BACKGROUND Computerized physician order entry, test results retrieval, medication administration, nursing care planning, and other functions have been in place at Virginia Commonwealth University Health System (VCUHS) for more than 20 years. Today there are multiple ways for communicating the patient plan of care in the computerized information system (CIS). Methods vary depending on the clinician's role and the setting and focus of the communication, but all are essentially variations in a basic pattern. Ultimately, all physician orders — but only some of the interventions, orders, and notes by other clinical disciplines—are printed together on the nursing Kardex, the working document for organizing inpatient care on a shift-by-shift basis. No similar computer-generated document exists for outpatients or emergency department patients, and none is available to disciplines other than nursing. This approach fragments communication and creates a sense that the patient care plan designed by each discipline is isolated from all others. We are currently building a replacement CIS using Cerner Millennium software. We believe the first step to improve these system-driven problems is to design the new system so that all patient care problems, interventions, and orders are entered in the same way. MAIN CONTENT POINTS Product functionality can replace traditional nursing care planning. Plans initiated by nonphysician clinicians tend to risk isolation. Software limitations (e.g., field lengths) and features such as duplicate order alerts must be taken into consideration when planning an overall redesign. To take advantage of the benefits offered by our new CIS, all licensed clinicians must have the ability to independently place orders and document problems that fall within their scope of practice. Our plan for identifying diagnoses/problems is to use the “Problem List” feature. A variety of nomenclatures such as CPT, ICD-9, and SNOMED are available within the software. With the development of NIC and NOC nomenclatures, it is now possible to expand the use of standardized language to capture and track new aspects of patient care delivery. The Virginia Board of Nursing does not permit or restrict the procedures a nurse is licensed to perform. Two important factors that influence scope of practice are reimbursement and organizational culture. The more important concept within scope of practice is validation of competency. The culture at VCUHS centers on the concept that the physician initiates all patient care orders. While the new system must allow nurses and other disciplines to enter orders as an agent for the physician, there are orders for activities that fall within each discipline's scope of practice that will not require order entry as an agent for the physician. The VCUHS design will be implemented in phases. The use of NIC within the backend programming structure is in phase 1. For phase 2 and beyond, the priority for system development should focus on the clinician's ability to complete the loop of the care process to include more assessment data, outcome identification, and measurement of progress toward outcomes. CONCLUSIONS To accomplish the goal of interdisciplinary care planning and to raise the standard of professional responsibility and accountability, the following must be present: ▪ Administrative support with effective change management process ▪ Organizational policies/procedures congruent with the approach ▪ Scopes of practice defined with validation and documentation for individuals and groups within disciplines ▪ Inclusion of appropriate clinicians in the design and implementation process. A well-designed CIS can provide the foundation for capturing the contributions of each discipline to the patient's plan of care, promote professional practice, and provide information for administrative decision making. In addition, it should continue to support administrative and research information needs such as resource utilization, workload, and patient acuity measurement. The VCUHS design will provide a framework for studying relationships between patient problems/diagnoses, interventions, outcomes and the structures of the healthcare organization.
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Apr 7, 2005
Melanie Jasper 
Open Access
