Reflection on a Clinical Documentation Journey
Susan Downs, RPN
Nurse Peer Leader, South West LHIN 2
Clinical Documentation Application Specialist
Grey Bruce Health Services
In 2008, our Network of hospitals (three corporations and 11 separate facilities) embarked on the project of Clinical Documentation and electronic MAR (eMAR), with the initial focus on Medical/Surgical Inpatient units. We took a phased in approach by starting at the smaller sites, initially going live with two sites as we had the vendor supporting us on-site for the initial go-live. After that, we launched one site at a time and accomplished 10 successful roll-outs over the time span of one year.
Looking back in review, it is clear that a large contributing factor to the success of this project was the time spent beforehand mapping the processes at each site to determine how the implementation would affect not only the nurses' workflow, but the entire multidisciplinary team; as well as keeping in mind that the product needed to be standardized as much as possible across 3 separate corporations consisting of a total of eleven hospitals. Early buy-in from our end-users was successful because we engaged them in the design and decision processes right from the beginning by forming a network steering committee. It was never questioned that this needed to be a clinical project with Information Technology (IT) support in order for it to be successful and the fact that the IT build team came with clinical experience was also a key piece to the success of this project.
The mapping process was an extremely valuable exercise, as not only did it spark ideas for fine tuning some processes but more importantly it gave the build team the opportunity to meet face-to-face with many of the stakeholders to share the vision and reinforce the fact that we valued what they had to say. Nurturing these relationships early on and earning the trust and buy-in of the future end-users, is equally (if not more important) than the program itself. Health care providers need to understand how critical their input is especially now as Canada moves towards the Electronic Health Record (EHR). It is imperative that all health care professionals gain an understanding of Informatics and eHealth in order to ensure the promotion of collaborative health care across Canada.
Online patient assessment tools and forms have ensured timely, efficient, and consistent data collection which is quickly accessible to all health care professionals in our Network no matter where they are physically.
This is truly a paradigm shift in the way nursing is practiced and we need to embrace it as it offers the potential to change clinical processes in a way that will improve patient care outcomes and provide nurses with point of care decision support tools. I would like to encourage all health care professionals to learn more about eHealth and how it affects your daily practice. A great place to start is to participate in the free RNAO eHealth course at: http://www.rnao.org/ehealth_course/.
Sue Downs is a Nurse Peer Leader from South West LHIN (LHIN 2).