Leveraging Nursing Information Technology To Improve NDNQI Outcomes And Achieve Meaningful Use Goals

Purpose:
Two pronged approach of implementing an evidenced based, outcome oriented electronic clinical documentation system which would meet the meaningful use and NDNQI (Fall and Pressure Ulcer) nursing sensitive indicator reporting requirements.

Significance:
Meaningful use reporting covers data elements directly related to the positive impact of evidence based nursing care. Comprehensive EHR documentation meets ARRA and NDNQI reporting requirements;it also improves the communication and involvement of professionals such as nutrition,wound specialists.

Strategy and Implementation:
An enterprise (3 hospitals) wide team of informatics nurses and IT professionals identified gaps in the existing electronic and hard copy medical record systems. Based upon those findings, informatics nurses engaged a myriad of professionals such as nutrition, wound and infection control, risk management to name a few to assist in the EHR content build. Evidence based practice tools were incorporated. These same professionals would be on the receiving end of “auto notices” based upon ongoing nursing assessments such as patients who are pressure ulcer vulnerable. The enhanced, real time electronic communication with expanded data fields met both Meaningful Use and NDNQI reporting requirements. In addition to building EHR content, the group also engaged in workflow process changes. The 100 bed community hospital partner in the enterprise served as the pilot for the new “Care Doc” system. The academic medical centers then followed with their implementation in the ensuing months

Evaluation:
Effective and consistent communication amongst all professional caregivers was the immediate success of the EHR which will ultimately contribute to positive patient outcomes. Data reporting for Meaningful Use requirements and NDNQI was now standardized and easily monitored.

Implications for Practice:
Standardized, evidence based practice was reinforced and directed by the EHR content build. Workflow sensitive tools that impact safety,quality and clinician and patient satisfaction will be consistently addressed.