The Gray Shades: CDS for Nurses at the Point-of-Care | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

The Gray Shades: CDS for Nurses at the Point-of-Care

March 13, 2014
by Gabriel Perna
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One of the highlights of this year’s HIMSS (Healthcare Information and Management Systems Society) conference was more focus on the growing field of nursing informatics.

During the conference, HIMSS released a study which revealed IT’s increasing prominence in nursing. Seventy percent of respondents from a survey of 1,000 nurses within informatics said they have titles that specified an informatics position, which is double the amount from the last HIMSS Nursing Workforce Survey conducted in 2011.

One of the prime areas of focus for this new wave of nursing informatics is within clinical decision support (CDS) systems. For many provider organizations, such as the Englewood, Colo.-based, 87-hospital, faith-based health system, Catholic Health Initiatives, putting CDS in the hands of nurses makes a lot of sense. Ann Shepard, R.N., the vice president and chief nursing informatics officer at Catholic Health, says that nurses make up the largest number of caregivers in the hospital and most spend the majority of the day directly interacting with the patients.

“For those people who are caring for our patients directly, we want to have the most up-to-date, current, and accurate information that we can provide,” Shepard says.

Thus, Catholic Health invested in a CDS tool (from the Philadelphia-based Elsevier) that acts essentially as a nursing consultant.  Shepard spoke with Healthcare Informatics Senior Editor Gabriel Perna at HIMSS about this technology, opportunities within CDS, and the challenges of fitting these systems into the provider’s workflow. Below are excerpts from that interview.

Ann Shepard, R.N.

Why did your organization invest in a CDS system? What were some of the challenges you were encountering before you made that dive?

A little background: Three years ago, we started down the path for the electronic health record (EHR). It’s a $2 billion-plus initiative to bring the EHR to all of our hospitals and all of our doctors for all of our providers in the next [few years]. We’re about half way there with implementation of these systems. Because of market competition and strong legacy relationships, we will have three EHRs for the hospital and two for the ambulatory. Today, we have our little bit of one-off [systems]. Our big program is called “OneCare.” When it is implemented there will not be as much variability, but there will still be some uniqueness by regions. Related to that are improvements in patient care and their outcomes, decreasing the duplication of tests and procedures, and [on CDS] improving the evidence-based content we use to make decisions. [CDS is] all about streamlining and decreasing variability wherever we can.

What makes nursing a prime area for CDS?

One of the reasons we chose to partner with Elsevier is their Mosby line of products, which focuses mostly on nursing procedures, nursing instructions, and nursing information, so that we have less variability in the way people work with the patients. It's found in the electronic environment. It is available wherever they have a computer. Back in the old days, we had a procedural manual and it sat on the shelf in the nursing station. If they could find it, they’d use it. But more likely, they couldn’t find it. And they were at the other end of the hallway anyway. This allows the clinicians to have access at their fingertips, wherever they are, if they choose to review the step-by-step instructions prior to doing something.  

Everyone was taught when they went to school how to do things. Many tests and procedures haven’t changed over time, but others have. The evidence supports you do something different. We want our patients to have the best, so we want them have the most current information. We chose it because it offered enhance functions for our nurses that we did not have prior to this.

How does the CDS system work?

The way we are using it today is as a referential tool. It’s not necessarily prompting me to change something, but it is there in the background to offer support and knowledge. It's passive. I have to go to it today, but it still offers me a lot of good information that I’d otherwise have to find in the manual or do a Google search. It’s opt-in.

One of the things I've heard about CDS is how it fits in the workflow. How did you account for those challenges?

We haven’t figured it out yet. We don’t have this embedded into the EHR yet, so when I get a doctor’s order to get an IV in their arm, it automatically gives me a hyperlink to the IV insertion protocol, so if I want to look at it, I can. It doesn’t do that. But we know that's part of the future, that’s how it will look in the future and clinicians are okay with that today.

It is interruptive, it’s not truly reviewed as often as it could be, but I think it’s better having it available close to where they are working, even if it’s interruptive.

[With decision support, clinicians say] it needs to be available when I want it, but don’t give it to me when I didn’t ask for it. The challenge is computers are black and white, you turn it on or you turn it off. You always alert for this, you never alert for this. Where healthcare is, is right in the middle where it’s gray. I need it when I need it, but I don’t want it when I know. Between the novice and the expert, you have all of these layers of ability. There is a huge push, pull. I want it, but it’s 100 percent situational.

That being said, what advice would have to those who want to invest in these kinds of CDS technologies?

What we've chosen to do with clinical decision support in general is to be very careful and decide with our clinical leadership team, what are the critical elements we need. Do you need to alert someone about having an aspirin before their discharge? Or a Beta-blocker if they have a heart problem? Those are some of the things we are teaching to the test. If you teach to the test and make sure those core measures and meaningful use elements are captured and then provide other good guides, we’re in a better place than we are in a paper world.

We’re careful about mandatory fields because people get so frustrated with them. We’re very cautious about alerting for medications that have been around for a while and people do know some of the counter indications, so we don't alert on a lot of them. You have to be careful. It’s a very tight line with being a good prompt reminder for me to do the right thing and being a severe annoyance and having the physicians in the CEO’s office talking about how it slows them down. It's tough but you have to do it anyway.

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