OPINION/PERSPECTIVES/COMMENTARY

Electronic Health Record Modernization: Nursing Excellence Through Virtual Care

Mary Kate Sweeney, DNP, RN, AMB-BC, CCCTM¹; Jenifer Dow, MSN, RN, AMB-BC¹; Vertina Dyson, MHA, BSN, RN, AMB-BC¹; Susan Keller, MSN, RN, AMB-BC¹; Andria Mingo, MSN-HCSM, RN, AMB-BC; GERO-BC¹; Angela Quimby, MSN, RN¹; Annarika Seecharan, MSN, CNL, RN¹; Nicole Zimmerman, LPN²

¹NESSU Outpatient Registered Nurse, U.S. Department of Veterans Affairs Central Office (VACO), Washington, DC, USA; ²NESSU Outpatient Licensed Practical Nurse, U.S. Department of Veterans Affairs Central Office (VACO), Washington, DC, USA

Keywords: ambulatory care, EHR, electronic health record, nursing, outpatient nursing, peer support, veteran, Veteran Affairs, Veterans Health Administration, virtual care

 

 

The U.S. Department of Veterans Affairs (VA) is undergoing an Electronic Health Record Modernization (EHRM) across the entire enterprise, with the goal of creating a shared Federal Electronic Health Record (FEHR). In 2017, the Veterans Health Administration (VHA) joined with the Department of Defense (DOD) to plan for the transition to a modernized, combined EHR platform to capture the healthcare delivery of both active-duty members and veterans.¹ The VHA anticipated transitioning to the new EHR across all medical centers nationally over a period of 10 years—“the largest EHR transition in history.”¹ The first rollout was in October 2020 in Spokane, Washington, USA.¹

Implementing a new EHR within an organization is challenging and requires flexibility and adaptability from the implementation team.² The VHA recognized that “EHR transitions tend to be highly disruptive, affecting health systems’ productivity, efficiency, care quality, and employee satisfaction.”³ A multi-site qualitative analysis was conducted of end-users following a new EHRM implementation at four U.S. healthcare systems. Several lessons learned included the need to provide scheduled time for EHR trainings, to reduce workload, and to incorporate robust internal support.⁴ To lessen some of these challenges while optimizing the opportunity to deliver safe and effective care to veterans, a multidisciplinary team was established within the VHA—the National EHRM Supplemental Staffing Unit (NESSU).

The NESSU consists of experienced VHA staff from across the country who represent various interdisciplinary sections, including primary care providers, nursing (inpatient and outpatient), behavioral health, pharmacy, and scheduling. This team is deployed to assist in the preparation (pre-Go Live), activation (Go Live), and sustainment (post-Go Live) as the FEHR implementation is rolled out across the VHA Enterprise.

At Go Live, the new FEHR is activated, prompting facilities to begin working solely from that platform for all aspects of veteran care. It is a critical time that requires all hands-on deck to facilitate a smooth transition, optimize various workflows, and troubleshoot concerns that arise. The NESSU’s mission is to support the clinical and administrative functions at VHA medical facilities to sustain services and honor America’s veterans during VA’s EHRM. The vision for NESSU is to offer services that strengthen a facility’s productivity mitigation plan during the pre- and post-Go Live phases of deployment, based on the teams’ knowledge and experience from multiple deployments across the enterprise.

Outpatient Nursing Team

The NESSU’s dynamic outpatient nursing team includes 18 experienced VHA primary care nurses from across the U.S., all of whom are dedicated to delivering safe, patient-centered healthcare for U.S. veterans. Upon its inception, the NESSU outpatient nursing team underwent significant training as new users of the FEHR. This 100% virtual team, all working remotely from home, plays a pivotal role in the FEHR transition by delivering excellent patient care, providing peer support to on-site teams, and enhancing efficiency in the use of the new platform.

Anticipating each site deployment to optimize their coverage ability, the NESSU outpatient nursing team reviews local policies and procedures, nursing scope of practice, and meets with the primary care teams to proactively obtain specific information. The NESSU outpatient nursing team virtually deploys to the primary care clinics, offering real-time clinical support to offset the on-site nurses’ workload and maintain the clinical coverage during the FEHR transition. This allows the on-site teams time to focus on the formal FEHR training, practice new skills, and optimize new workflows without compromising care. NESSU’s outpatient nursing team actively supports the FEHR implementation by delivering virtual care to veterans, providing peer support for on-site nurses, and participating in the manual migration of data.

Virtual Care

Virtual care has benefits in the primary care setting as it provides seamless access to care, reduces barriers based on the veteran’s or clinician’s location, and promotes safe delivery of healthcare for veterans. Telehealth visits “improve patient outcomes, increase access to services, reduce wait times, reduces travel, and are an efficient use of resources.”⁵ Telehealth is a vital component of ambulatory care nursing, allowing for ongoing care coordination and communication while integrating telehealth technologies into the delivery of care.⁶ The NESSU outpatient nursing team provides virtual clinical support for Go Live sites, delivering high-quality care to veterans who are using telehealth.

The virtual care delivered by the NESSU outpatient nursing team includes triage, post-discharge follow-up, pre-appointment calls, test result notification, patient education, and overall care coordination for veterans. The NESSU outpatient nursing team provides direct patient care through various virtual modalities such as telephone, VA Video Connect (VVC), and secure messaging via the VA’s patient portal while upholding data security, the Health Insurance Portability and Accountability Act (HIPAA) compliance, and patient consent when using virtual care modalities. The virtual modality utilized varies based on both the preference and the clinical needs of the veteran, with VVC preferred because of the opportunity for a face-to-face interaction.

Nurse appointments via VVC include blood pressure follow-up with a VA-issued monitor, chronic disease management, education, and triage of symptoms that must be visualized. The NESSU outpatient nurses utilize the VA patient portal and telephone to facilitate communication regarding medication and supply requests, answer clinical questions, and coordinate referrals. The nurses follow through with appropriate assessment and interventions, and effectively communicate with the multidisciplinary primary care team to meet the veterans’ needs.

The NESSU Nursing Outpatient team also conducts pre-appointment telephone calls to veterans in anticipation of their scheduled on-site provider appointment. Pre-appointment calls allow the veteran and provider to make “meaningful use of their time during each clinic visit, enhancing the quality of patient care alongside enhancement of patient-provider communication.”⁷ During this telephone contact, the NESSU outpatient nurses complete preventive healthcare screenings, verify medications and allergies, and remind veterans of their upcoming appointments. This proactive telephone contact aims to optimize appointment intake time, allow more time with their provider, identify any medication or allergy discrepancies, and reduce no-shows.

Peer Support

Peer support is vital to implementing a new EHR successfully, due to the profound changes and learning curve involved for end users. Peer support helps bridge the gap in educational needs and support by having approachable, knowledgeable colleagues available for guidance, offering practical insights, and helping troubleshoot issues. Peer support helps build end-user confidence, fosters a collaborative environment, and positively impacts staff morale and job satisfaction during the FEHR transition. The literature confirms that “identifying a champion or a group of champions who are trusted by peers and colleagues, have knowledge about the EHR system, and believe in it, remains key to a successful implementation.”⁸ This supportive environment leads to a smoother implementation process that contributes to the system’s overall success and improved patient care.

As part of NESSU’s larger peer support program, multiple NESSU outpatient nursing subject-matter experts (SME) provide peer support through various approaches. These include virtual group trainings, one-on-one meetings, and an ongoing Go Live chat. The outpatient nursing SMEs have provided hundreds of hours of FEHR education and peer support to on-site nursing staff pre- and post-FEHR implementation. Additionally, a nurse manager education and support group was established to build a stronger community of practice for pre- and post-Go Live facilities, sharing best practices, and promoting collaboration and communication.

Manual Data Migration

During the pre-Go Live phase of FEHR deployment, NESSU outpatient nurses assist with the facility’s manual data migration, a process of manually entering orders (laboratory/imaging) and consults that failed to migrate into the new FEHR. The nurses’ role in the timely completion of data migration and resolution of identified issues is crucial, ultimately helping prevent delays in veterans’ care and increasing efficiency.

Nursing Excellence

The NESSU nursing outpatient team is dynamic with extensive VA ambulatory care experience and expertise. These nurses are dedicated to delivering effective, virtual healthcare for veterans during the FEHR transition.

Conclusion

Throughout the deployment of NESSU at multiple facilities, local VA leadership and teams have expressed gratitude for the NESSU nurses’ clinical coverage and peer support provided during their FEHR implementation, both pre- and post-Go Live.

Veterans appreciated the virtual access to care that the NESSU team provides when the capacity of their primary care team became limited. The NESSU outpatient nursing team has played a critical role in ensuring safe, high-quality virtual care delivery for veterans during the FEHR transition at five facilities, awaiting further rollout across the VHA enterprise.

Contributors

Mary Kate Sweeney prepared the final manuscript. Mary Kate Sweeney, Jenifer Dow, Vertina Dyson, Susan Keller, Andria Mingo, Angela Quimby, Annarika Seecharan, and Nicole Zimmerman read and agreed to the published version of the manuscript.

Data Availability Statement (Das), Data Sharing, Reproducibility, and Data Repositories

Not applicable.

Application of AI-Generated Text or Related Technology

The authors did not use AI-Generated text or related technology.

Acknowledgments

Ms. Katherine Andersen, Ms. Kari Rhode, and Dr. James Weiss reviewed and approved the manuscript.

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