Applying the Concepts and Process of Meaningful Use to the Electronic Health Record

Purpose:
The proposed changes and impact on health care as a result of the continued roll-out of the HITECH (Health Information Technology for Economic and Clinical Health)Act will be described, along with lessons learned from implementation of an electronic nursing documentation system (eChart).

Significance:
Nursing leaders recognize the value of information technology and how it can be leveraged to support the achievement of maximizing efficiencies in healthcare processes and to achieve positive clinical outcomes. As "meaningful use" evolves, we are pivotal in shaping strategies for implementation.

Strategy and Implementation:
From the inception of the nursing documentation record (eChart), UNC Hospitals Nursing organization has utilized a Clinical Design and Implementation Committee (CDIC) to strategize change, shape educational efforts, and evaluate changes/improvements to the eChart system. The committee is comprised of members from the Information Systems Department and Nursing at both the staff and leadership levels. This committee meets monthly and provides ongoing feedback on the system and is intricately involved in designing changes. As ARRA is focused on outcome measures going forward, we are exploring how to organize our systems so that data can be abstracted to accurately measure these outcomes and meet the goals of ARRA. As a beginning, we are working on standardizing nursing documentation in order to perform eclectronic audits as much as possible. A subcommittee is meeting to formalize documentation. While our policies address what to document, we need to be clearer on where to document.

Evaluation:
CDIC has been extremely effective in using staff feedback to design and implement eChart. However, we are now working to establish tighter guidelines in documentation to facilitate electronic auditing and improved accountability. And we are modifying our systems to meet ARRA requirements.

Implications for Practice:
For those implementing electronic documentation, proceed from a framework of knowing what you want out of the record in advance. This will help you design fields and interfaces more efficiently (and avoid rework). Utilize staff feedback on an ongoing basis and communicate clearly and often!!