Transcript PROPOSITION 1: - e

One patient, one record
Informing Healthcare Informing Nursing
Tuesday 16th November 2004
Professor Dame June Clark
Professor of Community Nursing
University of Wales Swansea
Aim: To identify…...
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Implications of Informing Healthcare for
nurses
Implications of the Single Electronic
Health Record for nurses
What nurses have to do
Next steps
Implications of Informing
Healthcare for nurses
Informing Healthcare is not just
about the ICT elements of
Improving Health in Wales. It has a
fundamental role in facilitating the
whole range of structural and
process changes that are required
to deliver a modern NHS in Wales
IHC para 3.23
Informing Healthcare is a strategy
to support change. It is not a
technology strategy. Simply
purchasing new ICT facilities will
not solve our problems. We need to
integrate new technology with a
strategy that addresses new ways of
working, the requirement for new
skills and behaviours for staff and
patients and clarify about how new
information will be used
The implementation of Informing
Healthcare will involve significant
changes for the workforce, both in
developing new skills and in finding
new ways of working. The
exploitation of high quality
information is likely to become
more central to clinical culture and
to consultations with patients
Chapter 7: Summary
The modernisation of information
systems is necessary, but it will not
bring benefits unless it is properly
integrated with changes to current
working practices across the whole
health economy, which must be led
by health professionals themselves
IHC para 9.2
The most commonly cited cause of
technology related project failure is
failure to prepare the ground in an
organisation before implementing
the change process and introducing
new technology
IHC para 5.30
Implications for nurses:
Core messages
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The status quo is not an option, but
nurses must own the change and believe
in what they are doing
IHC involves radical changes in our ways
of working, and in some of our
traditional ideas about nursing
Technology is not the whole story: a
computer is just a sophisticated pen -you
still have to decide what to write
Changes to traditional ideas
about nursing
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2 ways of looking at nursing:
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nursing as “doing”
nursing as “deciding, then doing”
core of professional practice is clinical
decision making
“No man’s decision is better than his
information” (Paul Getty)
So nurses have to be able to…..
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Get information
Appraise it
Use it in their practice (evidence based
practice)
Transmit it to others (documentation)
This changes our whole
approach to documentation
Update use of the nursing process
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From
Assessment
Planning
Implementation
Evaluation
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To
Assessment
Diagnosis
Outcome
identification
Planning
Implementation
Evaluation
In short a new approach to record
keeping is needed in Wales because
the current system is simply no
longer appropriate to support
current and developing models of
healthcare and inconsistent with a
commitment to high quality and
responsive patient care.
IHC para 6.5
Implications for nurses of the
Single Electronic Health Record
Single Integrated Electronic Health Record
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A structured set of information about an
individual’s health and care status and encounters
across all healthcare sectors and settings
Accessible from a wide variety of locations
Organised to support continuing efficient quality
care across the complete patient journey
Protected by secure access to ensure that access is
on a “need” basis
Added to by both health professionals and patients
themselves
A replacement for existing paper records, including
use as a medico-legal document
The electronic patient record
“Health professionals will need
to reach agreement on the
structure, terminology,
communications and access
standards necessary”
Better Information Better Health para 44
Implications for nursing
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The status quo is not an option
Requires radically changed approach to
nursing documentation
Opportunity to make make nursing
visible: to demonstrate the difference that
nurses make
Accelerates what we should have been
doing anyway
How electronic records differ
from paper records
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Only put in what someone wants out
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clinical care
aggregated data
No more long narratives
Collect once, use many times for multiple
purposes
You can’t computerise chaos
Requirements for electronic
patient records
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Agreed data set
Architecture that enables concepts to be
located and linked
Standardised terminologies that include
concepts used by patients, doctors,
nurses, other health professionals, drugs,
equipment, etc
Supports data entry, retrieval and
analysis of data
Dispelling some myths
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Standardising nursing documentation is
not standardising nursing practice
Standardised terminology is not new - we
do it already
We already use different language for
different purposes
Standardised terminology
“There are thousands of LEGO elements
and knowing their proper names helps
you to organise and use them more
efficiently. When you create a naming
system for something to help you stay
organised, you are creating a
nomenclature. Learn the LEGO
nomenclature and build on!”
We use different languages for
different purposes
Informal
Formal
Clinical
Clinical
care
record
Local National
audit
Planning
statistics
(Adapted from Hoy 1995)
Standardisation is necessary to:
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Communicate with other people (Humpty Dumpty)
Aggregate data
Compare like with like
Save time
Structure is necessary to:
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Ensure all the elements are there (all
disciplines):
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what’s wrong (diagnosis)
what to do about it (intervention)
did it work (outcome)
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Link the elements
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Know where to look to get them out
The Interaction of Diagnoses, Interventions and Outcomes
Intervention
Problem/
Diagnosis
Outcome
25
So, what do we have to do?
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Recognise that nursing is decision
making, and therefore the significance of
nursing documentation
Update the use of the nursing process to
include nursing diagnosis
Get information management (IM) skills
Get basic IT skills
Next steps
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Review existing (paper) documentation
Learn to use the the language
(SNOMED-CT)
Get access to computers
Get basic IT skills
Help is at hand
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Informing Healthcare (Stakeholder
engagement programme)
ECDL
All-Wales e-health group for nurses
Which kind are you?
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Those who make things happen
Those who watch things happening
Those who wake up too late and wonder
what has happened