NURS 8210 Week 1 Technology Transformation Post Example

Week 1 Discussion: Initial Post

Installed but Not Transformed: Electronic Care Plans That Nurses Complete at Admission and Never Open Again

Installing a system changes where nurses document; transformation changes what the organization does with what they document. I want to hold that distinction against one example, because most organizations can show they digitized nursing work and far fewer can show they changed it.

A composite three-hospital system moved its nursing care plans into the electronic record several years ago. On paper, the plans had lived in a binder at the nurses' station. Now they live in the record, and completion rates are nearly perfect, because the admission navigator will not close until a plan is selected. But when I ask nurses on the medical units how the plan shapes their shift, the answer is that it does not. The plan is picked from a list at admission to satisfy a required field, and after that, nobody opens it. The shift's actual work is driven by the task list, the handoff conversation and the nurse's own notes on a folded sheet in a pocket. The care plan went digital, and nothing about planning care changed. That pattern is not unique to this system: in a study of nurses' work with electronic records, Keenan et al. (2013) reported that nurses struggled to retrieve and communicate care plan information and relied on informal tools to fill the gaps.

What transformation would have required is a redesign of the process the plan is supposed to serve. The Crossing the Quality Chasm report argued that information technology should support redesigned care processes rather than automate existing ones (Institute of Medicine, 2001), and this case shows what happens when it only automates. A transformed care plan would feed the shift's worklist, so that a goal such as walking three times a day generated the tasks to meet it; it would appear in the handoff view, so the next nurse saw progress against the goal; and it would be revised when the patient's condition changed, not frozen at admission. None of that is a technical barrier. The record can already do most of it. What is missing is a decision about what the care plan is for.

There is also evidence that the data nurses enter can carry clinical meaning when the organization pays attention to it. Collins et al. (2013) found that patterns in nursing documentation, such as how often nurses charted optional comments and vital signs, were associated with patient mortality, which suggests that nurses document more when they are worried. A care plan that nobody reads throws that signal away.

So my claim is that transformation is an organizational decision, not a software feature, and in this system nobody owns the decision about what the care plan should do. The informatics team owns the build; nursing practice councils own standards; unit managers own compliance. The redesign falls between them. Question for the thread: in your organization, who has the authority to decide that a digital tool should change a process, not just record it?

Reply to Daniel

Daniel, you described your hospital's go-live as a transformation because every unit switched to the new record on one weekend. I agree it was a major achievement, but I would call it an installation. The test I would apply is whether any process works differently a year later because of what the system makes possible. If nurses chart the same assessments in the same order and nobody acts on the data differently, then the organization changed its tools but not its work. What would you point to on your units that is done differently now, not just recorded differently?

Reply to Latoya

Latoya, your telehealth follow-up clinic is a strong example, and I want to push on what process it changed. If patients now see a nurse by video instead of driving an hour, that changes access, which matters. But the goal in the quality literature is redesigned care (Institute of Medicine, 2001), so I would ask whether the clinic also changed what happens between visits, such as how results reach patients or how the nurse decides when to escalate. If it did, that is transformation in the sense I mean. If the video visit is simply the old visit on a screen, it may still be worth doing, but it is a different kind of change.

References

Collins, S. A., Cato, K., Albers, D., Scott, K., Stetson, P. D., Bakken, S., & Vawdrey, D. K. (2013). Relationship between nursing documentation and patients' mortality. American Journal of Critical Care, 22(4), 306-313. https://doi.org/10.4037/ajcc2013426

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. National Academies Press. https://doi.org/10.17226/10027

Keenan, G., Yakel, E., Dunn Lopez, K., Tschannen, D., & Ford, Y. B. (2013). Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information. Journal of the American Medical Informatics Association, 20(2), 245-251. https://doi.org/10.1136/amiajnl-2012-000894