Dispatches from the hi-blogs.info krew

Suzanne Bakken – Policy and Advocacy Related to Informatics Approaches to Underserved Populations July 23, 2010

“If we’re going to make informatics part of the solution for decreasing health disparities in underserved populations then policy and advocacy efforts are needed.” She begins her lecture with a definition of Nursing Informatics that emphasizes that it supports patients, nurses, and other providers. Advocacy is a core competency for a nurse informaticist.

Underserved populations are a broader group than you might think – there are many interpretations and it doesn’t necessarily mean low income.  She presents a case study regarding the use of a Continuity of Care Document (CCD) for persons living with HIV/AIDS. She frames the study by saying it’s really about the interactions between persons (patients) and caregivers (clinicians and case workers). Her population is in New York City and does meet low income criteria for a special program at NY Presbyterian. There was an interest in sharing information about the patients between the various caregivers who participate in the program.

A specialized CCD document format was agreed upon for what data were to be shared.  It was called My Health Profile

• Diagnoses
• Medications
• Lab Results
•  Procedures / Imaging
• Allergies / ADRs
• Social History / Family History

A variety of data sources were used to obtain a limited data set that is only available intermittently. While the data were limited, they were sufficient to help patients obtain care and make their care known to subsequent providers.

As the program has moved forward, more data sources have been identified, expanding the scope of the CCD. As more data are available, evidence permits advocacy. She points out that having a codified data set allowed better use of the data and gave her a better tool for influencing policy.

The RE-AIM framework (Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance) (by Glasgow, adapted by Bakken & Roland) was utilized to begin a program of influence. She points out that unintended consequences can be positive as well as negative. In the case of My Health Profile, some unintended positive affects occurred.

There was a suspicion among staff that PLWH will be unwilling to have data electronically available via the CCD. They met with focus groups who were willing to have data available through CCD for both personal use and especially emergency situations. After a survey, they found that almost 100% of patients were willing to share data for their own care but were less willing to share data for aggregate reporting that would help others.  She points out that there was an opposing study that showed their patients were less willing to share data.

The introduction of this information to patients made them curious, and in some cases anxious. They had questions about their own care and needed teaching regarding the information that was made available. Further study revealed the types of needs that existed among the population. Viral Load was a particularly interesting topic to patients. This led to some possible strategies;

• Don’t display some types of data to prevent those information needs
• Sequester data for a period of time
• Integrate informatics strategies to deliver information at the point of need

There continue to be concerns among providers about patients seeing their data before the clinician sees their data. Dr. Bakken believes patients should have access to their own health data as soon as it’s available; but we need to deliver the information they need along with the data.

The evaluation findings showed that some high volume users and key informants found that they felt much better for having their data at hand. (Anecdotally, this generated tears of joy from the evaluators).

For future enhancements, they will move the program from the stand-alone CCD system to NYCLIX. This will provide better access and a more robust data set available. However, patient direct access to this data is not typical. They plan to implement a portal for patient access. There is also no access to the NYCLIX RHIO for case managers – the RHIO is really for those who generate data.

This means that advocacy is needed to assure access for those case workers. Patients will be the strongest voice in this discussion. Nursing informatics can be part of the solution to disparities in health care. But Advocacy is a key nursing informatics competency. We should all look for opportunities to research and generate data that supports policy change for the better.

Implementation of Critical Care Telemedicine – the eICU July 22, 2010

Presented by: Margaret Mullen-Fortino, MSN, RN; Joseph DiMartino, MSN, RN; Nicole Coles-Williams; Frank D. Sites, MHA, RN; and C. William Hanson, MD

This presentation was on the implementation of a system at the University of Pennsylvania. It was recommended that intensivists directly monitor all ICU patients. However, there was a finding that patients do better when they are able to stay near their homes. This is especially true for patients in critical condition being cared for in rural locations. The program was started to provide access to clinical expertise to rural settings.

Implementation required the installation of a camera, microphone, speaker and computer in every monitored room. In some ways, the technology overshadowed the availability of clinical expertise.

The system installed (VisiCu) includes decision support that provides users with information on changes expressed in percentage points and alerts them to changes in patient condition. Cameras are very good, but only one to two beds can be viewed by a user at a time.

Implementation occurred in a phased approach that brought up one unit at a time. It included education for staff nurses that covered history of telemedicine and the basic functions that could be done by the system. There were representatives of the telemedicine program on site providing go-live support.

There was some resistance from staff as they were concerned that Big Brother was coming and that the system would be used as a disciplinary thing. Some didn’t want help – they felt they had enough expertise to care for the patient. There was a period when poor interactions between telemedicine and floor staff were documented. In an effort to educate floor staff, they were invited to watch the telemedicine staff working. New hires were introduced as part of their orientation. Unit councils were formed to discuss issues – many process fixes occurred on the spot. The introduction of two-way video helped with communication as well (this was also beneficial to patients). Pizza and snacks were also helpful in the acceptance of telemedicine. Bringing some staff nurses onto the telemedicine team and allowing them to work in both has also improved acceptance by staff.

Challenges to the implementation included differences in standards of care across the multiple facilities being monitored. The eICU nurses had to become familiar with policies at each facility and learned to ‘back off’. Frequent downtimes during early operations made it difficult to attain confidence. Lack of partnership with all the stakeholders (staff nurses, IT staff, etc.) also slowed the implementation.

Benchmark reporting on patient conditions was used both to inform staff nurses of whether the eICU was making a difference and to demonstrate the efficacy of eICU monitoring. The eICU helped by tracking compliance with care standard monitors. This helped both by seeing the results and by remembering that the camera was watching for compliance. Reporting was carried on for Ventilator Acquired Pneumonia, Blood Transfusions, etc. Many of the reporting projects resulted in changes to process that improved patient outcomes. These reporting data are made known to floor staff through a variety of interaction strategies including meetings, publications and posters.

There is a data warehouse that the eICU staff use to do reporting with. There is a three day latency in data extraction/transformation/loading. The U Penn school of engineering works on this data and other methods to provide decision support for nurses. They have had success with extracting data from multiple monitoring systems and providing that information to clniicians in real-time. They continue to work on projects that will present data in better formats that makes it easier for clinicians to see what the real story is.

In conclusion, introduction of eICU didn’t change processes – it was the data that came from it that did so. Presentation of data to floor staff at the grass roots level made real changes that improved patient outcomes.

Nurse Computer Literacy in EMR Implementations – Julie Jacobs July 22, 2010

Julie works for a company that’s implementing EMR’s in clinics in Minnesota. She has been studying behavior of nurses in their use of computers since 2005. She noticed that an implantation she was working on had a great mission, but that nurses didn’t really understand it. As a result, she embarked on research to understand better what nurses’ knowledge level is and how they can be trained to become more literate.

One of the skills & conditions needed by a nurse for a computer implementation is the ability to have a conversation with managers that exchanges information without threatening her job. Therefore nurses should be enabled to have those conversations without fearing retribution in evaluations or job status.

It’s possible that the administrators who will implement a system will be very knowledgeable –other times they are not. It’s important to assess the knowledge level of all participants in a project.

Barriers to an implementation include nursing attitudes, familiarity with the original paper chart (there was a significant amount of work put into the design of paper processes), concerns about patient safety with an EMR, low touch vs. high touch (loss of patient contact), and lack of formal training. These items

The study consisted of questionnaires that asked nurses about their knowledge in computers. Each question also included a rating for the importance of a subject to the nurse. Highest gaps were regarding safety and overall implementation.  Thus, the lesson was that if safety is not built into the implementation, it will likely fail.

You can assure better implementations by assuring that resources are in place that are appropriate to the needs of the site. This includes items from the local site, the vendor, and generally available items. You can contact Julie at info@officesmarts.us

Translational Application of Meaningful Use for the Nurse Executive – Roy Simpson July 22, 2010

How do nurses put together valuable information on Meaningful Use for nurse executives? Roy made it clear that this presentation was for novices, but that he hoped there may be some pearls of wisdom for others. 

There was a discussion of the seven stages of MU and what’s really in them. CNO’s need to read and understand the scope of the stages. There are many terms and conditions that must be clearly understood. Understanding the scope of the final rule is important for all nurses in a hospital to understand – without that understanding it’s hard to support the work that’s involved in bringing the changes that satisfy the MU standards about.

October 1, 2010 is when the first incentive payments are set to go out. Healthcare is very costly today and many outsiders see it as a huge hole that money flows into. Healthcare did not help itself as it has not made available the evidence of what the money is being spent on.

The internet may not be the most secure and stable platform for HNIN transmissions of healthcare data. After all, the internet crashed when Victoria’s Secret released their new line in 2008.

The next thing to be aware of is that ARRA provides INCENTIVES for PHYSICIANS. There is no pay for performance initiative for nurses of any kind known today. (if there is one in a hospital today, please contact Roy at rsimpson@cerner.com )

Meaningful Use offers nursing an unparalleled opportunity. It should cover the full spectrum of care. Nurse informaticians are needed to help implement and help bedside nurses understand the value of what they do.

Technology may be a red herring in the overall health care picture. Where is the money going to come from to educate nurses in what they must do to comply with MU? Looking into the future, there will be a time when free-text will be minimized in the effort to assure consistent data. Does a check-mark in a form really mean that a care task has been completed? Let’s use MU as an opportunity to resolve some of the issues in health care today. Nurses and their executives must create and use data that quantifies the value of nursing in the health care system. This can only happen with unified efforts between nurses, nurse informaticians and nurse executives.

Nurse Informaticians must have a strong clinical base in Nursing Informatics – an independent specialty in nursing. They should have advanced degrees in the subject. But the degree is not the only critical element. NI’s must have key experience in Nursing Science, Information Science, and Computer Science. While Ni’s received their commission in the past as field promotions for nurses who happened to have some understanding of computers, there are now established practices and principles that require formal education and real-world experience to truly qualify as the Nurse Informatician.

The NI’s role in MU will educate nurses, help gather outcomes for staff, and help create the full culture of Meaningful Use. NI’s should spend 70 percent of their time assuring that technical choices are made in alignment with organizational direction – not building screens.

Nurse Informaticians are not the popular nurse, the geeky nurse with all the gadgets, or the great project manager. MU and the EHR will demonstrate the proof of the value of nurses. Per Alvin Toffler: “The illiterate of the 21^st century will not be those who cannot read and write, but those who cannot learn, unlearn and relearn.”

Dr Judith Warren – Harmonization of HIT Initiatives July 22, 2010

Dr Warren’s presentation on the harmonization of various health care initiatives from the federal government and how they affect American health care in general. She walked through several policy-making agencies, leading off with the National Committee on Vital and Health Statistics (of which she is the only nurse-member) and several of the subcommittees within it.

She then went on to the ONC HIT Policy Committee,  ONC HIT Standards Committee, The Affordable Care Act of 2010 (PPACA) and brief discussions of Health Care Reform, the simplification initiative and other trends in health care that all come to bear on nursing today.

She wrapped up with a slide (not in the currently published deck) that described some of the deadlines we are facing today:

• HIPAA throughout 2010 to 2016
• 5010 testing start 1/2011
• 5010 implementation 1/2012
• ICD10 10/1/2013
• Health Plan ID adopt by 7/1/2011
• Other ACA requirements – unknown deadlines
• Operative rules for health plans and haalth claims status adopt by 7/1/2011 implement by 1/1/2013
• Operative rules for electronic funds transfer: adopt 7/1/2012, implement 1/1/2014
• Operative rules for health claims referral, authorization, etc.: adopt 7/1 2014, implement 1/1/2016
• Meaningful Use throughout 2010 to 2016

She closed with remarks that more nurses are needed to participate in public forums like this and encouraged the audience to dial into meetings and to speak up!