One patient, one record Professor Dame June Clark Professor of Community Nursing University of Wales Swansea Informing Healthcare Informing Nursing Tuesday 16th November 2004

Aim: To identify…... l Implications of Informing Healthcare for nurses l Implications of the Single Electronic Health Record for nurses l What nurses have to do l 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 l The status quo is not an option, but nurses must own the change and believe in what they are doing l IHC involves radical changes in our ways of working, and in some of our traditional ideas about nursing l 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 l 2 ways of looking at nursing: l nursing as “doing” l nursing as “deciding, then doing” l core of professional practice is clinical decision making l “No man’s decision is better than his information” (Paul Getty)

So nurses have to be able to….. l Get information l Appraise it l Use it in their practice (evidence based practice) l Transmit it to others (documentation) This changes our whole approach to documentation

Update use of the nursing process From l Assessment l Planning l Implementation l Evaluation To l Assessment l Diagnosis l Outcome identification l Planning l Implementation l 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 l A structured set of information about an individual’s health and care status and encounters across all healthcare sectors and settings l Accessible from a wide variety of locations l Organised to support continuing efficient quality care across the complete patient journey l Protected by secure access to ensure that access is on a “need” basis l Added to by both health professionals and patients themselves l 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 l The status quo is not an option l Requires radically changed approach to nursing documentation l Opportunity to make make nursing visible: to demonstrate the difference that nurses make l Accelerates what we should have been doing anyway

How electronic records differ from paper records l Only put in what someone wants out l clinical care l aggregated data l No more long narratives l Collect once, use many times for multiple purposes l You can’t computerise chaos

Requirements for electronic patient records l Agreed data set l Architecture that enables concepts to be located and linked l Standardised terminologies that include concepts used by patients, doctors, nurses, other health professionals, drugs, equipment, etc l Supports data entry, retrieval and analysis of data

Dispelling some myths l Standardising nursing documentation is not standardising nursing practice l Standardised terminology is not new - we do it already l 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 ClinicalClinicalLocalNationalPlanning carerecordauditstatistics (Adapted from Hoy 1995)

Standardisation is necessary to: l Communicate with other people (Humpty Dumpty) l Aggregate data l Compare like with like l Save time

Structure is necessary to: l Ensure all the elements are there (all disciplines): l what’s wrong (diagnosis) l what to do about it (intervention) l did it work (outcome) l Link the elements l Know where to look to get them out

25 Intervention Problem/ Diagnosis Outcome The Interaction of Diagnoses, Interventions and Outcomes

So, what do we have to do? l Recognise that nursing is decision making, and therefore the significance of nursing documentation l Update the use of the nursing process to include nursing diagnosis l Get information management (IM) skills l Get basic IT skills

Next steps l Review existing (paper) documentation l Learn to use the the language (SNOMED-CT) l Get access to computers l Get basic IT skills

Help is at hand l Informing Healthcare (Stakeholder engagement programme) l ECDL l All-Wales e-health group for nurses

Which kind are you? l Those who make things happen l Those who watch things happening l Those who wake up too late and wonder what has happened