"We are a community hospital so we don't own most of our medical staff. And being community-based, we had to come up with a different strategy [for CPOE]. We thought that if all of our nurses became experts in the system first, then they would support the medical staff," Fleming says. "Nursing really has provided a great deal of support for medicine."
Empowering nurses in this way has also led to innovation, particularly in the design arena. Involving the end user in design is critical, she says. "People make the assumption that [if] you're electronic, you're automatically safer. That is not true." Poor design leads to as many or more errors as existed in a paper world, except that in the digital world "the errors happen faster," she says.
"The nurses and department coordinators will come up with things that nobody else has thought of," she says.
Jennifer Torosian, RN, MSN, NE-BC, administrative director of nursing services at CMC, agrees that there's a huge benefit to giving nurses that kind of responsibility. At CMC, when nurses have a concern, they don't hesitate to take it to the administration, in part because "they really believe we're going to do something about it," she says.
In some cases, the hospital was doing the right thing—such as removing catheters on time—but just wasn't proving it. Data helped there, too.
"We're pulling from the Foley insertion date. We need to work with nursing and make sure the nurses know how important it is to document the date," Torosian says.
Now the organization can run a report to calculate catheter days with an insertion date and a removal date. "I can go on at any time and print out and see how many patients in-house have catheters, the date they were inserted, and the date they were removed. And I can also see if one of the nurses hasn't documented an insertion date and work with the nurses to give them the feedback and the education that this is really important," Torosian says.
"It's definitely giving us a good starting point. We're able to give fairly close to real-time feedback. It's just a matter of figuring out who's going to monitor those reports," she says. "It's great that you have all these reports, [but] who validates? How are you going to validate the data, and who's going to monitor it and run the reports? I think we've done a great job in empowering the department coordinators to do that."
"We have seen a significant decrease in the number of missing insertion dates. Previously, on any given day we would have on average six patients on the report with no insertion date; we are down to an average of two," Torosian says.
Nurses are also doing a better job completing patient profiles. A year ago there could be 15 incomplete patient profiles in one month. That number steadily declined over the year—and in November 2011, there were no incomplete patient profiles for the month.
Order reconciliation is another area where informatics has made dramatic improvements, says Fleming.
On admission, nurses enter patients' historical or home medications. "Medication reconciliation has always been a challenge, but now the nurses are entering historical medications with the expectations that they are accurate, allowing the attending provider to convert it to an inpatient order. The nurse makes every attempt to confirm the correct medication, dose, unit of measure, frequency, how the medication was prescribed, and how the patient is actually taking it—all of that information is critical," Fleming says.