ABSTRACT
PURPOSE: This article reviews the missions of the U.S. Department of Veterans Affairs (VA) and the evolution of its electronic health record (EHR), the Veterans Health Information Systems and Technology Architecture (VistA). This system, along with its clinical graphical user interface the Computerized Patient Record System, form a key link in VA health care. A Veteran who receives healthcare through the VA can have their EHR accessed by clinicians at any VA healthcare facility across the United States and its territories. Data aggregated daily at a corporate data warehouse supports VA quality improvement and research. ORGANIZING CONSTRUCT: Serving over 9 million Veterans, the VA is one of the largest integrated healthcare systems in the United States. It has been a leader in the development and use of healthcare informatics, EHR, and big data analytics for over 30 years. Nurses engaged in major roles in the evolution of these developments. CONCLUSIONS: With over 500 nurses as members, the Office of Nursing Informatics' Field Alliance demonstrates the VA's continuing commitment to fostering nursing informatics. The commitment includes investment by the VA to develop nursing informaticists from among its own staff. CLINICAL RELEVANCE: Exemplars of the impact of nursing informatics are shared. Future directions include an EHR that begins during military service and follows the Veteran into VA health care.
Subject(s)
Big Data , Nursing Informatics , Veterans Health Services/organization & administration , Electronic Health Records , Humans , United States , United States Department of Veterans AffairsABSTRACT
Graduate nursing education is positioned to transform nursing documentation so that it more fully describes nursing assessments, diagnoses, interventions, and outcomes to measure improvements in care. Learning to document with structured nursing terminology is an integral part of "Information Technology for Evidence-Based Practice", a required online course taken by all students in the Rutgers Doctor of Nursing Practice program. Beginning with SOAP and terminology required for billing, students create a clinical note adding elements of the Nursing Minimum Data Set, using Clinical Care Classification terms. Next, students are asked to select a nursing-related clinical practice guideline, electronic clinical quality improvement measure, and a screening tool that applies to their encounter note. Then, they identify Patient Reported Outcome Measures as well as improvement activities in the CMS Quality Payment Program. The course is well-received; many graduate students now face changes in documentation and electronic tools and can predict future evolution.
Subject(s)
Documentation , Students, Nursing , Education, Nursing, Graduate , Humans , Learning , StudentsABSTRACT
Evidence suggests that inaccurate and incomplete pressure injury (PI) documentation threatens the validity of treatment and undermines policy and quality improvement. This quality improvement project sought to identify barriers and facilitators when conducting and documenting the daily comprehensive skin assessment in 31 Department of Veterans Affairs (VA) facilities. Evaluators in this 1-year, cross-sectional quality improvement project, using a qualitative approach, interviewed nurses of medical-surgical and critical care units. Participants (N = 62) from 12 high reassessment units (HRUs) and 13 low reassessment units (LRUs) were interviewed using telephone focus groups. Staff from HRUs reported 9 activities that ensured consistency in clinical practices, in validating data, and in correcting inaccuracies. The LRU staff tended to report performing only 2 of the 9 activities. The main barriers to accurate documentation were lack of knowledge, poor templates, and staffing issues such as understaffing and turnover, and main facilitators were an internal data validation process and a documentation template to local practices. Findings from this project led to increased VA leadership engagement, development of 3 innovative, award-winning VA mobile PI prevention and management applications, updated policies and directives on PI prevention, and upgrading of the national VA HAPI workgroup to an advisory committee and improved collaboration between the PI advisory committee and nursing informatics.
