Module 1 - Question #2

The use of technology and informatics continues to expand. I can remember when VS were performed manually, tests were ordered by paper requisitions, and there was only paper charting. We’ve now used computer documentation for several years. It took awhile, but I can see how it promotes more than just data extraction. It also supports documenting to requirements that are based on best practices and includes prompts to aid nursing. For example, the documentation is programmed to provide a reminder ‘pop-up’ for all the admission assessment requirements, such as vaccine assessment, fall risk score, tobacco use, Braden score, etc…plus the ‘pop-up’ returns at pre-programmed timeframes if the information isn’t complete or requires additional assessment based on standards. This is a great job aid for the busy nurse, plus it would be too difficult to rely on memory for all the documentation requirements we have today. Later this year, our Infusion pumps are being upgraded to WiFi capability so that any programming to the pump will automatically transfer to the documentation system. The IV pumps already have “smart pump” technology that includes a drug library with pre-set safety parameters programmed by pharmacy. The vast computerized documentation data is retrieved in many report forms that meet the needs of the various disciplines, and the data can be extracted for audits. A new enterprise clinical information system (ESIS) is being developed that will incorporate the parameters of clinical guidelines and protocols as prompts within the documentation tool to aid in the standardization of practice patterns based on EBP. Computerized physician order entry will also be a part of this.
Other IT applications being used that ultimately benefit patient care include bar-code medication administration; glucose meters that transmit the patient result into their electronic record that can be accessed by the MD/NP from any computer…along with access to any procedure report and accompanying image; another application are wireless communication systems – we use an on-line paging system to send pages to an individual or set up to a group, and the nurses have wireless phones that the patient can call directly by-passing a call-light system; and the extracted documentation is useful for process improvement initiatives. Wow, I’m stopping here but I can think of even more ways that we use IT in everyday patient care and others currently in development. This is definitely a day where technology has a major impact in providing patient care….and promotes quality patient care.