Providing access to timely, comprehensive patient information across the continuum of care--from ambulatory to inpatient settings--is crucial for today's nurse leaders. In rural facilities, where nurses and clinicians may work in relative isolation, connecting with members of the care team at hospitals and other facilities becomes even more critical to providing superior care.
One nurse leader from an isolated community in northwest Washington state overcame multiple obstacles to adopt an electronic community health record, giving her the power to work as a team with her patients' caregivers at the regional medical center located a day's journey away. Her story offers a shining example of how remote rural care centers and large hospitals can use clinical information systems to standardize high-quality care and foster communication not only across ambulatory and acute environments, but also between distant geographic locations.
When the Point Roberts Aydon Wellness Clinic opened in June 2003, it was the first time residents of this remote community were able to get routine medical care without crossing the United States-Canada International border four times during the round trip or taking a boat or helicopter. The unique geography of Point Roberts turned a 50-mile journey to the nearest regional hospital into a daylong excursion (see Figure 1).
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Because of the clinic's isolation, Virginia Lester, MSN, FNP, RN, the nurse practitioner managing the facility, saw the need to provide more than a freestanding source of basic health care services. She wanted to offer the level of patient safety and quality of care associated with more comprehensive medical centers. Lester also wanted to provide a seamless experience for patients traveling between Point Roberts and PeaceHealth's St. Joseph Hospital, the region's only inpatient medical center, in Bellingham, Washington, as well as other ambulatory clinics located in surrounding Whatcom County.
With funding and information technology (IT) resources from community, regional, and federal sources, Lester connected the Aydon Wellness Clinic to PeaceHealth's Community Health Record (CHR), built on the IDX LastWord[R] integrated enterprise clinical information system. PeaceHealth developed the CHR as a community initiative, working with a range of providers to establish a lifetime electronic medical record for residents of the areas it serves. By giving access to complete patient information--both inpatient and ambulatory--to all members of the care team, the CHR allows Lester and Whatcom County clinicians to actively collaborate in the care of Point Roberts community members.
Evolution of a Rural Clinic
More than 15 years ago, Point Roberts resident Ed Aydon hatched an idea to give his neighbors a local resource for medical care. Aydon collected 4,000,000 aluminum cans to raise $40,000 in seed money for the clinic, and then engaged a group of community members to form the Point Roberts Pioneer Project. Eventually, several state and regional organizations came on board, including Hoagland's Pharmacy, located in Bellingham; HInet, a secure community-wide network linking PeaceHealth and Whatcom County outpatient clinics; Interfaith Community Health Center (ICHC), a Bellingham ambulatory clinic; St. Joseph Hospital; the Washington State Department of Health; Whatcom County; and Whatcom Fire District.
In 2001, the Pioneers collaborated with the ICHC and the Whatcom Fire District to secure a Health Resources and Service Administration (HRSA) federal grant. The clinic was on its way.
In 2002, Glenn Gelhar, director of ICHC, which administers medical services at the clinic as stipulated in the grant, brought Lester on board to manage and serve as the facility's sole clinician and project manager. A veteran nurse practitioner with 20 years experience working in large physician groups and private physician offices, Lester set to work on everything from purchasing equipment to outlining care programs. Her husband, a retired medical laboratory director and a volunteer at the clinic, built a point-of-care laboratory so that Lester could conduct a limited number of tests on-site.
Although Lester had virtually no experience with clinical information systems, she saw the new clinic as an opportunity to integrate care practices with an electronic medical record at the outset--and avoid the challenges of implementing clinical technology after paper-based processes were established. Lester contacted PeaceHealth to explore the possibility of tapping into its CHR.
For PeaceHealth, Lester's proposal created a significant opportunity to test the idea of reaching out to caregivers and closing the loop on care for patients in the remote rural communities it serves. PeaceHealth committed to provide the funding, IT support, and training to get the clinic up and running on LastWord.
Connecting with Innovation
The pilot project was one step in a long track record of innovation for PeaceHealth, an integrated delivery network with six acute care hospitals, 41 medical practices, and a range of other services and facilities in Alaska, Washington, and Oregon.
Building on the CHR it first implemented in 1996, PeaceHealth has developed sophisticated disease registries to track the health progress of entire populations of chronically ill patients. The initiatives earned St. Joseph Hospital and community partners a 'Pursuing Perfection' grant from the Robert Wood Johnson Foundation, which helps support two pilot disease management programs for diabetes and congestive heart failure. Since implementing the program, adherence to guidelines for diabetic care has tripled among patients in three of PeaceHealth's facilities.
Implementation and Training
To overcome the technical challenges of Point Roberts' extremely remote location (the community does not even receive cell phone coverage), the PeaceHealth/HInet IT team devised a combination wired and wireless network to link the clinic with St. Joseph Hospital. Staff members access PeaceHealth's CHR and LastWord via a secure Internet connection. Working on a single laptop computer, Lester logs on to the system via a wireless LAN, which allows her to stay on-line as she moves between rooms seeing patients throughout the day.
The PeaceHealth team worked with Lester for 3 months prior to the clinic's opening, training her to navigate the on-line clinical documentation, medication ordering, laboratory data entry, and other system components. Once the clinic opened, the team stayed on-site for 2 weeks to support Lester until she was completely comfortable with the system. The team continues to provide ongoing support.
An Automated Outpost
Today, the Aydon clinic is virtually paperless. LastWord allows Lester to automate a variety of functions, including clinical documentation, to take advantage of many of the time-saving tools enjoyed by her counterparts at PeaceHealth. St. Joseph Hospital is known for its use of technology to reduce clinical documentation time in the inpatient setting. Nurses at the hospital have cut in half the time they spend an administrative tasks by using on-line clinical documentation, freeing up an additional 1.5 hours per 12-hour shift. Charting by exception reduces paperwork and accelerates documentation at the Aydon Clinic, just as it does for the inpatient nurses at St. Joseph.
In addition, LastWord's decision support and alerts provide important safeguards to help guide Lester's care and improve patient safety. Patient information alerts let providers share information across the network, allowing them to treat patients more effectively. For example, a new patient visited the clinic to have a Protime test. After reviewing the test, Lester recorded the lab results in LastWord, immediately issued an order to change the patient's medication dosage, and alerted the patient's Bellingham cardiologist. The physician replied to ask Lester to continually monitor the patient, whose compliance had been poor because of hassle involved with traveling to his appointments. With the CHR, Lester manages the patient's day-to-day care while the cardiologist--who receives regular alerts about new developments in the patient's care--can monitor changes and intervene at any time.
The system's medication order entry capabilities allow Lester to send prescriptions electronically to Hoagland's Pharmacy, located 50 miles away in Bellingham and linked to the PeaceHealth CHR. Once the pharmacy receives Lester's orders electronically, it ships the medication to the Point Roberts clinic. Electronic ordering makes a significant difference in ensuring the pharmacy receives accurate information about medications and dosage. And although having the medications shipped adds 2 or 3 days to the entire process, it saves patients the grueling trek across the border and back.
The clinic also relies on LastWord to automate administrative functions. A half-time assistant--the clinic's only other staff member--uses the system to manage scheduling for approximately 80 patients who visit the clinic each month. In addition, Lester can generate monthly reports on the number and type of patient encounters to help manage clinic administration and meet reporting requirements for the HRSA grant. Daily reports show Lester all patient records that have not been charted, to help prevent lost or missing information. Using the system, the clinic and St. Joseph also collaborate on discharge planning to support a seamless care transition.
Collaboration and Clinical IT
The CHR provides significant benefits to Lester, Whatcom County, clinicians and their shared patients. Because the CHR captures data from St. Joseph Hospital and any participating ambulatory facility in Whatcom County, Lester has fingertip access to complete medical records for all of her patients.
All information is stored in a single database, so the entire care team views the same accurate, up-to-date patient data. The integrated patient record also eliminates multiple data entry and the need to ask patients repeatedly for the same information, which is important for individuals seeing clinicians located 50 miles apart.
Last fall, a 65-year-old man visited the Aydon Clinic with minor chest pain. Suspecting that he was on the brink of a heart attack, Lester performed an EKG and then sent him on to St. Joseph for treatment. Because the man's entire medical history--including Lester's clinic notes and results from the EKG performed that morning--were immediately available for St. Joseph's clinicians, Lester was able to contact a cardiologist in Bellingham and give him a complete picture of the man's health. The patient was hospitalized and the cardiologist performed an angioplasty and stent insertion.
Lester also works within PeaceHealth's disease management programs to treat chronically ill Point Roberts patients. Before the clinic opened, patients with diabetes seen at St. Joseph Hospital would be sent home with instructions and medications, but would face challenges with the ongoing monitoring and guidance necessary to manage their disease. Often, because of the distance to the nearest health care services, their next contact with a physician would be in the emergency room after a problem arose.
Now, Lester has the same level of access to PeaceHealth's chronic disease registry as St. Joseph's physicians. The chronic disease registry and CHR enable Lester and clinicians at the hospital to work together to help patients understand the warning signs related to their disease and administer the appropriate intervention methods--from pre-emptive tests to behavioral change--to help patients manage their illness, avert trips to the emergency room, and prevent further decline in health.
Successful Connection
The success of the Point Roberts and PeaceHealth project shows that rural facilities can be just as wired as health centers in urban settings. Clinical information systems offer nurse executives and other clinicians the tools to shrink the gap between inpatient and ambulatory care, and indeed, the distance between clinic sites. PeaceHealth's CHR and LastWord have enabled Lester to overcome the communication barriers inherent to practicing in a remote setting and, along with clinicians in Whatcom County and at St. Joseph Hospital, create an environment of fail-safe care for the residents of Point Roberts.
DERRA KIRKLEY, PhD, RN, is Director of Nursing Informatics, IDX Systems, Seattle, WA.
DEBRA BROWN, RNC, is Community Health Record Analyst, St. Joseph Hospital and Point Roberts Project Lead, Bellingham, WA.
VIRGINIA LESTER, MSN, FNP, RN, is Project Manager and Nurse Practitioner, Point Roberts Aydon Wellness Clinic, Bellingham, WA.
NOTE: The Aydon Clinic and St. Joseph Hospital story is only one of the numerous ways innovative nurse executives can leverage information technology to support patient safety, provider communication, and nursing excellence. Throughout the year, this column will focus on the stories, experience, and advice of forward-thinking organizations such as PeaceHealth and the Aydon Clinic. The authors will focus on how technology, is making an impact on nursing practice, highlight best practices, and spotlight organizations that are leaders both in nursing quality and in technology innovation.
The 'Information Systems & Technology' column is sponsored through a grant from IDX, a leading provider of software, services and technologies for health care provider organizations based in Seattle, WA. For more information, visit www.idx.com
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