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Nursing Resource Considerations

for Implementing an Electronic


Documentation System
LAURIE ANN SALETNIK, RN, MSN; MARGARET K. NIEDLINGER, RN, MIS, BC, CPHIMS;
MARISA WILSON, DNSC, MHSC, RN

I
mplementing a computerized OR • interface with at least three other
management information system computer systems; and
(ORMIS) requires an enormous • subsume some of the work of three
commitment of human resources for separate and independent informa-
the various tasks associated with pre- tion technology (IT) departments.
paring for, launching, using, and main- A rigorous, two-year process of eval-
taining such a system. In December uation, demonstration, and discussion
2000, in recognition of the need for with the vendors who responded to the
seamless fluidity of patient information RFP resulted in a contract with one
sharing between ORs, procedure ORMIS designer. The hospital submit-
rooms, affiliated nursing care areas, ted a Certificate of Need application to
and other affiliated facilities, The Johns the Maryland Health Services Cost Re-
Hopkins Hospital, Baltimore, Mary- view Commission. This state require-
land, released a request for proposal ment is designed to
(RFP) to identify and select a single,
unified, vendor-developed ORMIS. promote cost containment by decreas-
This process also included a considera- ing both service duplication and invest-
tion of the future construction of new, ment in excess capacity. . . . Certain
acute care towers, which are envi- health care providers must obtain state
sioned to encompass and integrate a approval for substantial changes in
majority of these service areas. The their scope of services or for capital
ORMIS needed to include scheduling, investments.1
perioperative, and procedural nursing
documentation; an anesthesia data re- The Certificate of Need was approved
cord; case cart and materials manage- in April of 2003, and a final contract
ment; patient tracking; day manage- was executed in June of that same year.
ment; professional fee billing; supply
billing; instrument tracking; and
report-generating functionality.
The selected system would be target-
ABSTRACT
ed for deployment throughout the peri- IMPLEMENTATION OF AN OR MANAGEMENT
operative and periprocedural areas information system (ORMIS) requires a significant
within The Johns Hopkins Hospital and commitment of human resources.
the Johns Hopkins Bayview Medical
THE EXPERIENCES OF THE PERSONNEL at The
Center. This included more than 85 OR
Johns Hopkins Hospital, Baltimore, MD, as they
and procedure rooms and all affiliated
transitioned to using a single, unified, computer-
preparation and postanesthesia care
ized ORMIS are detailed in this article.
units (PACUs). The system would
• replace five other legacy systems; INCLUDED ARE DISCUSSIONS of the nursing
• affect approximately 500 nurses; resources involved in the process, the lessons
• encompass seven separate depart- learned, and the work that remains to be completed
ments; for the hospital to fully utilize the system. AORN J
• incorporate real-time, online nursing 87 (March 2008) 585-596. © AORN, Inc, 2008.
documentation at the point of care;

© AORN, Inc, 2008 MARCH 2008, VOL 87, NO 3 • AORN JOURNAL • 585
MARCH 2008, VOL 87, NO 3 Saletnik — Niedlinger — Wilson

CRITICAL SUCCESS FACTORS • organizational impact.2


FOR A HIGH-RISK PROJECT It was necessary to consider which system at-
The ORMIS project carried a very high level tributes would best contribute to these success
of risk. It was essential that activities related to factors. The team had to consider how to rec-
the implementation of this system would not ognize and define system quality, informa-
• have a negative effect on patient safety, tional quality, user attributes, user satisfaction,
• disrupt or slow down the patient flow dur- and effect on individuals and the organiza-
ing any part of the implementation, tion. A set of relevant components of this six-
• place undue time constraints on the circu- category framework was derived based on the
lating nurses in each OR, or literature review conducted by Van Der Meij-
• negatively affect the revenue generated by den et al.3 In that study, 33 papers highlighting
each department. 29 patient care information systems were re-
The project Steering Committee recognized that viewed, and components comprising success
they needed to guarantee a level of success by factors proposed in the Delone and McLean
fully understanding several important issues: framework2 were highlighted. Table 1 lists
• the circuitous workflow processes within components of the categories of the Delone
each area, and McLean framework as proposed by Van
• the policies and procedures guiding each Der Meijden.3
department, The components selected and considered
• the existing forms and documents in use by most important to the nursing staff and IT
end users, and team members were
• the existing network of information sharing • documentation time,
that had developed over the years to man- • system response time,
age the more than 36,000 patients who pass • system availability,
though the perioperative and periprocedural • ease of learning,
areas each year. • time savings,
In an effort to reduce risks, the Steering • completeness of data,
Committee developed a list of critical factors • accuracy of data,
related to the probable success of the imple- • timeliness of data,
mentation. Included in this initial list were • user satisfaction,
• a concrete and unwavering scope of the • changed clinical work patterns,
project, • communication, and
• priority and support of the division chiefs • impact on patient care.
and nursing leaders of the affected areas, To ensure that these success factors could be
• demonstrated long-term commitment of fully realized during the course of the project,
staff members in the affected areas, and the IT team developed a process and structure
• a willingness to resolve operational issues based on the sociotechnical approach as de-
either by adjustments in practice or re- fined by Berg.4 This approach places emphasis
design of entire workflows. on understanding the work practices of the end
The hospital’s IT team provided guidance users in each division, department, and area.
and consultation to the Steering Committee. The IT team, acting as consultants to the end
Working together, they expanded the list of user clinical team, was relatively small, com-
critical factors using a framework proposed by prising a project manager with responsibilities
Delone and McLean2 in which success factors for other clinical systems; a senior project
fall into six distinct categories: leader who also is a nurse; and three systems
• system quality, analysts, one of whom is a nurse. This was a
• information quality, small team for a project of this magnitude, so
• usage, future end users of this system (eg, nurses,
• user satisfaction, anesthesiologists, surgeons, schedulers, materi-
• individual impact, and als management staff members) along with

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TABLE 1
Attributes of Different Success Factors*
System Information Usage User Individual Organizational
quality quality attributes satisfaction impact impact
Ease of use Completeness Number of Changed patterns Communication
User satisfaction
entries and collaboration
Response Accuracy of Attitude Direct benefits
time data Frequency of Impact on patient
use User-friendliness Changes in care
Time savings Legibility documentation
Duration of use Expectations habits Costs
Intrinsic Timeliness
features Self-reported User computer More Time savings
creating Perceived usage competence administrative
extra work usefulness tasks Reduced number
Location of of staff members
Perceived Availability data entry Time of day for
ease of use documenting Number of
Ease of Frequency of procedures
Usability comprehension use of specific Documentation required
functions frequency
Availability Consistency
Information
Ease of Reliability recall
learning
Format Accurate
Rigidity of interpretation
system/
built-in rules Integration of
information/
Reliability overview

Security Information
awareness
Ease of
access to Efficiency and
help effectiveness of
work
Data
accuracy Job satisfaction
* Originally published in Van Der Meijden MJ, Tange HJ, Troost J, Hasman A. Determinants of success of inpa-
tient clinical information systems: a literature review. J Am Med Inform Assoc. 2003;10(3):238. Reprinted with
permission from Elsevier, Philadelphia, PA.

those in authority to make decisions (eg, di- ing departments in the six affected divisions
vision chiefs, directors, assistant directors, (ie, the Wilmer ophthalmological OR, general
managers) also were intimately involved in all OR, Weinberg ORs, Bayview ORs, endoscopy
aspects of the selection, analysis, design, im- suite, cardiovascular diagnostic laboratory).
plementation, and ongoing evaluation of the In a separate investigation of information
system. The sociotechnical approach on a proj- systems in health care organizations, Berg5
ect of this size also required enormous re- wrote that implementation of a patient care
source allocation, particularly from the nurs- system will have a fundamental effect on the

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MARCH 2008, VOL 87, NO 3 Saletnik — Niedlinger — Wilson

organizational structure. Information technolo- NURSES INVOLVED IN


gy implementation is not a mere technical proj- PLANNING AND IMPLEMENTATION
ect and, as such, cannot be left to the IT depart- Many nurses played key roles in the plan-
ment alone. Health care is typified by a level of ning and implementation of this system. They
complexity that defies the predictability re- included the director of surgical nursing, the
quired in many IT implementations. The devel- assistant director of surgical nursing, the clini-
opment team, therefore, must be prepared to cal systems manager for surgical nursing, sev-
learn from and adapt to problems.5 eral nurse managers and clinical nurses, the
nurse educator, the case cart facilitator, and the
THE COMMITTEE AND WORKGROUP CONFIGURATION OR nursing coordinator.
To integrate core end users into the process DIRECTOR OF SURGICAL NURSING. The director of
and to implement the framework and compo- surgical nursing was one of the primary mem-
nents of success, a matrix of committees and bers of the Steering Committee. She helped
workgroups was established direct the design of the sys-
at the beginning of the proj- tem and provided support for
ect to oversee all aspects of the clinical documentation
the system life cycle. The project whenever necessary.
project included the follow- ASSISTANT DIRECTOR OF SURGICAL
Nurses played key
ing committees: NURSING. The assistant director
• Steering, with oversight roles during the of surgical nursing was the
over the entire project; person ultimately responsible
• Nursing Documentation; planning phase and for each task that led to the
• Case Cart and Materials successful implementation of
Management; implementation of the the ORMIS. She also served on
• Scheduling; the Steering Committee as the
• Billing; OR management representative of OR and pro-
• Report Generation; information system at
cedure area nursing. In addi-
• Interface; and tion, the assistant director was
• Technical. Johns Hopkins. co-chair of the Clinical Docu-
Most of the committees were mentation Committee with the
chaired by an end user, with the ORMIS project leader. The
exception of the Report Genera- ORs that were chosen to im-
tion, Technical, and Interface plement the system first were
Committees, which were those for which the assistant
chaired by senior analysts from the IT team. Each director had direct responsibility. The depart-
committee also had an assigned working group of ment of surgery was the largest of all the areas
end users who were given the task of developing affected in the facility.
• workflow diagrams for each division, CLINICAL SYSTEMS MANAGER FOR SURGICAL NURSING. In
• policies and procedures as the system addition to strong supportive nursing leader-
unfolded, ship from the director and assistant director of
• standardized data dictionaries across the surgical nursing, a nursing informatics posi-
enterprise, tion was created in the nursing department.
• communications to all affected end users, This position was created to help guide and
• the system training regimen, and support the implementation of a nurse staffing
• support protocols for implementation and and scheduling system, the OR management
ongoing use. system for scheduling and clinical documenta-
Each committee and workgroup included a tion, and the provider order entry system. The
committed core group of nurses from each di- person hired for this role was a seasoned
vision who met weekly or biweekly to com- nurse with more than 25 years of nursing ex-
plete the tasks assigned. perience in a variety of clinical areas as well as

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approximately 15 years of experience working CLINICAL NURSES. Clinical nurses were involved
with information systems in nursing and in all aspects of the project as well. Prior to the
health care. The position initially was titled software selection, an open invitation was ex-
“program coordinator,” but it evolved into the tended to all nurses to attend the vendors’
clinical systems manager for surgical nursing. demonstrations of their systems. Many nurses
Although the system selection was made participated by asking questions, and they
before this position was filled, the clinical sys- provided feedback by completing a survey.
tems manager was included in the Steering Throughout the planning process, nurses were
Committee membership roster, the Nursing involved in many tasks such as reviewing
Documentation Committee, the Technical preference cards for physicians with whom
Committee, and the Reports Committee, and they worked. They also reviewed equipment
also served as an invited guest when required lists for accuracy and supply lists for com-
in the Scheduling Committee. pleteness. As the process for screen develop-
The clinical systems manager has been the ment began, a subcommittee was formed and
liaison between nursing leaders and the IT chaired by one of the nurse managers from the
implementation team. Informatics expertise RN Documentation Committee. This group
enabled her to analyze the clinical needs ex- consisted of clinical nurses from every special-
pressed by staff members and leaders and ty, a nurse educator, the project leader, and the
apply that knowledge as the ORMIS system clinical systems manager on an ad hoc basis.
was developed and implemented. This group provided critical input into the
Though nurses frequently are included in an screen design, and all members were trained
implementation team under the direction of the to be super users. Hardware selection also was
IT department, they often are presented with discussed with the nursing staff members who
conflicting demands related to the project time- provided the input that ultimately led to the
line and the development of the system. The selection of computers on wheels for use in
clinical systems manager was employed by the each OR or procedure room.
nursing department, which allowed her to em- NURSE EDUCATOR. The OR nurse educator was
phasize clinical needs and incorporate those included on the RN Documentation Committee
needs into the system. This individual was able and was integral to the development of the
to provide input in the screen designs for the computer skills refresher course and the train-
system, placement and design of hardware to ing for the clinical documentation rollout. The
support the system, dictionary development, educator was able to bring feedback to the RN
and process redesign. She added a unique point Documentation Committee on the issues and
of view with both her IT and clinical expertise. questions that others raised throughout the
NURSE MANAGERS. Nurse managers were in- training process so that adjustments could be
volved in several aspects of the project. Nurse made when necessary.
managers were members on the RN Documen- CASE CART FACILITATOR. The case cart facilitator is
tation Committee and represented all specialty the nurse who developed the existing case cart
areas that would be affected by the system. As system for the ORs several years before and who
each OR and procedure area prepared to im- oversaw the management of the preference
plement the system, the nurse managers in- cards. This nurse was a member of the RN Doc-
volved in those services took on the responsi- umentation Committee, the Scheduling Commit-
bility of preparing staff members and ensuring tee, and the Case Cart and Materials Manage-
that necessary templates had been developed ment Committee, as well as an ad hoc member
and clinical nurses in their areas had complet- of the Report Generation Committee. This indi-
ed the assigned tasks. Each nurse manager vidual was responsible for updating all of the
also was trained to be a super user (ie, a staff preference cards as well as assisting in some
member who receives additional training and areas with the creation of preference cards where
acts as a resource for other staff members dur- none existed. As a member of the Case Cart and
ing their training on the system). Materials Management Committee, the case cart

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nurse managers or designees from each clini-


cal specialty, an OR nurse educator, the nurs-
When creating a clinical documentation
ing case cart facilitator, the OR nursing coor-
dinator, the surgical nursing informatics
system, the goal is not to duplicate
nurse, and the nurse programmer analyst.
This group met weekly for approximately
an existing paper documentation
three years to develop the base scheduling
system and clinical documentation applica-
system but to reduce redundancy,
tions. The large committee continues to meet
monthly, and subgroups are established as
reevaluate practices, and improve the
needed to support the implementation in each
clinical area (eg, outpatient ORs, diagnostic
quality of the documentation.
laboratories). Updates from each subgroup
are provided at the monthly committee meet-
ings to ensure consistency across ORs and
procedure areas. The decision to do this was
made early in the process to address the
facilitator was essential to the process of creating unique OR needs collectively.
the supply dictionary and ensuring that there The preliminary and collective work of this
was nursing input in the categorization of indi- committee was focused on preparing for the
vidual supplies so that groupings made sense to implementation of the scheduling system. This
the users. The case cart facilitator also was instru- process included the following tasks:
mental in developing procedure lists because the • Review the supply catalog to categorize
decision was made early in the process not to use supplies appropriately (eg, implants, tubes
current procedural terminology codes for sched- and drains, dressings, lines and casts).
uling procedures. • Review and revise the existing preference
THE OR NURSING COORDINATOR. The OR nursing cards in the inventory management system.
coordinator was a member of the RN Docu- These were distributed to the attending sur-
mentation Committee and represented the geons for revision and then were updated
views of the coordinator role. Since the co- and prepared for entry using the new cata-
ordinators already were versed in the entry of log information.
emergency and add-on procedures into the • Create equipment lists and identify the equip-
scheduling system, that knowledge served the ment location within the organization.
committee well. The nursing coordinator was • Identify items to be considered in conflict
trained as a super user because her role often checking (ie, items for which there are limit-
involves moving in and out of each OR on an ed quantities, the use of which must be re-
hourly basis. This made her the individual stricted when posting cases).
most likely to be contacted by clinical staff The committee then developed the clinical
members for questions or concerns during the documentation system. The goal of this step
implementation of the system. She also was was not to duplicate the paper documentation
responsible for staff member scheduling, so system but to reduce redundancy, reevaluate
her input was essential to committee discus- documentation practices and forms, revise
sions related to training, availability, and mo- documentation, and improve the quality of
bilization of staff members for support roles. documentation. A workflow analysis was per-
formed, and the existing clinical documenta-
THE NURSING DOCUMENTATION COMMITTEE tion process was analyzed. This revealed that
The Nursing Documentation Committee more than 80 separate paper forms were be-
was co-chaired by the IT project leader for the ing used. The intent of the new system was
ORMIS and the assistant director for surgical not to eliminate all paper because the ORMIS
nursing. Members of this committee included does not interface with all other institutional

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systems. The clinical documentation system becoming overwhelmed with the information.
was designed, however, to eliminate as much It also was easier to accommodate other staff
paper as possible. members’ schedules when the hours were
The committee translated the existing paper scheduled this way. For example, nurses
documents into requirements for screen lay- could attend a class in the morning and then
outs in the selected system. It was tempting at be available in the afternoon to provide lunch
first to create electronic documents that mim- breaks or relief in the OR for the remainder of
icked all existing paper documents, but this the shift.
was intentionally avoided to eliminate the dou- The first four-hour session covered the ba-
ble and sometimes unnecessary documentation sics of the electronic document system and a
that was occurring. In addition, the basic lay- review of each screen. The second four-hour
out of the screens prevented this from happen- session focused more on the clinical aspects of
ing because interventions and information the system and included how to document an
were grouped differently in the electronic doc- entire case successfully. Having clinical staff
uments. After the basic application had been members in the training room for each session
designed by the IT team, members of the Nurs- was helpful, because staff members had many
ing Committee actively participated in the questions that required the response of a clini-
screen development; building; testing; and ulti- cian, especially related to changes in work-
mately, in the final approval of the system. Ap- flow and work processes.
proval for screen design was obtained from the The first groups to be trained were the des-
Nursing Documentation Committee as well as ignated super users from the clinical staff.
from selected end users who met under the di- Super users were selected from each service
rection of the nurse managers participating in and usually were nurses who volunteered for
the larger group. this role. Clinical staff members and managers
agreed that the individuals who volunteered
TRAINING to be trained as super users were making a
In an effort to establish a baseline of com- commitment to support not just their own
puter skill competence, a questionnaire was service area but all service areas during the
distributed to all RNs who worked in the implementation phase. Super users or IT staff
ORs. Based on the results of this, e-mail ac- members provided around-the-clock support
counts were established for all staff members during the implementation. These staff mem-
to help enhance their basic computing skills. bers were paid at a special rate designated for
This provided an opportunity for the nursing nurses working to provide system support.
staff to gain comfort with and skills in inter- Though it easily could be overlooked, it is
acting regularly using a computer. In addi- essential to designate a training room when
tion, a basic computer skills training class was implementing a system of this magnitude. The
made available for those self-identified indi- nurse educator and the clinical systems manag-
viduals who required more assistance. er worked together to procure the appropriate
Training was one of the more challenging furniture and equipment to create a training fa-
parts of the implementation. Although initial cility that would support the training needs
efforts were made to schedule extra staff during implementation as well as the needs of
members during the training dates, the imple- future orientees who would be trained to use
mentation date was changed several times the ORMIS software. In The Johns Hopkins
throughout the process, making scheduling of Hospital, the training area commonly used for
additional staff members extremely difficult. orientation of new nursing staff members was
Further, the content that needed to be covered renovated to facilitate the required computer
during training required approximately eight training. Ergonomic computer desks in which
hours of classroom time. The decision was the computers could be stored were selected to
made to divide the training into two separate accommodate a variety of training that would
four-hour sessions to prevent staff members occur in that one classroom.

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IMPLEMENTATION week’s respite was scheduled between imple-


The initial implementation of the system mentations in each service. After the first two
occurred when the scheduling portion of the services went live with the system, it was evi-
software was activated. To accomplish this, dent that the two-week timeframe was exces-
admission, discharge, and transfer; inventory sive and staff members typically were able to
management; and billing system interfaces use the system independently after the first two
were created. Equipment, supply, employee, or three days. After full-time staff members
room, procedure, and service dictionaries had were comfortable using the system, training ac-
to be created and standardized. The prefer- tivities were focused on educating part-time
ence cards also had to be reviewed, revised, staff members or those who were on vacation
and converted or created from an existing in- when the implementation began.
ventory system into the ORMIS. The desire of The Nursing Documentation Committee de-
the Steering Committee was to start with pref- cided to have one extra person in each OR
erence cards that were as current as possible, during the implementation of the system. Staff
because the preference card members who were learning
would be attached to the pro- to use the system were en-
cedure and would be used to couraged to enter data into
generate the pick list and case and use the system rather
cart. The preference card also An extra staff member than performing their custom-
would provide the basis for ary tasks, which were com-
charging for supplies by ex- was present in each OR pleted by the extra nurse in
ception. Before the implemen- the room. At the end of the
tation of this system, the case so staff members could implementation week, nurses
cart facilitator went through supporting the rollout did not
each OR schedule manually, use and enter data into need to be in each room but
determining the appropriate were available by pager to an-
the OR management swer questions.
preference card and then
printing it from an existing information system. COMMUNICATION. During the
system for supply manage- initial rollout, a super user
ment staff members to use as e-mail group was created. At
they prepared case carts. All the end of each day, tips or
of these efforts required an lessons learned were sent by
enormous commitment of e-mail to super users to help
human resources towards a successful imple- avoid revisiting the same issues repeatedly. By
mentation of the scheduling portion of the the time the last half of the ORs had been con-
ORMIS software. The complexity of this verted to the system, this process no longer was
process was a significant challenge for nurs- necessary. Frequently asked questions also were
ing leaders. published in the OR nursing newsletter that is
FIRST ROLLOUT. The Nursing Documentation produced every other week and distributed to
Committee decided to implement the ORMIS in staff members with their paychecks.
stages within the ORs affected by the first roll- Throughout the planning process, staff
out. This decision was in part to ensure ade- members received frequent updates on the
quate support for each nurse as the system was status of the project in an effort to keep them
implemented. Cardiac surgery was the first spe- engaged. The Nursing Documentation Com-
cialty group selected because of the homogene- mittee communicated with staff members by
ity of the procedures performed, the consistency newsletters and by regular discussions at staff
of the staffing needs, and the stability of the meetings. The screen designs also were shown
sending and receiving units. Each service was to and reviewed with staff members on sever-
scheduled for a two-week implementation with al occasions. Good communication was essen-
support from the IT team and super users. A tial to the success of this project.

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NURSE SATISFACTION. The project developers also plates for specific procedures. In addition, as
wanted to measure nurse satisfaction with the new initiatives are developed, changes continu-
system; therefore, a pre-implementation survey ally need to be made to the screens to collect the
was used to evaluate satisfaction with the exist- necessary information both for quality and
ing documentation system. Several months process improvement.
after the implementation of the new system, a It is important to note that no system is per-
postimplementation survey was made avail- fect. Users are required to work within the
able for the nurses to complete via the facility’s limitations of any system that is selected. A
intranet. The developers intend to conduct an- health care organization must continue to
other survey of nurses after they have used the work with the software vendor when signifi-
system for one year or longer to determine their cant changes are required.
level of satisfaction and to identify any changes
that are needed. EVALUATING THE COSTS AND BENEFITS
Meyer and Driscoll6 presented the results of
LESSONS LEARNED two case studies related to the implementation
Nursing managers thought that nurses of comprehensive perioperative IT systems.
would want to practice with the system after Their findings indicate that one hospital in the
their training session and before the go-live study was able to
date. A training version of the software appli- • capture millions of dollars in lost revenue
cation, therefore, was placed on selected com- through charging by exception from prefer-
puters in the ORs and staff workrooms. The ence cards;
training version was made available to all staff • provide the costs per procedure by surgeon,
members along with the training scenario data. leading to improved decision making;
Despite encouragement to practice with the • make schedules more efficient;
system before it was implemented, few staff • provide data on block time and equipment
members took advantage of the opportunity. usage; and
Communicating as much information as • improve multidisciplinary and patient
possible in as many forums as possible is rec- relations.6
ommended. Staff members commonly said that The second hospital they studied was able to
they were not aware of an aspect or implemen- • make a $500,000 to $750,000 one-time reduc-
tation date for the system. For this implemen- tion in on-hand inventory;
tation, verbal communication included written • improve billing accuracy, which captured
notices in newsletters, e-mails, hand-outs, and 5% more charges;
announcements made to staff members at reg- • enhance decision making through the study
ularly scheduled meetings. of trending data; and
It is difficult to estimate the time and re- • increase regulatory compliance.6
sources needed for this type of project, particu- Implementing a comprehensive perioperative
larly when implementation dates are subject to system can help organizations improve process-
change. The amount of nursing resources re- es, reduce costs while increasing revenues, and
quired for this type of project is enormous. The enhance caregiver satisfaction. Operating room
preparation work involves months of tasks to managers can increase the success of imple-
create or update lists with necessary information. menting an ORMIS by following the framework
After implementation, the system also re- of Delone and McLean2 and incorporating the
quires maintenance of preference cards and factors of that framework proposed by Van Der
templates and updates to the screens to make Meijden et al.3
them as efficient and effective as possible. Some
clinical services elected not to create many tem- CHALLENGES FOR THE FUTURE
plates before the system was implemented. Now that the system has been in effect for al-
After staff members had used the system for most one year and a variety of services are using
awhile, there were many more requests for tem- it, there have been many requests for revisions,

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and certain changes are needed. Some of the additional training is required when changes
screens have been particularly challenging and are made. As staff members continue to access
have required modification. These include the the system and use it to analyze data, the posi-
specimen screen, the count screen, the position- tive impact of the system is being realized.
ing screen, and some of the charge screens with- Overall, staff members’ reception of the soft-
in the system (eg, for implants). Nursing Docu- ware has been positive, and most facility per-
mentation Committee members continue to sonnel have adjusted well to the changes.
answer questions and receive users’ concerns, It takes the commitment of the entire health
and they work to make appropriate adjustments. care team to realize the type of success we have
They also continue to prepare for implementa- had at The Johns Hopkins Hospital. This commit-
tion of the system in other service areas. ment must be sustained from the planning stage
Another required functionality of the through the implementation to the ongoing main-
ORMIS that needs to be developed is a routine tenance of such a system.
mechanism to review the documentation that
the nursing staff members have completed. REFERENCES
When the system was first introduced, some 1. Schneiter EJ, Riley T, Rosenthal J. Rising health care
nurse managers chose to have their staff mem- costs: state health cost containment approaches. Nation-
bers print two copies of final reports so one al Academy for State Health Policy. http://www.nashp
.org/Files/GNL46.pdf. Accessed January 9, 2008.
copy could remain with the chart and the 2. DeLone WH, McLean ER. Information systems
other copy could be reviewed for accuracy and success: the quest for the dependent variable. Inf
completeness. There is a need to standardize Syst Res. 1992;3(1):60-95.
this process and to determine how often this 3. Van Der Meijden MJ, Tange HJ, Troost J, Hasman
documentation should be reviewed. A. Determinants of success of inpatient clinical in-
formation systems: a literature review. J Am Med In-
Some functionality of the system (eg, use of form Assoc. 2003;10(3):235-243.
the Perioperative Nursing Data Set [PNDS], 4. Berg M. Patient care information systems and
imaging capabilities) has not been fully uti- health care work: a sociotechnical approach. Int J
lized, and additional efforts are warranted to Med Inform. 1999;55(2):87-101.
incorporate these features. Refinement of the 5. Berg M. Implementing information systems in
health care organizations: myths and challenges. Int
system’s use of the PNDS is a future goal. Use J Med Inform. 2001;64(2-3):143-156.
of this standardized terminology, however, 6. Meyer M, Driscoll E. Perioperative surgery in the
will require further education of nursing staff twenty-first century—two case studies. AORN J.
members. As described by Doyle,7 the PNDS 2004;80(4):725-733.
establishes a standard nursing language using 7. Doyle M. Promoting standardized nursing lan-
guage using an electronic medical record system.
a taxonomic structure, and it provides the op- AORN J. 2006;83(6):1336-1342.
portunity to collect and compare data to pro-
mote an evidence-based model for nursing
practice. Laurie Ann Saletnik, RN, MSN, is the as-
The system also contains the ability to store sistant director of surgical nursing at The
and link images; however, this functionality Johns Hopkins Hospital, Baltimore, MD.
needs to be developed further. Images of diffi-
cult set ups, unique instruments, and pre- Margaret K. Niedlinger, RN, MIS, BC,
ferred patient positioning can be made avail- CPHIMS is the clinical systems manager at
able to help nursing staff members who use The Johns Hopkins Hospital, Baltimore, MD.
the system. This feature has not yet been fully
utilized. Marisa Wilson, DNSc, MHSc, RN, is an
Although ongoing changes are required to assistant professor at the University of
further customize the system, the essential ele- Maryland School of Nursing, Baltimore.
ments of the system remain unchanged. Little

596 • AORN JOURNAL


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