CNPE DRAFT POSITION STATEMENT (04-25-2011) 1
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Nurses’ Involvement With the EHR: Advocating Patient Safety 3
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Purpose:
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The purpose of this position statement is to identify the American Nurses Association’s 7
(ANA’s) position related to nurses, patient safety, and the electronic health record 8
(EHR), a health information technology receiving much local, national, and international 9
attention in public, private, and governmental organizations. This position statement 10
identifies principles and expectations addressing patient safety issues related to the 11
EHR.
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Definitions:
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EHR: The Health Information Technology for Economic and Clinical Health (HITECH) 16
Act defines an EHR to be “an electronic record of health-related information on 17
an individual that is created, gathered, managed, and consulted by authorized 18
health care clinicians and staff” (Section 13400(5). The National Alliance for 19
Health Information Technology (NAHIT) defines the EHR as follows: “An 20
electronic record of health-related information on an individual that conforms to 21
nationally recognized interoperability standards and that can be created, 22
managed, and consulted by authorized clinicians and staff across more than one 23
health care organization.”
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Implementation: Includes the initial installation and start-up of a system, and for the 26
purposes of this position statement, also includes system upgrades and 27
modifications.
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Lifecycle: All the phases of an electronic health record or information system, including 30
planning and design, development, product selection, customization, 31
implementation, evaluation, and updates and maintenance.
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Statement of ANA Position:
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It is the position of the ANA that patient safety requires that nurses must be deeply 36
involved throughout the EHR lifecycle.
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If patient care systems do not work for the nurses providing care, they do not work for 39
patients. Nurses must be involved in all stages of the healthcare information system’s 40
lifecycle (ANA, 2008). The ANA believes that certain key principles are essential to the 41
protection of patient safety as electronic health records become the primary mode of 42
data capture and information management in healthcare settings. One key principle 43
requires that end users be meaningfully involved throughout the healthcare information 44
system lifecycle. Nurses are important users of the EHR, but are not universally 45
involved in decision making related to EHR and system selection and implementation 46
2 processes.
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When key principles are not followed, the anticipated system benefits may not be 49
achieved and unintended consequences can occur that create threats to patient safety.
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To obtain the full benefits of EHRs and to protect patient safety, the key principles for 51
successful systems must be followed.
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Principles:
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Patient safety is a primary concern in healthcare. Implementation of computer 56
systems in the patient care arena has implications for patient safety.
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Safe and effective systems selection and implementation of an EHR require the 59
collaboration of computer systems experts and an interprofessional healthcare 60
team.
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The wisdom of the end user must be incorporated into all phases of the EHR 63
lifecycle to ensure successful adoption and use.
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Nurses who are knowledgeable and experienced in informatics must collaborate 66
in decision making through the entire EHR lifecycle in all sites and settings.
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Ergonomics, human factors, and usability principles are integral components of 69
EHR system design.
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The development of evidence-based clinical decision support, including prompts 72
and alerts, must be incorporated into EHR system design.
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A systematic feedback process that encourages users to report EHR problems 75
and concerns must be available, and supported by leadership.
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A system for communicating best practices across user groups must be 78
available.
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Privacy and security of patient information must be protected.
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Background:
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EHRs provide the possibility of great improvements in care management. It is especially 85
true that EHRs have the potential to support nursing’s efforts to improve patient safety 86
and quality of care, as well as nursing education, and research. EHRs also have the 87
potential to empower patients and their families to better manage their own care.
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The ECRI Institute, a not-for-profit organization, has evaluated health technology issues 90
and created an annual list of top ten health technology hazards (ECRI, 2010). Problems 91
with “data loss, system incompatibilities, and other health IT [information technology]
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3 complications” ranked fifth. Of all information technology errors, “wrong patient” was 93
the most common and most worrisome (Gardner, 2010). With these dangers in mind, 94
information systems that are developed to support patient care must use the best 95
possible information and expertise to build in components that support patient safety.
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Information system failures are most often produced when designers do not incorporate 98
the experience of end-users into the system design. Design occurs at two key points:
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initial system design by the vendor and system customization after purchase. Nurses 100
must be included in decision making at all points. Major vendors of clinical information 101
system products today include nurse informatics specialists in their design teams. This 102
strategy is essential for the development of quality EHRs to be used by nurses. It is 103
equally necessary to include nurses in the purchasing decisions. Many of the EHRs 104
purchased are customized extensively. Inadvertently, patient care risks may be created 105
during system customization. Features intended to save money or streamline 106
processes may actually impair patient care functions.
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Failure to incorporate the practical needs of end-users is the highest prediction factor 109
for failure of a new system. Even if systems operate as planned by designers, they will 110
fail if they impede the workflow of nurses and other providers in ways that impact 111
patient safety. Testing of EHRs should follow a carefully designed plan that includes 112
testing and retesting of all aspects of the system throughout the design and 113
implementation of the system. This process encompasses testing the hardware, 114
software, and system interfaces as well as evaluating the effectiveness and efficiency 115
of the educational materials and planned training program. Testing must allow all 116
anticipated end-user groups to participate and provide feedback on the strengths and 117
limitations of the system and concerns about interference with work processes.
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EHR implementation requires sufficient investment of monetary and human resources 120
to ensure a smooth, safe process. The implementation phase must include sufficient 121
training to prepare all users, including patients, in the operation of the EHR. Extra 122
caregivers must be provided during implementation so that the usual learning curve 123
does not unduly stress the staff or create safety hazards for patients. End-user 124
concerns about problems encountered with the EHR should be solicited. Those 125
concerns should drive system adjustments, additional training, or other assistance to 126
end users, with the result that users can accomplish their work safely and efficiently.
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Implementation of a new system, system updates, or system enhancements places 129
many demands on the healthcare team. Anything that distracts nurses from patient care 130
poses a threat to patient safety. Therefore, it is imperative that planners explicitly 131
address the issue of patient safety. Key areas that must be addressed are education of 132
the staff and appropriate staffing levels. Inadequate training or inadequate staffing 133
during training may delay patient care and result in errors. Strategies that can reduce 134
safety risks include:
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Provide timely, high quality training.
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4 Ensure staffing matches patient care requirements during system
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implementation.
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Increase help desk and information technology support staff during 140
implementation activities 141
Quality EHR system design should incorporate some decision support features.
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Decision support can be used to greatly improve patient safety by assisting nurses to 143
address important aspects of patient care. At the least, clinical actions known to be 144
errors or probable errors should result in a system alarm or an alert message to the 145
user that a potential problem has been detected. Certain actions are always an 146
immediate threat to patient safety and the EHR should support nurses’ attempts to 147
avoid such errors.
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Evaluation of EHRs requires an organized assessment program beginning with the 150
initial decision to purchase an information system solution through the implementation 151
process and more importantly, during ongoing use. End-users should be primary 152
participants in the testing and evaluation process. Because nurses are the largest 153
number of clinicians using EHRs, their input provides critical insights about the EHR 154
and its use.
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Recommendations:
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Include informatics nurse specialists in all phases of the EHR life cycle from 159
initial design to the reevaluation of an installed system.
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Include end-user nurses in all aspects of the institution’s EHR selection and 161
installation process, including the initial workflow analysis.
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Provide adequate system testing prior to implementation.
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Integrate nurses in the process of analyzing the effect of the EHR on clinical 164
workflow.
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Provide adequate resources for high quality pre-implementation, implementation, 166
and post-implementation training for end-users.
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Ensure technology support personnel are onsite and/or immediately available 168
during the life of the system.
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Provide back-up systems so that care and care documentation can proceed if 170
the EHR system is unavailable.
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Include error prevention and decision-support capabilities in the EHR.
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Summary:
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The federal imperative for greater implementation of EHRs has provided a strong 176
impetus for many patient care provider organizations to move toward implementation of 177
this technology. The EHR will bring many benefits to both clinicians and patients, but 178
there are risks involved in changing to paperless health records. The best way to 179
reduce the probability of patient harm from such systems is to employ key principles in 180
5 the planning, design, development, selection, implementation, evaluation, and
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maintenance of EHRs. The EHR lifecycle must include the end-user’s perspectives and 182
wisdom in system planning, design, implementation, and evaluation.
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References:
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American Nurses Association. (2008). Nursing Informatics: Scope and Standards of 187
Practice. Silver Spring, MD: Nursesbooks.org.
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ECRI. (2010). Devices: Top 10 Health Technology Hazards for 2011. Accessed on 1- 190
31-2011 from:
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https://www.ecri.org/Forms/Documents/Top_10_Health_Tech_Hazards_2011.pdf 192
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Gardner, E. (2010). Danger: EHR's can replace one set of medical errors with another.
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Health Data Management, 18 (8), 30 - 34.
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The HITECH Act. Accessed on January 28, 2011, at 197
http://www.gpo.gov/fdsys/pkg/PLAW-111publ5/pdf/PLAW-111publ5.pdf 198
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The National Alliance for Health Information Technology. (2008). The National Alliance 200
for Health Information Technology Report to the Office of the National Coordinator for 201
Health Information Technology on Defining Key Health Information Technology Terms 202
April 28, 2008.
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