- Email: [email protected]
Electronic communications: E-mail in the emergency department
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o m m u n i c a t i o n m i g h t b e c o n s i d e r e d to b e at t h e h e a r t of nursing. To facilitate c o m m u n i c a t i o n s in our e m e r g e n c y d e p a r t m e n t , w e d e c i d e d to p u t our c o m p u t e r s to w o r k as c o m m u n i c a t i o n tools b y u s i n g t h e following s t e p s .
n a t e d to m o r e t h a n 150 staff m e m b e r s at t h e t h r e e sites. It b e c a m e a p p a r e n t t h a t all t h e s e efforts could be facilitated through improved communication. Electronic c o m m u n i c a t i o n s , or E-mail, h a d p r o m i s e to help us m e e t our goals.
Determining need Our e m e r g e n c y d e p a r t m e n t is one of t h r e e in a
System design and planning activities
r e c e n t l y r e g i o n a l i z e d h o s p i t a l s y s t e m in Portland, Oregon. Two a r e s i t e s in l a r g e (450- a n d 480-bed) m e t r o p o l i t a n hospitals, c a r i n g for 45,000 a n d 38,000 p a t i e n t s annually. R e g i o n a l i z a t i o n efforts m a g n i f i e d t h e n e e d for b e t t e r c o m m u n i c a t i o n a m o n g a g r e a t e r n u m b e r of p e o p l e w o r k i n g in multiple hospital sites. In addition, our ED s y s t e m is m a n a g e d w i t h a s h a r e d g o v e r n a n c e model, r e q u i r i n g a g a t h e r i n g of m i n d s a n d i d e a s to d e t e r m i n e a n d a c h i e v e d e p a r t m e n t goals.
Communication challenges T h e ED r e g i o n a l d i r e c t o r m a n a g e s t h r e e s e p a r a t e s i t e s w i t h s e v e r a l levels of staff: r e g i s t e r e d nurses, physicians, t e c h n i c i a n s , a n d s e c r e t a r i e s , e a c h g r o u p having individual information needs. Each site has a clinical coordinator w h o is challenged to provide educational activities, track a n d m a n a g e p a t i e n t care a n d satisfaction issues, act as intermediary between a d m i n i s t r a t i o n a n d staff, a n d to facilitate t h e s m o o t h daily functioning of t h e d e p a r t m e n t . In a d d i t i o n to d e p a r t m e n t a l c o m m i t t e e s for c o n t i n u o u s q u a l i t y improvement, n u r s i n g council, a n d education, regional c o m m i t t e e s m a d e u p of staff from e a c h d e p a r t m e n t m e e t to develop policy t h a t affects all three sites. Collaborative efforts b e t w e e n e m e r g e n c y n u r s e s a n d p h y s i c i a n s are b e i n g e n c o u r a g e d . All t h e d e c i sions and information generated must be dissemiLeeta Stoughton is staff nurse, and acts as the coordinator and clinical resource for the computer system in the Emergency Department, St. Vincent's Hospital, Portland, Oregon (E-mail address [email protected]) Reprints not available from author. J Emerg Nuts 1996;22:336-8. Copyright 9 1996 by the Emergency Nurses Association. 0099-1767/96 $5.00 + 0 18/62/73549 336
Volume 22, Number 4
Our work g r o u p c o n s i s t e d of a p r o j e c t coordinator, t h e r e g i o n a l director, t h e clinical c o o r d i n a t o r s from e a c h ED site, a n d I n f o r m a t i o n S e r v i c e s (IS), our regionalized hospital computer department. H a v i n g e s t a b l i s h e d t h e n e e d , w e d e f i n e d our objectives, w h i c h t r a n s l a t e d into s o f t w a r e requirem e n t s . We n e e d e d a s y s t e m w i t h t h e c a p a b i l i t y for i n d i v i d u a l c o m m u n i c a t i o n s , b o t h small a n d large
These eight "supertrainers" t r a i n e d t h e r e s t of t h e s t a f f members during the next 2 to 3 w e e k s a n d a c t e d a s resource persons while on duty.
g r o u p c o m m u n i c a t i o n s , a n d a n e l e c t r o n i c "bulletin board" for a n n o u n c e m e n t s a n d d i s c u s s i o n . Our hosp i t a l u s e s L o t u s c c : m a i l (Lotus D e v e l o p m e n t Corporation, C a m b r i d g e , Mass.) a s its d e s i g n a t e d Em a i l application. This E-mail s y s t e m p r o v i d e d all t h e c o m m u n i c a t i o n tools w e s o u g h t ; t h u s f u r t h e r research and purchase decisions were unnecessary. A s s e s s i n g our r e s o u r c e s i n c l u d e d a work site a s s e s s m e n t : a look at e x i s t i n g h a r d w a r e a n d software, a n d c o n s i d e r a t i o n of h o w to i n t e g r a t e t h e n e w s y s t e m into daily w o r k flow w i t h m i n i m a l disruption. Our existing c o m p u t e r a c c e s s w a s adequate; w e h a d u p g r a d e d our personal c o m p u t e r s w h e n w e m o v e d
Stoughton/JOURNAL OF EMERGENCY NURSING
to n e w facilities 3 y e a r s ago. T h e r e a r e 10 p e r s o n a l c o m p u t e r s for staff a c c e s s in our 3 7 - b e d c o m b i n e d E D / U r g e n t Care d e p a r t m e n t , d i s t r i b u t e d a m o n g four n u r s i n g w o r k s t a t i o n s a n d one d o c t o r ' s area. T h e pers o n a l c o m p u t e r s a r e n e t w o r k e d to c e n t r a l h o s t servers, a n d o p e r a t e u n d e r t h e W i n d o w s (Microsoft, R e d m o n d , Wash.) e n v i r o n m e n t . E m e r g e n c y n u r s e s h a v e a c c e s s to p a t i e n t data, i n c l u d i n g a d m i s s i o n information, order entry, a n d l a b o r a t o r y a n d r a d i o l o g y r e p o r t s t h r o u g h t h e h o s p i t a l i n f o r m a t i o n s y s t e m . We c a n a c c e s s C h e c k o u t (Logicare Corp., E a u Claire, Wis.), a c o m p u t e r i z e d d i s c h a r g e i n s t r u c t i o n p r o g r a m t h a t also p r o v i d e s a d a t a b a s e a n d r e p o r t g e n e r a t o r for t h e ED e l e c t r o n i c log. T h e s e c o m p u t e r a p p l i c a t i o n s p r o v i d e t h e e m e r g e n c y n u r s e s w i t h critical d a t a u s e d to p r o v i d e p a t i e n t care. In a d d i t i o n , t h e Portland hospitals a r e electronically l i n k e d t h r o u g h t h e c o m p u t e r n e t w o r k , a n d all t h e h o s p i t a l s in t h e S i s t e r s of P r o v i d e n c e H e a l t h S y s t e m from A l a s k a to California s h a r e a c c e s s t h r o u g h E-mail. A p r o p o s a l w a s m a d e to IS to p r o v i d e E-mail a c c o u n t s to e a c h m e m b e r of t h e ED staff at t h e t w o P o r t l a n d h o s p i t a l s to c r e a t e a g r o u p c o m m u n i c a t i o n e n v i r o n m e n t . W i t h i n this s y s t e m , w e p r o p o s e d t h e following c a t e g o r i e s a n d levels of c o m m u n i c a t i o n : 9E-marl a d d r e s s e s for e a c h staff m e m b e r : individual communications 9P r i v a t e mail groups: c o m m i t t e e c o m m u n i c a t i o n s 9Public m a i l groups: i n t e r d e p a r t m e n t a l a n d i n t r a d e partmental communications 9B u l l e t i n b o a r d s : a n n o u n c e m e n t s , discussion groups, educational postings
Computers were already i n t e g r a t e d into our e v e r y d a y practice, a n d a d d i n g E-mail communications addressed a defined need.
Implementation I m p l e m e n t a t i o n i n v o l v e d i n s t a l l a t i o n of t h e p r o g r a m a n d t r a i n i n g of t h e s y s t e m users. During t h e p l a n n i n g s t a g e , w e f o u n d it helpful to d r a w up a w r i t t e n p l a n t h a t i n c l u d e d tasks, c o m p l e t i o n d a t e s , a n d a s s i g n e d p e r s o n n e l . (It h e l p s to k e e p a log of your a c t i v i t i e s as y o u i m p l e m e n t this w r i t t e n plan.) Our E-mail p r o j e c t w a s o n e of m a n y in p r o g r e s s for our r e g i o n a l c o m p u t e r d e p a r t m e n t . K e e p i n g t r a c k of w h o is d o i n g w h a t , a n d w h e n , h e l p s k e e p y o u r t i m e line on track, a n d f a c i l i t a t e s p r o b l e m solving w h e n n e e d e d .
Table 1 E-mail training: Using the system The basics Accessing the program Using and changing p a s s w o r d s What the icons m e a n and w h a t they do Sending n e w marl m e s s a g e s Sending mail: addressing to individuals and groups Deleting mail and exiting the program More a d v a n c e d applications Personalizing your mailbox: more on icons Creating folders and storing mail Creating private mail groups Sending mail via the Internet Miscellaneous, but important Netiquette (E-marl manners and mores) Security and confidentiality (know what your institution's policies are!)
Before i m p l e m e n t a t i o n , w e c o m p l e t e d s e v e r a l tasks. We s t r u c t u r e d our E-mail s y s t e m b y c o m p i l i n g lists of n a m e s a n d d e t e r m i n e d p u b l i c mail g r o u p s to b e s e t u p b y IS. W e d e c i d e d to h a v e a n all-staff m a i l g r o u p ( a d d r e s s list) for e a c h d e p a r t m e n t , a n d s e p a r a t e a d d r e s s E - m a i l lists for r e g i s t e r e d n u r s e s a n d p h y s i c i a n s . A s i n g l e r e g i o n a l i z e d list w a s not s e t u p b e c a u s e it w a s a s i m p l e m a t t e r to a d d r e s s c o m m u n i c a t i o n s to t w o s e p a r a t e m a i l g r o u p s , a n d b e c a u s e it w o u l d m i n i m i z e t h e c h a n g e s r e q u i r e d b y t h e IS E-mail administrator accompanying a n y staff c h a n g e s . All e x i s t i n g p e r s o n a l c o m p u t e r s normally u s e d d u r i n g p a t i e n t c a r e w e r e c o n f i g u r e d to p r o v i d e t h e staff a c c e s s to t h e E-mail p r o g r a m . Training i n v o l v e d t e a c h i n g 160 staff m e m b e r s h o w to u s e a n E - m a i l s y s t e m . Our r e g i o n a l i z e d syst e m h a s a r e s o u r c e p e r s o n available to p r o v i d e training, b u t t r a i n i n g a large n u m b e r of p e o p l e on a n e w p r o g r a m still p r e s e n t e d a challenge. We i m p l e m e n t e d o n e s i t e at a time; t r a i n i n g m e t h o d s differed, w h i c h affected how quickly the communication system was u s e d b y staff. A t one site, a c a d r e of staff w a s c h o s e n for e a c h shift a n d w e e k e n d ; t h e y a t t e n d e d a 2-hour t r a i n i n g s e s s i o n in a c o m p u t e r t r a i n i n g r o o m w i t h t h e IS trainer. T h e s e e i g h t "supertrainers" t r a i n e d t h e r e s t of t h e staff m e m b e r s d u r i n g t h e n e x t 2 to 3 w e e k s a n d a c t e d as r e s o u r c e p e r s o n s while on duty. D u r i n g d o w n t i m e on a s c h e d u l e d shift, t h e s u p e r t r a i n e r s w o r k e d w i t h o n e or t w o i n d i v i d u a l s a t a t i m e in t h e d e p a r t m e n t for 10- to 2 0 - m i n u t e periods. Basic u s e of t h e E-mail s y s t e m w a s t a u g h t initially, a d d i n g m o r e c o m p l e x functions, s u c h a s c r e a t i n g p r i v a t e m a i l i n g lists, a s n e e d a n d r e a d i n e s s arose. S o m e staff m e m -
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bers are quite computer literate and can master the complexities early, but others may be nearly computerphobic and benefit from an incremental learning process (Table 1).
Our s t a f f m e m b e r s r e p o r t that they have a much better s e n s e of b e i n g u p - t o - d a t e e v e n w h e n w o r k i n g part-time. N u r s e s u s e t h e s y s t e m to s e e k shift c o v e r a g e , a n n o u n c e committee meetings and share minutes, survey other staff for n e e d s a n d o p i n i o n s , s e n d n o t e s of a p p r e c i a t i o n or s u g g e s t i o n s for p r a c t i c e , a n d k e e p in t o u c h w i t h staff with schedules different from their own.
The second site began one-on-one training during downtime on individual work shifts, without establishing a supertrainer group. Training the entire staff took m u c h longer, and general use of the system also was delayed. Using a group of supertrainers definitely facilitated the implementation process. Written materials, including a tip sheet and quick reference guides, were placed by each computer where E-mail was accessed.
for departmental communications (memos, policy changes, newsletters, patient compliments, continuous quality improvement concerns and results, educational opportunities, and position postings), it became a very useful tool, replacing our communication notebook as the primary source of information. The notebook is still maintained to avoid printing multiple copies for those who prefer hard copies. Administration now has a reliable means for communicating essential information to each staff member. Each staff member must check E-mail daily early in the shift for the system to be effective. This expectation is best expressed early in implementation. Staff members can then develop strategies to read E-mail messages without affecting patient care. Our staff members report that they have a much better sense of being up-to-date even when working part-time. Nurses use the system to seek shift coverage, announce committee meetings and share minutes, survey other staff for needs and opinions, send notes of appreciation or suggestions for practice, and keep in touch with staff with schedules different from their own. This asynchronous communication system meshes well with our asynchronous staffing patterns. Physicians, skeptical at first, increasingly find the system useful for their own communications and physician group work. Through E-mail, health care providers are given an avenue to explore the potential uses of informatics in practice. Continued development of this communication system is planned. Implementation of the E-mail bulletin board will provide a shared access area for a n n o u n c e m e n t s and group discussions. Dial-in access from home computers with modems will increase access to communications by staff. Adding Internet connections will open the channels to tremendous assets of on-line knowledge resources and professional networking.
Evaluation Several factors contributed to the initial success of our communication system. Computers were already integrated into our everyday practice, and adding E-mail communications addressed a defined need. When the clinical coordinators began to use the system
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Volume 22, Number 4
Contributions to this column should be sent to Vicky Bradley, RN, MS, 4017 Palomar Blvd., Lexington, Is phone (606) 257-2350 (E-mail address: vmbradle 0~taonode.mvs.hosp.uky.edzO
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o m m u n i c a t i o n m i g h t b e c o n s i d e r e d to b e at t h e h e a r t of nursing. To facilitate c o m m u n i c a t i o n s in our e m e r g e n c y d e p a r t m e n t , w e d e c i d e d to p u t our c o m p u t e r s to w o r k as c o m m u n i c a t i o n tools b y u s i n g t h e following s t e p s .
n a t e d to m o r e t h a n 150 staff m e m b e r s at t h e t h r e e sites. It b e c a m e a p p a r e n t t h a t all t h e s e efforts could be facilitated through improved communication. Electronic c o m m u n i c a t i o n s , or E-mail, h a d p r o m i s e to help us m e e t our goals.
Determining need Our e m e r g e n c y d e p a r t m e n t is one of t h r e e in a
System design and planning activities
r e c e n t l y r e g i o n a l i z e d h o s p i t a l s y s t e m in Portland, Oregon. Two a r e s i t e s in l a r g e (450- a n d 480-bed) m e t r o p o l i t a n hospitals, c a r i n g for 45,000 a n d 38,000 p a t i e n t s annually. R e g i o n a l i z a t i o n efforts m a g n i f i e d t h e n e e d for b e t t e r c o m m u n i c a t i o n a m o n g a g r e a t e r n u m b e r of p e o p l e w o r k i n g in multiple hospital sites. In addition, our ED s y s t e m is m a n a g e d w i t h a s h a r e d g o v e r n a n c e model, r e q u i r i n g a g a t h e r i n g of m i n d s a n d i d e a s to d e t e r m i n e a n d a c h i e v e d e p a r t m e n t goals.
Communication challenges T h e ED r e g i o n a l d i r e c t o r m a n a g e s t h r e e s e p a r a t e s i t e s w i t h s e v e r a l levels of staff: r e g i s t e r e d nurses, physicians, t e c h n i c i a n s , a n d s e c r e t a r i e s , e a c h g r o u p having individual information needs. Each site has a clinical coordinator w h o is challenged to provide educational activities, track a n d m a n a g e p a t i e n t care a n d satisfaction issues, act as intermediary between a d m i n i s t r a t i o n a n d staff, a n d to facilitate t h e s m o o t h daily functioning of t h e d e p a r t m e n t . In a d d i t i o n to d e p a r t m e n t a l c o m m i t t e e s for c o n t i n u o u s q u a l i t y improvement, n u r s i n g council, a n d education, regional c o m m i t t e e s m a d e u p of staff from e a c h d e p a r t m e n t m e e t to develop policy t h a t affects all three sites. Collaborative efforts b e t w e e n e m e r g e n c y n u r s e s a n d p h y s i c i a n s are b e i n g e n c o u r a g e d . All t h e d e c i sions and information generated must be dissemiLeeta Stoughton is staff nurse, and acts as the coordinator and clinical resource for the computer system in the Emergency Department, St. Vincent's Hospital, Portland, Oregon (E-mail address [email protected]) Reprints not available from author. J Emerg Nuts 1996;22:336-8. Copyright 9 1996 by the Emergency Nurses Association. 0099-1767/96 $5.00 + 0 18/62/73549 336
Volume 22, Number 4
Our work g r o u p c o n s i s t e d of a p r o j e c t coordinator, t h e r e g i o n a l director, t h e clinical c o o r d i n a t o r s from e a c h ED site, a n d I n f o r m a t i o n S e r v i c e s (IS), our regionalized hospital computer department. H a v i n g e s t a b l i s h e d t h e n e e d , w e d e f i n e d our objectives, w h i c h t r a n s l a t e d into s o f t w a r e requirem e n t s . We n e e d e d a s y s t e m w i t h t h e c a p a b i l i t y for i n d i v i d u a l c o m m u n i c a t i o n s , b o t h small a n d large
These eight "supertrainers" t r a i n e d t h e r e s t of t h e s t a f f members during the next 2 to 3 w e e k s a n d a c t e d a s resource persons while on duty.
g r o u p c o m m u n i c a t i o n s , a n d a n e l e c t r o n i c "bulletin board" for a n n o u n c e m e n t s a n d d i s c u s s i o n . Our hosp i t a l u s e s L o t u s c c : m a i l (Lotus D e v e l o p m e n t Corporation, C a m b r i d g e , Mass.) a s its d e s i g n a t e d Em a i l application. This E-mail s y s t e m p r o v i d e d all t h e c o m m u n i c a t i o n tools w e s o u g h t ; t h u s f u r t h e r research and purchase decisions were unnecessary. A s s e s s i n g our r e s o u r c e s i n c l u d e d a work site a s s e s s m e n t : a look at e x i s t i n g h a r d w a r e a n d software, a n d c o n s i d e r a t i o n of h o w to i n t e g r a t e t h e n e w s y s t e m into daily w o r k flow w i t h m i n i m a l disruption. Our existing c o m p u t e r a c c e s s w a s adequate; w e h a d u p g r a d e d our personal c o m p u t e r s w h e n w e m o v e d
Stoughton/JOURNAL OF EMERGENCY NURSING
to n e w facilities 3 y e a r s ago. T h e r e a r e 10 p e r s o n a l c o m p u t e r s for staff a c c e s s in our 3 7 - b e d c o m b i n e d E D / U r g e n t Care d e p a r t m e n t , d i s t r i b u t e d a m o n g four n u r s i n g w o r k s t a t i o n s a n d one d o c t o r ' s area. T h e pers o n a l c o m p u t e r s a r e n e t w o r k e d to c e n t r a l h o s t servers, a n d o p e r a t e u n d e r t h e W i n d o w s (Microsoft, R e d m o n d , Wash.) e n v i r o n m e n t . E m e r g e n c y n u r s e s h a v e a c c e s s to p a t i e n t data, i n c l u d i n g a d m i s s i o n information, order entry, a n d l a b o r a t o r y a n d r a d i o l o g y r e p o r t s t h r o u g h t h e h o s p i t a l i n f o r m a t i o n s y s t e m . We c a n a c c e s s C h e c k o u t (Logicare Corp., E a u Claire, Wis.), a c o m p u t e r i z e d d i s c h a r g e i n s t r u c t i o n p r o g r a m t h a t also p r o v i d e s a d a t a b a s e a n d r e p o r t g e n e r a t o r for t h e ED e l e c t r o n i c log. T h e s e c o m p u t e r a p p l i c a t i o n s p r o v i d e t h e e m e r g e n c y n u r s e s w i t h critical d a t a u s e d to p r o v i d e p a t i e n t care. In a d d i t i o n , t h e Portland hospitals a r e electronically l i n k e d t h r o u g h t h e c o m p u t e r n e t w o r k , a n d all t h e h o s p i t a l s in t h e S i s t e r s of P r o v i d e n c e H e a l t h S y s t e m from A l a s k a to California s h a r e a c c e s s t h r o u g h E-mail. A p r o p o s a l w a s m a d e to IS to p r o v i d e E-mail a c c o u n t s to e a c h m e m b e r of t h e ED staff at t h e t w o P o r t l a n d h o s p i t a l s to c r e a t e a g r o u p c o m m u n i c a t i o n e n v i r o n m e n t . W i t h i n this s y s t e m , w e p r o p o s e d t h e following c a t e g o r i e s a n d levels of c o m m u n i c a t i o n : 9E-marl a d d r e s s e s for e a c h staff m e m b e r : individual communications 9P r i v a t e mail groups: c o m m i t t e e c o m m u n i c a t i o n s 9Public m a i l groups: i n t e r d e p a r t m e n t a l a n d i n t r a d e partmental communications 9B u l l e t i n b o a r d s : a n n o u n c e m e n t s , discussion groups, educational postings
Computers were already i n t e g r a t e d into our e v e r y d a y practice, a n d a d d i n g E-mail communications addressed a defined need.
Implementation I m p l e m e n t a t i o n i n v o l v e d i n s t a l l a t i o n of t h e p r o g r a m a n d t r a i n i n g of t h e s y s t e m users. During t h e p l a n n i n g s t a g e , w e f o u n d it helpful to d r a w up a w r i t t e n p l a n t h a t i n c l u d e d tasks, c o m p l e t i o n d a t e s , a n d a s s i g n e d p e r s o n n e l . (It h e l p s to k e e p a log of your a c t i v i t i e s as y o u i m p l e m e n t this w r i t t e n plan.) Our E-mail p r o j e c t w a s o n e of m a n y in p r o g r e s s for our r e g i o n a l c o m p u t e r d e p a r t m e n t . K e e p i n g t r a c k of w h o is d o i n g w h a t , a n d w h e n , h e l p s k e e p y o u r t i m e line on track, a n d f a c i l i t a t e s p r o b l e m solving w h e n n e e d e d .
Table 1 E-mail training: Using the system The basics Accessing the program Using and changing p a s s w o r d s What the icons m e a n and w h a t they do Sending n e w marl m e s s a g e s Sending mail: addressing to individuals and groups Deleting mail and exiting the program More a d v a n c e d applications Personalizing your mailbox: more on icons Creating folders and storing mail Creating private mail groups Sending mail via the Internet Miscellaneous, but important Netiquette (E-marl manners and mores) Security and confidentiality (know what your institution's policies are!)
Before i m p l e m e n t a t i o n , w e c o m p l e t e d s e v e r a l tasks. We s t r u c t u r e d our E-mail s y s t e m b y c o m p i l i n g lists of n a m e s a n d d e t e r m i n e d p u b l i c mail g r o u p s to b e s e t u p b y IS. W e d e c i d e d to h a v e a n all-staff m a i l g r o u p ( a d d r e s s list) for e a c h d e p a r t m e n t , a n d s e p a r a t e a d d r e s s E - m a i l lists for r e g i s t e r e d n u r s e s a n d p h y s i c i a n s . A s i n g l e r e g i o n a l i z e d list w a s not s e t u p b e c a u s e it w a s a s i m p l e m a t t e r to a d d r e s s c o m m u n i c a t i o n s to t w o s e p a r a t e m a i l g r o u p s , a n d b e c a u s e it w o u l d m i n i m i z e t h e c h a n g e s r e q u i r e d b y t h e IS E-mail administrator accompanying a n y staff c h a n g e s . All e x i s t i n g p e r s o n a l c o m p u t e r s normally u s e d d u r i n g p a t i e n t c a r e w e r e c o n f i g u r e d to p r o v i d e t h e staff a c c e s s to t h e E-mail p r o g r a m . Training i n v o l v e d t e a c h i n g 160 staff m e m b e r s h o w to u s e a n E - m a i l s y s t e m . Our r e g i o n a l i z e d syst e m h a s a r e s o u r c e p e r s o n available to p r o v i d e training, b u t t r a i n i n g a large n u m b e r of p e o p l e on a n e w p r o g r a m still p r e s e n t e d a challenge. We i m p l e m e n t e d o n e s i t e at a time; t r a i n i n g m e t h o d s differed, w h i c h affected how quickly the communication system was u s e d b y staff. A t one site, a c a d r e of staff w a s c h o s e n for e a c h shift a n d w e e k e n d ; t h e y a t t e n d e d a 2-hour t r a i n i n g s e s s i o n in a c o m p u t e r t r a i n i n g r o o m w i t h t h e IS trainer. T h e s e e i g h t "supertrainers" t r a i n e d t h e r e s t of t h e staff m e m b e r s d u r i n g t h e n e x t 2 to 3 w e e k s a n d a c t e d as r e s o u r c e p e r s o n s while on duty. D u r i n g d o w n t i m e on a s c h e d u l e d shift, t h e s u p e r t r a i n e r s w o r k e d w i t h o n e or t w o i n d i v i d u a l s a t a t i m e in t h e d e p a r t m e n t for 10- to 2 0 - m i n u t e periods. Basic u s e of t h e E-mail s y s t e m w a s t a u g h t initially, a d d i n g m o r e c o m p l e x functions, s u c h a s c r e a t i n g p r i v a t e m a i l i n g lists, a s n e e d a n d r e a d i n e s s arose. S o m e staff m e m -
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bers are quite computer literate and can master the complexities early, but others may be nearly computerphobic and benefit from an incremental learning process (Table 1).
Our s t a f f m e m b e r s r e p o r t that they have a much better s e n s e of b e i n g u p - t o - d a t e e v e n w h e n w o r k i n g part-time. N u r s e s u s e t h e s y s t e m to s e e k shift c o v e r a g e , a n n o u n c e committee meetings and share minutes, survey other staff for n e e d s a n d o p i n i o n s , s e n d n o t e s of a p p r e c i a t i o n or s u g g e s t i o n s for p r a c t i c e , a n d k e e p in t o u c h w i t h staff with schedules different from their own.
The second site began one-on-one training during downtime on individual work shifts, without establishing a supertrainer group. Training the entire staff took m u c h longer, and general use of the system also was delayed. Using a group of supertrainers definitely facilitated the implementation process. Written materials, including a tip sheet and quick reference guides, were placed by each computer where E-mail was accessed.
for departmental communications (memos, policy changes, newsletters, patient compliments, continuous quality improvement concerns and results, educational opportunities, and position postings), it became a very useful tool, replacing our communication notebook as the primary source of information. The notebook is still maintained to avoid printing multiple copies for those who prefer hard copies. Administration now has a reliable means for communicating essential information to each staff member. Each staff member must check E-mail daily early in the shift for the system to be effective. This expectation is best expressed early in implementation. Staff members can then develop strategies to read E-mail messages without affecting patient care. Our staff members report that they have a much better sense of being up-to-date even when working part-time. Nurses use the system to seek shift coverage, announce committee meetings and share minutes, survey other staff for needs and opinions, send notes of appreciation or suggestions for practice, and keep in touch with staff with schedules different from their own. This asynchronous communication system meshes well with our asynchronous staffing patterns. Physicians, skeptical at first, increasingly find the system useful for their own communications and physician group work. Through E-mail, health care providers are given an avenue to explore the potential uses of informatics in practice. Continued development of this communication system is planned. Implementation of the E-mail bulletin board will provide a shared access area for a n n o u n c e m e n t s and group discussions. Dial-in access from home computers with modems will increase access to communications by staff. Adding Internet connections will open the channels to tremendous assets of on-line knowledge resources and professional networking.
Evaluation Several factors contributed to the initial success of our communication system. Computers were already integrated into our everyday practice, and adding E-mail communications addressed a defined need. When the clinical coordinators began to use the system
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Contributions to this column should be sent to Vicky Bradley, RN, MS, 4017 Palomar Blvd., Lexington, Is phone (606) 257-2350 (E-mail address: vmbradle 0~taonode.mvs.hosp.uky.edzO