Nurses are assuming greater roles in defining and implementing electronic medical record (EMR) systems, such as an ongoing project at Mountain States Health Alliance (MSHA), an integrated healthcare delivery system composed of 11 hospitals with 1,462 beds, including 21 primary/preventive care centers and 13 outpatient care sites.

When the decision was made to move from paper to EMR in 2001, "caregivers were involved in working to optimize complete and effective communication by hardwiring safety and service excellence into the system functionality to allow us to constantly improve our patient care-giving ability," says Kathryn Wilhoit, vice president and chief nursing executive of MSHA.

In the MSHA health system, all 5,000-plus employees, whether clinical, administrative, or housekeeping are considered "caregivers," and personnel from multiple disciplines were involved in the selection and implementation of an improved information technology (IT) system. This participation "made a difference in our change management process when we deployed the new system, and a byproduct of this was that we had a balanced approach to hardware and software build and process redesign," says Wilhoit.

Wilhoit co-chaired the project and oversaw the electronic health record (EHR) rollout, a role typically played by a physician. And in keeping with MSHA's "culture of caring," 32 other registered nurse (RNs) served on the vendor selection committee, including nurses involved in direct patient care and RN clinical system analysts experienced in information systems (IS) applications. "Nurses were paired with IT partners and worked together to design specific parts of our project, says Wilhoit. Workflow mapping was especially important she says.     

In the vendor selection, close attention was paid to infectious disease issues and potential hardware contamination, logistics of patient care delivery, and patient-provider or doctor-nurse communication. Nurse opinion was a major factor in switching from  a "best-of-breed" preference  to choosing a fully integrated, Web-based product.

After the lengthy vendor selection process, MSHA selected Siemens Medical Solutions to implement its clinical and financial information system and "MAK," a bar-coded medication management system.

"Project: SAFETYfirst" as it is called, is currently halfway through the rollout process," says Wilhoit. When fully implemented, it will provide online medical records and electronic clinical documentation for all MSHA patients in the Johnson-City, Tenn., area. The MAK system, integral to SAFETYfirst, was implemented first, and provides a triple check in medication administration, with bar codes on medications, patient wristbands, and nurse badges ensuring correct dosage, time, and recipient, thus reducing medication errors. Customized reports can be generated for nurse managers.

An assisted charting system and computerized physician order entry (CPOE) are next in the deployment queue. The "high risk, high reward" project did encounter resistance, but involving caregivers early in the design helped mitigate problems, according to Wilhoit.

The lessons learned were numerous and ranged from establishing "super users" as resource experts for on-site training to allowing downtime for culmination and assimilation of new skills and constantly redefining workflow. MSHA also created assessment tools to measure areas of change readiness, including level of support and commitment for the project, personal adaptation and communication methods. Pre-implementation baseline readiness measures were taken and metrics continue to analyze staff readiness for change and adoption.

"Our shared leadership council brought in groups of experts from all across the frontline at Mountain State Alliance. We have disciplines such as nursing, physical therapy, dietary, medical records, and respiratory therapy as well as finance at the table. That's a lot of worker bees coming from the frontline and all disciplines are involved at the appropriate time. It's important to involve stakeholders and involve them if necessary," says Wilhoit.

MSHA's "shared leadership philosophy" and the key role of the RN may become a commonplace model in the acquisition, implementation, and evaluation of IT systems. Just this month, the American Organization of Nurse Executives (AONE) gathered for a session to create guiding principles and identify the concrete actions that a chief nursing officer (CNO) should be prepared to take when helping to implement health information technology (HIT) systems.

"The CNO will have a more robust role in IT projects in the future," says Gail Latimer, CNO for Siemens, who participated in the AONE workgroup.

"I'm hearing from nurses across the country that EMRs are too time-consuming, especially during a shortage. They're supposed to be helping nurses, but nurses are saying there are redundancies and not enough stations for recording info, etc.," says Diana Mason, the editor-in-chief of American Journal of Nursing (AJN), the largest and oldest nursing trade journal. "That says it's not a well-designed system. The last thing we need is computer information systems that take more time. Nurses need to be at the table when selecting vendors; they need to be involved at all levels every step of the way."

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