spokesperson Redwood City, California Saint Peter’s Health Care Services Don Lindamood, R.N.C. Albany, New York Certified in Nursing Informatics, Kathleen Charters, Ph.D., R.N. Certified Professional Health Information Assistant Professor Management Systems School of Nursing Manager, Clinical Systems Department of Administration, Adventist Health Health Policy and Informatics Roseville, California University of Maryland Linda Travis Macomber, R.N., M.B.A. Baltimore, Maryland Clinical Informatics Analyst Marie DiFrancesco, R.N., B.S.N., M.B.A. Children’s Hospital and Health Center Lead Clinical Analyst San Diego, California Alamance Regional Medical Center Burlington, North Carolina 28 | CALIFORNIA HEALTHCARE FOUNDATION Dorothy Upson McCabe R.N., M.S., Med. Erin Popescu, R.N., M.S., C.N.O.R., C.N.A. Director, Nursing Department and Operating Room Manager Career Services Saint Joseph’s Hospital Massachusetts Nurses Association Atlanta, Georgia Canton, Massachusetts Kathy Ryan Sharon McGourn, R.N. Clinical Instructor Clinical Service Manager Medical Center at Princeton Bridgeport Hospital Princeton, New Jersey Bridgeport, Connecticut Jean Ann Seago, R.N., Ph.D. Laura Miley, R.N. Assistant Professor Director of Clinical Information Systems School of Nursing Forrest General Hospital University of California Hattiesburg, Mississippi San Francisco, California Therese Morley, Ed.D., R.N. Joanne Spetz, Ph.D. President, Association of California Assistant Adjunct Professor Nurse Leaders School of Nursing Senior Nurse Consultant University of California Kaiser Permanente San Francisco, California Pasadena, California Senator Leonard Teitelbaum Judy Murphy Maryland State Senate Director of Application Development Annapolis, Maryland Aurora Health Care Nancy Tepping Milwaukee, Wisconsin Data Systems Coordinator Lisa O’Connor Yale-New Haven Hospital Director of Nursing New Haven, Connecticut Boston Medical Center Boston, Massachusetts Barbara Odin, R.N. Nurse Manager Stanford Medical Center Palo Alto, California Jeanette Polaschek, R.N. Director of Informatics Cedars-Sinai Health System Los Angeles, California The Nursing Shortage: Can Technology Help? | 29 Appendix B: Vendor References Vendor/Product Contact Information Relevant Functionality Alaris Medical Systems* 10221 Wateridge Circle medication administration: MEDLEY Medication Safety System San Diego, CA 92121 infusion pumps with Guardrails software www.alarismed.com (800) 854-7128 Baxter International/ One Yorkdale Road, Suite 310, medication administration AUTROS Healthcare Toronto, Canada M6A 3A1 Solutions, Inc. www.autros.com; www.baxter.com (800) 537-2255 Becton, Dickinson and Company 1 Becton Drive medication administration BD Rx System Franklin Lakes, NJ 07417 www.bd.com (201) 847-6800 Bridge Medical, Inc. 120 South Sierra medication administration Medpoint Solana Beach, CA 92075 www.bridgemedical.com (858) 350-0100 Cerner Corporation 2800 Rockcreek Parkway hospital information system with Millenium Kansas City, MO 64117 clinical data repository, EMR, and www.cerner.com CPOE functionality among others (858) 221-1024 CliniComp International* 9655 Towne Center Drive computerized patient record, San Diego, CA 92121 order-entry www.clinicomp.com (800) 350-8202 Eclipsys Corporation* 777 E. Atlantic Ave., Suite 200 hospital information system with Sunrise products Delray Beach, FL 33483 automated nursing documentation, www.eclipsys.com EMR, CPOE functionality among (561) 243-1440 others GE Medical Information Systems 8200 West Tower Avenue monitoring systems, hospital infor- Milwaukee, WI 53223 mation system with automated www.gemedicalsystems.com nursing documentation, clinical data repository, order entry, clinical decision support, and messaging functionality among others IDX Systems Corporation 40 IDX Drive hospital information system with LastWord/Carecast P.O. Box 1070 automated nursing documentation, Burlington, VT 05402-1070 CPOE, clinical data repository www.idx.com functionality among others (802) 862-1022 McKesson 5995 Windward Parkway hospital information system with Horizon Clinicals Alpharetta, GA 30005 clinical documentation, clinical data www.mckesson.com repository, CPOE, and messaging (404) 338-6000 functionality among others 30 | CALIFORNIA HEALTHCARE FOUNDATION Vendor/Product Contact Information Relevant Functionality MEDITECH MEDITECH Circle hospital information system with Westwood, MA 02090 EMR, CPOE, patient education, www.meditech.com and scheduling functionality (781) 821-3000 among others Per-Se Technologies* 2840 Mt. Wilkinson Parkway computerized patient record with Patient1, Resourse1 Atlanta GA 30339 clinical documentation and medica- www.per-se.com tion management functionality (770) 444-5300 among others, staff scheduling Pyxis Corporation* 3750 Torrey View Ct. medication administration MEDSTATION system San Diego, CA 92130 www.pyxis.com (858) 480-6000 RNJobs* www.stpetershealthcare.org staff scheduling Siemens Medical Solutions 51 Valley Stream Parkway hospital information system with Health Services Corporation Malvern, PA 91355 EMR, CPOE, and medication www.smed.com administration functionality among (610) 219-6300 others Symbol Technologies, Inc. One Symbol Plaza mobile information/ Holtsville, NY 11742-1300 communications www.symbol.com (631) 738-5200 3M Health Information Systems 575 W. Murray Boulevard hospital information system with Murray, UT 84123 clinical data repository, CPOE, clinical www.3mhis.com documentation, and patient educa- (801) 265-4400 tion functionality among others VasTech, Inc.* 222 Severn Avenue, Suite 14 staff scheduling, credential tracking, Nightingale Nursing Information Annapolis MD 21403 time and attendance Systems www.vastech.net 877-7-VASTECH VisualMED Systems 391 Laurier West hospital information system with Montreal, Qc, Canada clinical data repository, EMR, and H2V 2K3 CPOE functionality among others www.vmedsys.com (888) 333-0243 The above list provides contact information for representative vendors. Vendors marked with an asterisk contributed to this report. The Nursing Shortage: Can Technology Help? | 31 Appendix C: Glossary Adverse Drug Event (ADE)—An injury result- Data—Pieces of information or commands. ing from a medical intervention relating to Database—An aggregation of records or other a drug. data that can be updated. Databases are used to Clinical Data Repository (CDR)—A central manage and archive large amounts of informa- clinical database that supports applications such tion. Also see relational database. as automated order entry/management, results Electronic Medical Record (EMR)—Generic display, and basic data entry of patient informa- term describing a computer system that auto- tion (clinical and demographic). mates the care delivery processes and stores Clinical Decision Support (CDS)—Information patient clinical data in support of inpatient care tools that support a health care provider in services (also referred to as an computerized decisions related to diagnosis, therapy, and care patient record, CPR). planning of individual patients. Error—Failure of a planned action to be com- Computerized Patient Record (CPR)—Generic pleted as intended or use of a wrong plan to term describing a computer system that auto- achieve an aim. mates the care delivery processes and stores Handheld Device—See mobile computing patient clinical data in support of inpatient care device. services (also referred to as an electronic medical record, EMR). Handheld PC—Small hand-size, personal com- puter that uses a keyboard. Computerized Physician Order Entry (CPOE)— Clinical software application designed specifically Hospital Information System (HIS)—Generic for use by physicians to write patient orders term used to describe computer systems that electronically rather than on paper. (The current support the administrative and care delivery industry focus is on inpatient CPOE, and the processes for a hospital. term generally refers to electronic ordering for Internet—An international network of com- hospitalized patients.) Although other providers puters that operates on a backbone system may enter orders, the term Computerized without a true central host computer. Physician Order Entry is most commonly used to describe inpatient order-entry systems in Local Area Network (LAN)—A group of client which the provider initiating the order enters it computers connected to a server. directly into a computer. Medication Administration Record— Data Entry—The transcription of information Documentation associated with medication from the original source into a machine-readable administration. form. Although keyboard entry is the most famil- iar, other fast-growing methods include scanners, speech recognition, and automatic device-to- system technology. 32 | CALIFORNIA HEALTHCARE FOUNDATION Mobile Computing—Any solution where the Tablet—A flat-panel laptop that uses a stylus pen application is accessed from a portable device. or touch-screen technology. Transport of data to and from the device can Web-enabled—Software programs that can be either be accomplished using wireless technolo- used directly through the World Wide Web, gies or batch-processed from docking cradles including financial and human resources applica- attached to the local area network (LAN). tions. Web enabling extends the client/server Mobile Computing Device—End-user handheld concept to the largest server in the world—the wireless computer device that displays, collects, Internet. and stores data. Web Site—A group of related files, including Network—A general term for terminals, pro- text, graphics, and hypertext links, on the cessors, and devices linked either by cable or World Wide Web. Accessed by typing its unique wireless technology. Peripherals, programs, and address, a site usually includes layers of support- applications can be shared by the network users. ing pages as well as a home page. Personal Digital Assistant (PDA)—Mobile, Wireless—Using radio frequency spectrum for handheld devices, such as Palm series and transmitting and receiving voice, data, and video Handspring Visors, that give users access to signals for communication. text-based information. Users can synchronize World Wide Web—An international group of their PDAs with a PC or network using a databases within the Internet that uses hypertext cradle device. Some models support wireless technology to access text, pictures, and other communication. multimedia with a click of a mouse. Sites on the Server—A computer on a network that manages Web usually are created in HTML, Java, or both. a specific set of network resources. A server A browser program is needed to access multi- may manage network traffic, printer use, store media aspects. files, or run remote applications. Smart Phone—Cellular phone that supports a number of data transmission capabilities includ- ing a Web browser; sends and receives faxes and emails; provides organizer functions such as a calendar and address book. Software Application—A non-customized computer program developed for sale to multiple customers. While some tailoring of the pro- gram may be possible, it is not intended to be designed for each user or organization. The Nursing Shortage: Can Technology Help? | 33 Endnotes 1. First Consulting Group. The Healthcare 10. Berens, M. “Nursing Mistakes Kill, Injure Workforce Shortage and Its Implications for Thousands: Cost-Cutting Exacts Toll on America’s Hospitals. Commissioned by Patients, Hospital Staffs.” Chicago Tribune, American Hospital Association (AHA), the September 10, 2000. 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