Strictly Clinical

How nurses drive rapid electronic records implementation

In 2010, Tenet Healthcare launched an aggressive rollout of electronic health records (EHRs) at 49 hospitals in 12 states, to be completed by spring 2014—only 4 short years. Although federal meaningful-use incentives contributed to our desire to accelerate the schedule, the main driver was to improve patient care through technology, achieving both meaningful use and meaningful care.

To reach this goal, we knew our project, called IMPACT (IMproving PAtient CAre through Technology) had to be clinician-driven. We needed to design a repeatable methodology that targeted sustainment, not implementation, as the success criteria. Our challenge was to involve clinicians at all levels of the organization in planning and implementing the EHR so they would own the “care and feeding” of the clinical system beyond the go-live date. As a result, nurses have played, and continue to play, critical roles at all levels, including project and hospital leadership, standards and governance, and training and support.

Project leadership

As Tenet’s vice president of applied clinical informatics, author Liz Johnson is the executive leader for IMPACT. Her focus is on maximizing use of the electronic record environment to improve care, rather than just implementing clinical systems. A registered nurse, Johnson is co-chair of the implementation workgroup of the federal Health Information Technology Standards Committee. In 2010, she received the Nursing Informatics Leadership award from the Healthcare Information and Management Systems Society (HIMSS). She brings both clinical and public policy perspectives to the project. One-third of Johnson’s senior directors and half of her directors are nurses, providing a balance of clinical and technical talent to the leadership team.

Hospital leadership

Every Tenet hospital has a clinical informatics director—a nurse who serves as the clinical leader during EHR implementation and acts as clinical guardian for post-implementation system and workflow optimization. Each hospital’s chief nursing officer (CNO) leads the multidisciplinary clinical-process improvement committee that defines new workflow, policies, and procedures to improve efficiency in the electronic environment. In many Tenet hospitals, the CNO also serves as the hospital executive sponsor for IMPACT, providing the drive and sense of urgency to the organization.

Standards and governance

To realize the full benefits of the EHR, our organization recognized the importance of developing and maintaining the clinical standards that are used across our hospitals. As EHR implementations reach a critical mass, this will enable us to mine the data in a meaningful way, identifying opportunities to improve patient safety and gain efficiencies.

Nurses play a key role in defining these clinical standards. They participate in clinical advisory teams with other clinicians to set the standards embedded in the EHR. Hospital nursing representatives collaborate with regional and national nursing leaders on the nursing advisory team. Nurses also participate in the clinical leadership council, comprising chairs of all advisory teams, to approve standards that cross multiple disciplines. In addition, teams of nurses are responsible for translating clinical standards into clinical system designs that are built into the EHR. Each team specializes in different aspects of the system, such as obstetrics, emergency department, surgery, perioperative services, general nursing, orders, and others.


Training and support

Nurses play a significant role in EHR training and ongoing support throughout the organization. At the hospital level, nurses fill most of the training and “super-user” roles during EHR implementation to prepare colleagues. After implementation, many continue their roles to provide new employee training, refresher sessions, and support during clinical system upgrades, enhancements, or added functionality. At the enterprise level, nurses account for a high percentage of our clinical support teams, including a special clinical help desk that serves physicians.

Tenet’s EHR project has led to new career-development opportunities for nurses within the organization. Many nurses continue to provide post-implementation optimization and new functionality design. The most significant addition to Tenet’s core competencies is the creation of a clinical informatics director position at each of its 49 hospitals. Nurses in this role represent all clinical disciplines, ensuring alignment of workflow and practices across the continuum of care within each hospital. They also serve as change agents and are educated on the principles of behavioral-change management, following a formal methodology. The organization has developed a formal clinical informatics program to recruit, educate, and continuously mentor our clinical informatics directors.

Since the inception of IMPACT, we’ve hosted three clinical informatics academies, providing continuing education credits to more than 70 nurses. We’ve also developed a skills assessment to provide guidance to clinical informatics directors in their development and performance. Recently, we conducted a behavioral analysis of our clinical informatics population and identified the “behavioral DNA” of our top performers.

Tenet nurses are playing a critical strategic role in enabling rapid EHR implementation across our health system. They’ve had a tremendous influence on the continuous improvement of our repeatable EHR implementation methodology, which accounts for our ability to sustain an aggressive rapid rollout schedule across a large enterprise. We conduct formal “lessons learned” sessions after each hospital implementation and incorporate follow-up actions in our methodology for future implementations. Because of such feedback, our 2013 hospital implementations achieved higher performance in such areas as computerized provider order entry use and online medication reconciliation use, compared to initial hospital implementations. Our nurses are involved at all levels of the project implementation, as well as the ongoing operational support systems.

Selected references

Johnson L, DuSold D. Driving change through clinical informatics. Paper presented at: ANIA-Caring; 2012; Orlando, FL.

Johnson L, DuSold D. The purpose-driven clinical informatics leader: A behavioral analysis. Poster presented at ANIA-Caring; 2013; San Antonio, TX.

The authors work at Tenet Healthcare Corporation in Dallas. Liz Johnson is vice president of Applied Clinical Informatics. Dorothy I. DuSold is senior director of Applied Clinical Informatics.

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