There is increasing concern about EHR systems

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1 FEATURE: WORKFLOW Workflow Viewpoits Aalysis of Nursig Workflow Documetatio i the Electroic Health Record Lua Whitteburg, RN, FNP Keywords Workflow, electroic health record, ursig, cocept aalysis. Abstract This article amplifies the emphasis o orgaizatioal workflow reigited by the Istitute of Medicie reports o healthcare quality. The aalysis of ursig workflow is cetral to uderstadig the power of techology to modify the fudametal costructs of ursig practice. The aim is to uderstad the evolutio of ursig workflow ad the cocept of workflow from the maagemet ad computer sciece perspectives used i electroic health records ad computerized provider order etry. The uderstadig of the workflow models withi health iformatio disciplies may improve the model of ursig workflow uderlyig the implemetatio of electroic health record systems. The article follows the Walker ad Avat evolutioary method of cocept aalysis. 19 There is icreasig cocer about EHR systems streamliig the ursig process. The perceptio is that the EHR has a propesity to overlook the data ad cotributio of ursig care to patiet healthcare outcomes. This cocer origiates from the clear absece of a objective method i electroic health record systems to collect structured, coded ursig data to aalyze the beefit of the ursig process: assessmet, diagosis, outcome idetificatio, plaig, implemetatio ad evaluatio. A examiatio of ursig workflow may provide a uderstadig of the urses workflow ad cotributios. This article reports o the backgroud of the coceptual developmet for the cocept of ursig workflow as urses carry out patiet care i a acute care settig usig the EHR. NURSING THEORY IN HEALTHCARE TECHNOLOGY Nursig iformatics is a relatively youg specialty 2,8 with precedig research focused o problem-drive studies such as electroic health record implemetatios; the professioal orgaizatio of ursig iformatics as a ursig specialty; ad ursig termiology i preferece to research o cocept developmet about ursig workflow i relatio to techology. volume 24 / umber 3 SUMMER 2010 jhim 71

2 Early health iformatio systems represeted a workflow perspective differet from the traditioal ursig workflow. Today, health iformatio systems are compellig ew ursig competecies ad iovative ursig workflow strategies to accommodate the protea electroic health record systems istalled i may healthcare facilities. If the objective of ursig iformatics is to improve ursig practice through the use of techology, the ursig workflow must be established to guide the coditios for techology trasformatio ad provide the appropriate costraits. While the term workflow is a uiversal cocept applicable to multiple disciplies, this article used the Walker & Avat 19 cocept developmet framework to guide the review of the literature ad idetify the atecedets ad cosequeces of ursig workflow alog with empirical referets ad opportuities for further research. BACKGROUND From ay eviromet, at a basic level, a workflow represets a sequece of activities. At a practical level, workflow allows the assessmet of activity i cotext ad the review of a sequece of work; such as all the urse s activities related to patiet care o a give day o a give uit. At a greater level of abstractio, workflow is a patter of processes for iformatio processig. I the early 1920s, F.W. Taylor ad H. Gatt were itellectual leaders ad pioeers of cocept of workflow, with the Gatt Chart established as the icoic stadard for the visual represetatio of workflow processes. Others participated i the developmet of cocepts ivolvig iformatio workflows icludig M. Dewey of the Dewey Decimal System. 20 However, the classic 1956 book o workflow was The Orgaizatio Ma by William H. Whyte. The 1920s to 1960s were the peak periods of workflow formulatio. By the 1980s, the cocept of workflow was beig dismissed by Abraham Maslow, who developed the Hierarchy of Needs theory ad gaied wide acceptace i ursig schools as the key theory of the coceptualizatio of huma eeds. 3 I the 1990s, the emphasis o orgaizatioal workflow was reigited by the Istitute of Medicie reports o healthcare quality: To Err is Huma 11 ; Crossig the Quality Chasm. 12 This period, , experieced the emergece of Total Quality Maagemet ad Six Sigma, ad witessed the evolutio of Busiess Process Reegieerig. The bright spot i the emphasis o quality was that workflow agai became the focus of maagemet ad researcher surveillace. TRADITIONAL NURSING WORKFLOW The historical perspective of ursig workflow is as a cliical sequece of work focused o patiet status, ursig itervetios performed ad the patiet s respose. I the traditioal view of ursig workflow, the urse would perform activities to detect chages i the patiet s coditio. Aother example of traditioal ursig workflow would be the work to observe a patiet s coditio; e.g., o chage i size or coditio of a right foot pressure ulcer or observace of a patiet s or family member s respose to teachig. I geeral, iformaticias accept that iformatio, whe give meaig through iterpretatio, becomes kowledge. Maagemet ad computer sciece colleagues focusig o the impact of computers i their disciplies have bee preparig studets for successful workig relatioships with computerized iformatio systems for decades. 18 Maagemet views computers as supportig the accomplishmet of maagemet objectives ad supports the treds i iformatio processig that ecourage decetralizig data for example, iphoe applicatios ad social etworkig by employees. Early health iformatio systems represeted a workflow perspective differet from the traditioal ursig workflow. Today, health iformatio systems are compellig ew ursig competecies ad iovative ursig workflow strategies to accommodate the protea electroic health record systems istalled i may healthcare facilities. Gibbos ad Smith 7 report maagemet results derive from the workflow of the team, while computer sciece defies workflow as the schedulig of idepedet jobs o a computer ad the set of relatioships betwee all the activities i a project, from start to fiish. 6 I this disciplie, the commo refrai is that data is less tha iformatio; iformatio is less tha kowledge; ad iformatio processig should be isolated from workflow. As derived from past experiece, the statemets accurately reflect the data coditios i today s healthcare iformatio systems. However, the purpose of collectig data, iformatio ad kowledge is to be able to make wise decisios (e.g., create wisdom), ad if data sources are flawed; meaig that if data is collected i isolatio from workflow, the oe might reaso that maagemet decisios based o a classic computer sciece model ad iterpretatio of the established stadard iformatio workflows will be flawed. The et effect of a isolated workflow model must be surmised to have trasformed the data collectio processes i healthcare ad ursig i particular. Nursig data collectio is more tha discrete facts stored i a relatioal database. Nurses reply o the data for patiet care plaig. Nurses trasform the data withi electroic health systems by judgmet ito meaigful iformatio. While the iformatio by itself does ot ifer kowledge the cogitive ad aalytical ability of the urse places EHR data ad iformatio, i the cotext of the ursig workflow; ad demostrates that iformatio processig for patiet care delivery should ot be isolated from workflow for the cofidet delivery of healthcare quality. 72 jhim SUMMER 2010 volume 24 / Number 3

3 METHODOLOGY As metioed, the methodology used i this aalysis is the Walker ad Avat cocept aalysis method. 19 The geeral fidigs of the literature are that workflow articles were typically associated with specific problems such as patiet safety, medicatio admiistratio, specific ursig uits or specific departmets such as the emergecy departmet. A review of the computer sciece literature through the Applied Sciece ad Techology Abstracts database, which has abstracts ad periodicals from 1983 to preset i egieerig, aeroautics, chemistry, computer techology ad applicatios, earth scieces, eergy ad eviromet, mathematics, metallurgy ad physics, idetified 805 articles usig the term workflow primarily related to iformatio messagig schemas. Clarificatio of the cocept was accomplished by aalyzig the commo use of the cocept through the way i which the cocept was expressed. 16 The literature icluded articles over a 29-year spa, from 1970 to 2009, that is especially relevat to the evolutioary method of aalyzig a cocept over time. The articles selected from the multidiscipliary databases were based o relevace ad pertiece to the cocept of ursig workflow i the electroic health record. The literature was idetified by a combiatio of title, abstract ad key word searches usig the terms: ursig workflow, electroic health record, workflow, electroic health record, electroic medical record, CPOE ad other terms combiatios developed for use with the presetatio egie at the time of the search. Over the course of this article, more tha 105 articles from three key disciplies ursig, icludig social sciece, maagemet sciece ad computer sciece were selected for the evolutioary cocept aalysis. Refereces with similar cocept cotet were orgaized through a process of comparable aalysis. A theme idetified durig the literature review was that workflow aalysis has ofte bee researched with the goal of improvig efficiecy. A classic study was the observatio of routie tasks performed by the operatig room (OR) team by Ceda ad Good. 4 CONCEPTUAL DEFINITIONS Workflow: 1. A process descriptio of how tasks are doe, by whom, i what order ad how quickly. Workflow ca be used i the cotext of electroic systems or people, i.e. a electroic workflow system ca help automate a physicia s persoal workflow The set of relatioships betwee all the activities i a project, from start to fiish. Activities are related by differet types of trigger relatio. Activities may be triggered by exteral evets or by other activities Workflow is defied activities delivered by urses to the provider, patiet or orgaizatio, regardless of techology The movemet of documets aroud a orgaizatio for purposes icludig sig-off ad evaluatio. 14 DEFINING THE ATTRIBUTES The defiitios of the essetial attributes idetified through the literature are listed below: Work items. Represetatio of work to be processed i the cotext of a activity i a workflow istace. 10 Documetatio. Nursig data collected as discrete facts, stored i a relatioal database, processed, ad trasformed ito meaigful iformatio. 17 Practitioer orders. Practitioer istructios, writte or oral, for the treatmet of a patiet s medical care. ANTECEDENTS AND CONSEQUENCES The atecedets ad cosequetial occurreces for the cocept of ursig workflow are: Atecedet occurreces: Patiet eed. Cosequetial occurreces: Applicatio of the America Nurses Associatio (ANA) Nursig Process, actor self-efficacy ad care delivery. ASSUMPTIONS Otological assumptio: Huma iteractio is a edless process of the fusios of horizos. 15 Epistemological assumptio: Kowledge ad uderstadig of huma existece is by uderstadig how a problem egages the preset. 1 CASES Model case. Hospitals ad other healthcare orgaizatios are istallig electroic health records mobile statios called Computers-o-Wheels (COW), which support the ursig workflow 24/7 with electroic access to patiet iformatio. COWs perform as persoal computers, despite beig shared amog a team of urses, ad streamlie the daily patiet care task for urses who eed patiet iformatio readily available. The demad for the right iformatio at the right time for the right patiet at the bedside is the COW strategy that achieves efficiecies i patiet care. The ursig workflow with COWs, give greater access to iformatio, traslates ito greater patiet safety i high volume areas (e.g., electroic medical admiistratio). For example, the urse wheels the COW to patiet s door ad prior to dispesig iitiates a electroic audit of the patiet s medicatio schedule, dose, ad allergies. I aother example, a urse assesses a patiet after admiisterig pai medicatio. The patiet reports less pai ad while i the room the urse coducts aother assessmet. With the mobile electroic health record, COWs, the urse is able to coordiate with the patiet s care pla ad icorporate ursig itervetios ad assessmets from the EHR, as well as ay data from the patiet, at the bedside istead of goig to a computer at the urses statio. This is the beefit of the COWs; the ability to adapt to the urses workflow ad support the availability of electroic iformatio at the bedside. As a model case COWs is a o-disruptive ursig workflow techology. Borderlie Case I a borderlie care, computerized provider order etry (CPOE) is EHR software istalled usig a compoet model. I CPOE, ursig workflow must adapt to the capabilities of the electroic health record. A immobile CPOE offers less data at the bedside volume 24 / umber 3 SUMMER 2010 jhim 73

4 ad o every day, of ay shift, the CPOE has a fixed locatio ofte remote to the patiet s locatio of care. CPOE is a borderlie case sice a majority of direct care by urses i.e., vital sig moitorig, iput ad output, performig patiet Activities of Daily Livig (ADL) requires urses to be tethered to the ursig statio computer termial. CPOE is effective for specific workflow tasks such as laboratory order messagig; however, the electroic ursig workflow is ot completely supported by the CPOE electroic health record applicatio. Cotrary Case The cotrary case is the complete opposite of the cocept beig defied ad ca clearly show what the cocept is ot. 19 The traditioal workflow sceario is a cotrary case because the attributes show i the ursig workflow model case are missig. The traditioal perspective of ursig workflow is a sequetial accout of the patiet s care, ursig itervetios performed, ad the patiet s respose. I the traditioal view, ursig would typically idetify workflow as activities performed to care for a patiet s coditio such as progressio, regressio or the developmet of ew problem; for example, ambulatig for three miutes ad feelig tired or the workflow icluded i providig treatmet or medicatio ad the ursig activities to assess the patiet eed, perform the ursig actio, teach the patiet or family ad maage ay subsequet ursig itervetio that cotribute to the urses traditioal ursig workflow. The cotrary case of ursig workflow documetatio reflects ad describes the iability or missed opportuity of the urse to use the EHR. The urse cotiues to work i the traditioal maer. The urse coducts all care processes i the traditioal maer durig the ursig shift ad provides all care ad iteractios without the beefit of techology icludig the Electroic Health Record. Therefore, ursig workflow tasks are maaged i the traditioal maer without electroic support for the followig: a.) preparig patiets for respiratory support such as oxyge, IVs, laboratory orders, ad documetatio of patiet status ad symptoms; b.) performig vital sigs; c.) providig medicatio; ad d.) moitorig ay adverse effects of therapies ad medical regimes. 17 IMPLICATIONS FOR NURSING PRACTICE AND EDUCATION The advatage of cocept aalysis is that it reders very precise theoretical as well as operatioal defiitios for use i theory ad research. 19 The aalysis of the ursig workflow cocept is to better uderstad the essetial compoets of ursig care for the electroic medical record to allow urses to demostrate their cotributio to patiet healthcare outcomes as effective advocates for patiets. The aalysis of the ursig workflow cocept is to better uderstad the essetial compoets of ursig care for the electroic medical record to allow urses to demostrate their cotributio to patiet healthcare outcomes as effective advocates for patiets. Nursig iformatics research o the ursig workflow cocept supports the developmet of electroic health record data systems to collect ad record the sigificat care kowledge ad wisdom of urses with stadard, coded ursig termiology. CONCLUSION Nursig workflow documetatio is a fuctioal ad essetial compoet of ursig practice. This paper is a iitial cocept aalysis o the ursig workflow i relatioship to the electroic health record system to provide a basis for further research ito the impact of the electroic health record o ursig processes ad to iform ursig educatio. Nursig workflow is patietcetered ad must be supported by electroic health record. While, i geeral the cocept of workflow is o-ursig-specific, health data is uique i that much of the iformatio ad kowledge is patiet rather tha disciplie-related. While ursig cosiders the trasformative affects of ew techology ad examies the iterdepedece betwee the electroic health record ad ursig practice, the cotiuatio of ursig iformatics research i this area is critical to haressig ew health iformatio techology to support ursig care. JHIM Lua Whitteburg, RN, FNP, received a MSN from Marymout Uiversity. She is Board Certified as a Nurse Practitioer i Family Practice ad Nursig Iformatics. She is a PhD cadidate at George Maso Uiversity ad Chief Nursig Iformatics Officer with Medicomp Systems, Ic. i Chatilly, VA. 74 jhim SUMMER 2010 volume 24 / Number 3

5 Refereces 1. Alle D. Hermeeutics: Philosophical traditios ad ursig practice research. Nursig Sciece Quarterly. 8(4): America Nurses Associatio. Scope of practice for ursig iformatics. Washigto DC: America Nurses Publishig Barker PJ, Reyolds W, Ward T. The proper focus of ursig: A critique of the carig ideology. Iteratioal Joural of Nursig Studies. 32(4): Ceda JC, Good M. Iterdiscipliary workflow assessmet ad redesig decreases operatig room turover time ad allows for additioal caseload. Archives of Surgery. 141(1): Davis MW, Dykes PC, Keedy R, Fitzmaurice JM, Rallis MC, Whitteburg L, et al. HIMSS dictioary of healthcare iformatio techology terms, acroyms ad orgaizatios. Chicago: HIMSS Dussart A, Coseil R, Beoit AA, Paltry M. A evaluatio of iterorgaizatioal workflow modelig formalisms. Joural of Database Maagemet. 15(2): Gibbos L, Smith JW. Orgaizatio of busiess: A summary of progress i the COMATOSE (COmputerized MAagemet TOols ad SErvices) program. Joural of Data Quarterly Review. 3(3): Graves J, Corcora S. The study of ursig iformatics. Joural of Nursig Scholarship. 21: HIMSS Nursig Iformatics Task Force. A emergig giat: Nursig iformatics. Nursig Maagemet. 11(3): Holligsworth D. The workflow referece model. The Workflow Maagemet Coalitio Specificatio. 1(1): Istitute of Medicie. To Err is huma: Buildig a safer health system. Washigto, DC: Natioal Academy Press Istitute of Medicie. Crossig the quality chasm: A ew health system for the 21st cetury. Washigto, DC: Natioal Academy Press Istitute of Medicie. Keepig Patiets Safe. Washigto, DC: Natioal Academy Press Jooste S, Purao S. A rigorous approach for mappig workflows to objectorieted IS models. Joural of Database Maagemet. 13(4): Mueller-Vollmer K. (Ed.). The hermeeutics reader. New York: The Cotiuum Publishig Compay Rodgers BL, Kafl KA. Cocept developmet i ursig: Foudatios, techiques ad applicatios (2d ed.). Philadelphia: Sauders Saba VK. Cliical Care Classificatio (CCC) System maual: A Guide to Nursig Documetatio. New York: Spriger Publishig Saders DH. Computers ad Maagemet. New York: McGraw-Hill Walker LO, Avat KC. Strategies for theory costructio i ursig (4th ed.). Upper Saddle River, NJ: Pearso Pretice Hall Weiberger D. Everythig is miscellaeous: the power of the ew digital disorder. New York: Hery Holt ad Compay Whyte WH. (1956). Orgaizatio Ma. Philadelphia: Uiversity of Pesylvaia Press volume 24 / umber 3 SUMMER 2010 jhim 75

Nurses have an extremely important healthcare

Nurses have an extremely important healthcare FEATURE: NURSING INFORMATICS Nursig Termiology Documetatio of Quality Ooutcomes By LuA Whitteburg, RN, FNP Keywords Quality, iformatio systems, ursig termiology, atomic data, structured data, coded data,