International Journal of Medical Informatics (2005) 74, 960—972
Nurses’ information management across complex health care organizations Ragnhild Hellesø a,∗, Lena Sorensen b, Margarethe Lorensen a a
Faculty of Medicine, Institute of Nursing and Health Sciences, University of Oslo, P.O. Box 1153 Blindern, NO-0318 Oslo, Norway b School of Nursing, University of Colorado Health Sciences Center, 4200 East Ninth Ave Denver, CO 80262, USA KEYWORDS Information management; Hospital nurses; Home care nurses; Information exchange; Electronic patient record; Organizational management
Summary The purpose of this study was to describe the information management used by hospital and home care nurses for patients in need of continuing care after an episode of hospitalization. Method:: A prospective descriptive design was used. In total 287 hospital nurses and 220 home care nurses were asked to complete a questionnaire before and after the hospital implemented nursing documentation integrated in the electronic patient record (EPR). Results:: Discrepancies between the policies expressed by the health care organizations and the authorities in formal documents and the information management used by the nurses were identified. Differences were also found between nurses in hospital and home care with regard to how they assessed the information management during patient admission, throughout the patient’s hospital stay and at the patient’s discharge. The perceived differences decreased, however, after the hospital introduced electronic nursing documentation. The study shows a need to contextualize and customize the information that nurses exchange. In addition technological problems with the lack of integrated EPR systems between the hospital and the home health care as well as different practice models in the two organizations entail complex information handling during a patient’s trajectory through the health system. © 2005 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Communication and coordination between providers have been identified as crucial for patients who ∗ Corresponding author. Tel.: +47 22 85 05 66; fax: +47 22 85 05 70. E-mail address:
[email protected] (R. Hellesø).
need health care across different organizational settings [1]. Managing patients’ trajectories in health care is considered to be a collective and cooperative enterprise [2]. Patients, however, experience two types of trajectories: the course of their illness and the trajectory of the health care systems [1]. The purpose of this paper is to report a descriptive study that explores the information management used by hospital and home care
1386-5056/$ — see front matter © 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijmedinf.2005.07.010
Nurses’ information management acrosscomplex health care organizations nurses for patients in need of inter-organizational care, i.e. the patients’ trajectory from home to hospital to home. A study from a university hospital and the affiliated home care agencies in Oslo, the capital of Norway, is used to illustrate information management before and after the hospital introduced nursing documentation in the electronic patient record (EPR). At the time the present study was conducted, the university hospital was the only one in Norway which had planned to implement the nursing documents in the EPR. Health care systems are characterized by complexity, diversity, and variation [2—4]; they are information-intensive [4,5], and specialized [6]. Complexity is a result of the shift in health care delivery from individual to organizational processes, the diversity of the professional providers, and the diversity of the organizational settings in which the providers work: hospitals, nursing homes, home care, etc. A shift in the community’s responsibility has also taken place [7]. Due to earlier discharge, more complex patient problems must now be solved in the community [8]. This places greater demands on the coordination and information flow between the two organizational levels. Two perspectives have been identified in inter-organizational continuity of care: an individual and organizational perspective. At the individual level, the emphasis is on informal networks and communication between health care providers or between patients and providers. From the organizational perspective, informal as well as formal structures are emphasized as coordination mechanisms [9]. This paper focuses on the organizational rather than the individual perspective. The structure in an organization in turn has two perspectives: an external perspective that clarifies the type of organization and an internal perspective where the purpose is to ensure regularity and predictable behavior from the staff [10]. Mintzberg (1983) claims that all organizations are based on two fundamentally opposed requirements: (1) the division of labor into distinct tasks, and (2) the coordination mechanisms among these tasks [11]. Formal structures refer to the division of labor which shows how an organization coordinates the work for achieving its goals [12]. According to Shortell and Kaluzny (1983), hospitals and community-based service are two different types of organizations. They are, however, interdependent organizations within the health care systems, especially when patients need care across these organizational levels. This requires the organizations to consider the coordination mechanisms for managing inter-organizational interdependency [10].
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Mintzberg (1979) developed a typology of coordination mechanisms comprising five basic components: (1) mutual adjustment, (2) direct supervision, (3) standardization of work processes, (4) work output, and (5) worker skills [13]. Argyris and Sch¨ on (1996) point out that structures and procedures link individual members of the organization to organizational processes: ‘‘organizational actions cannot be reduced to the action of individuals’’ and ‘‘there is no organizational action without individual action’’ [14, p. 8]. The individual acts on behalf of the organization based on the organization’s policies and rules. These policies and rules must be made explicit inorder for the members of the organization to act. Nikula (1999) points out that an organization’s policies and written values do not always correspond with the values and assumptions guiding its daily actions [15]. Argyris and Sch¨ on (1989) describe this conflict in terms of espoused theory and theory-in-use [16]. An organization’s policies, for example as set out in formal documents, regarding the organizational structures or strategic plans become the official version, but what really happens may be different [17]. How the formal structures are implemented reflects the informal structures and depends on the people involved. Yet at the same time, both formal and informal structures influence each other [18].
1.1. Formal structures In Norway, the National Board of Health has developed strategic information management plans for health care systems, stating that it is a goal to provide a health care system characterized by quality and continuity of care [7,19,20]. Information technology is presented as one of the tools to be used in an effort to compensate for the fragmentation of health care which has arisen from the modernization of the health care organization. The implementation of electronic patient records (EPR) to bridge gaps in patient care has, however, not been as successful as expected [2,21,22]. Systems to support clinical care and decision support systems have been developed and demonstrated potential benefits, but have been used by the providers only to a limited extent [23]. In Norway, health care is financed by taxes. Hospitals are financed by the State and home care by the local authorities. The two health care levels have different legislations [24,25] which govern their responsibility of care to protect patients’ rights to appropriate health care [26]. A hospital may not discharge a patient in need of continuing care unless appropriate care has been arranged. In addition, the health authority has developed
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regulations which permit the hospital to charge the community unit for a patient stay if home care in the community is assessed to be more appropriate for the patient than further hospitalization [27]. Health care providers are obligated to exchange patient details when a patient needs continuing care post-hospital [28]. The university hospital that participated in this study has developed a written policy based on the legislation and regulations. The policy governs the coordination procedure and the financial responsibility when a patient needs post-hospital community care. To ensure a standardized exchange of information in the discharge planning process the use of two different referrals, named A- and Breferrals, is specified. The A-referral is intended to be used when a patient is admitted to inform the community services about a patient who might need post-hospital care. The head nurse or the primary nurse is responsible for issuing the A-referral and for making a telephone call in this connection. When the patient is assessed as ready for discharge, the B-referral is used. The B-referral can be faxed to the home care agency. The B-referral has been integrated in the hospital EPR system since 1998. However, the hospital is not able to send this electronically because the hospital information system cannot interface with the home care information system.
charge [9,38,39]. Gaps [40] and delays [33] in the information exchange are also reported.
1.2. Informal structures
2.1. Participants and procedure
Attention to organizational aspects is necessary to realize the benefits of health care informatics [29]. The nurses’ response to the formal policy is what Argyris and Sch¨ on call the theory-in-use. Various aspects of theory-in-use have been identified to facilitate the process of a patients’ trajectory. Systems for structured exchange of information, such as special and standardized referral have resulted in the exchange of more nursing information [30,31]. Telephone calls, however, seem to be a preferred method for information exchange but are found impractical [32]. In addition, clarifying the content of information to be exchanged at the patient’s admission [33,34], developing effective communication and information management processes during the discharge planning process [35] as well as structures for and content of information at discharge [36] seem to be of importance to ensure continuity of inter-organizational care. It is stated that a nursing discharge note should be available for nurses in EPR as a tool to contribute to inter-organizational care for patients [37]. It is, however, found that the nurses do not always exchange a discharge note at the patient dis-
A convenience sample consisting of head nurses, staff nurses, and clinical nursing specialists in the hospital and home care agencies were invited to participate and respond to a questionnaire both before and after the hospital implemented the electronic nursing discharge note. The communities had structured their organizations between an administrative department whose health care providers decided the goals and interventions for patient care and the nurses who provided the direct care for the patient. Both the administrative office and the direct care providers were included in the study. All the participants had to have been in their position for at least 1.5 year, either as temporary or permanent staff, and be able to read and understand Norwegian. The discussions with the contact persons were conducted to obtain background data about the organizations in which they worked and cooperated with. A total of 507 nurses met the inclusion criteria. The pre-implementation data collection conducted in 2002 138 hospital nurses and 115 home health care nurses were included. After the hospital implemented nursing documentation in EPR, 149
2. Methods and materials A prospective descriptive study with a pre- and post-test approach was conducted on 10 wards in the Department of Internal Medicine and two wards in the Cardiopulmonary Department at the University Hospital. In addition, the 11 home care agencies affiliated with the hospital were invited to participate. The university hospital was in the process of implementing nursing documentation containing nursing notes and a nursing discharge note integrated in the hospital’s DocuLive ® EPR system [41,42]. In this paper, the term EPR implementation refers to the stage at which the nurses received access to the documentation in EPR. Doctors and some other providers had received access since 1999. The EPR implementation was accomplished in a natural setting without the researchers’ intervention. Both hospital and home care nurses were invited to complete a questionnaire before and after the hospital implemented nursing documentation integrated in the hospital’s EPR. Notes were taken during meetings and discussions with contact persons in both the hospital and the home care agencies.
Nurses’ information management acrosscomplex health care organizations hospital nurses and 105 home care nurses were included. This data was collected between March and September 2003, at least 3 months after the nurses in the hospital nurses had started to use electronic documentation. The focus of this study is on the organizational systems and how they influence the communication process before and after the EPR implementation. Due to high turnover and organizational changes both in the community services around the first time of data collection and between the two times of data collection in the University Hospital, it was not possible to track the individual nurses. Tracking individual nurses would have reduced the total sample at the post-implementation data collection. Before the data collection started, the researcher organized meetings with all the hospital wards and home care agencies and informed them about the study. In addition, each ward and agency received written information about the project, and who the nurses could contact if there were any questions. A contact person in each ward and at each home care agency was responsible both for distribution and for reminding the nurses about the questionnaire.
2.2. Questionnaire Questionnaires aiming at exploring aspects of continuity of care were assessed. There were, however, no questionnaires that specifically covered the research questions for this study. Therefore, questions relevant for this study were developed based on previous literature about patients’ trajectory and related to continuity of care [26,43—48].
Table 1
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Content validity of the questionnaire was based on the conceptualization of inter-organizational care [9,48]. An expert panel, consisting of two nurse researchers, two hospital nurses, two home care nurses and one nurse with long experience in helping patients who need a nurse during their transfer from hospital, was used to evaluate the questionnaire in accordance with the recommendations of Haraldsen (1999) and of Polit and Beck (2004) [49,50]. The instrument was pilot-tested by nine home care nurses and 16 hospital nurses. Some minor revisions were made after the pilot test. This paper addresses the findings from the sections reflecting how the hospital and home care nurses assess the structures and content of information exchange throughout the patient’s trajectory from admission to discharge from hospital. The hospital and home care nurses were asked the same questions, replacing ‘‘send’’ with ‘‘receive’’ to correspond with the direction of the information flow. The questions and number of items the nurses were asked to answer are described in Table 1. The nurses scored each item on a Likert-type scale on a 1—4 scale, where 1 = never, 2 = sometimes, 3 = often, and 4 = always. The overall Chronbach’s alpha for the questions was .94. In addition, the hospital nurses were asked to: ‘‘indicate the two most important aspects on which information should be received at a patient’s admission’’. They could choose between six items (reason for admission, medication, current services, physical functional level, psychological functional level, and social/family network). The question referred to those patients who had already received home nurse care before hospitalization.
The questions addressed in the present paper are shown in the table Hospital nurses were asked
Home care nurses were asked
On admission
1. How do you receive information about the patient admitted to hospital (when the patient is already receiving home health care) (six items) 2. If you receive information about the patient, what is the content of the information? (six items)
1. How do you inform the hospital about patient admitted to hospital (when the patient already is receiving home health care) (six items) 2. If you send information about the patient, what is the content of the information? (six items)
During the patient hospital stay
1. What structures for communication tools do you have with the home care nursing services during the discharge planning process? (six items) 2. How does the contact with the home care nursing services take place (in the discharge planning process) (two items)
1. What structures for communication tools do you have with the hospital during the discharge planning process? (six items)
1. How do you exchange written information? (six items)
How do you exchange written information? (six items)
At discharge
2. How does the contact with the hospital take place (in the discharge planning process)? (two items)
R. Hellesø et al.
(˚): 2 -exact test has been performed; ( ): Independent-samples t-test has been performed. * p < .05. ** p < .01. *** p < .001.
84 (86.6) 11 (11.6) 50 (67.6) 24 (32.4) 70 (83.3) 14 (16.7)
(˚)*
50 (79.4) 13 (20.6)
(˚)*** 45/18 (71.4/28.6) 84/8 (91.3/8.7) 55/20 (73.3/26.7) 76/8 (90.5/9.5)
(˚)**
3.6 (2.9) 3.0 (2.3) 4.2 (4.1) 3.2 (2.9)
( )*** ( )***
p-value Home care nurses (n = 64)
61/3 (95.3/4.7) 40.7 (8.4) 12.8 (7.5) 89/6 (93.7/6.3) 31.5 (8.3) 5.6 (6.4)
Hospital nurses (n = 97) p-value Home care nurses (n = 80)
72/8 (90.0/10.0) 39.8 (8.7) 12.5 (8.8)
Hospital nurses (n = 88)
Demographic information
Demographic characteristics of the study participants
A total of 337 (66.4%) questionnaires was returned, consisting of 189 (65.9% response rate) from the hospital nurses (90 before and 99 after EPR) and 148 (67.2% response rate) from the home care nurses (84 before and 64 after EPR, respectively). Eight questionnaires, six at the first time of data collection and two at the second time-point of data collection, were excluded for further analysis due to deficiencies. Two of the 11 home care agencies were not able to participate in the study. Differences between the hospital nurse group and the home care nurse group were found. The nurses in home care were older and more experienced than the nurses in the hospital (hospital nurses: mean age 31.7, S.D. 8.4; home care nurses: 39.8, S.D. 8.7, p-value < .001 at the preimplementation data collection and 31.5, S.D. 8.3 and 40.7 S.D. 8.4 respectively, p-value < .001 at the second time) (see Table 2). More hospital nurses held full-time positions. No difference at the two times of data collection was found within each nurs-
Table 2
3. Findings
After EPR implementation
SPSS version 11 was used for descriptive analysis of the data. The providers’ assessment of the extent to which they used different structures and exchanged information throughout the patient hospital stay is presented as frequencies. The Likert scale was dichotomized into two categories, where ‘‘seldom’’ and ‘‘sometimes’’ classified as ‘‘sometimes’’, while ‘‘often’’ and ‘‘always’’ were classified as ‘‘often’’. To compare differences in views between the hospital and home care nurses, and between administrative and direct provider nurses in home care, a 2 -test was used. In the cases when the assumptions for 2 -test were not met, Fischer’s exact test was used. A P value of
