Informatics Strategies & Tools to Link Nursing Care with Patient Outcomes in the Learning Health Care System

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1 Nursing Informatics Working Group Informatics Strategies & Tools to Link Nursing Care with Patient Outcomes in the Learning Health Care System Patricia C. Dykes PhD, RN, FAAN, FACMI Judy Murphy RN, FHIMSS, FAAN, FACMI Dana Womack MS, RN March 31,

2 Overview Best Care at Lower Cost: The Learning Health Care System (LHCS) Meaningful Use Informatics strategies to support the LHCS Credentialing in nursing education and practice Data harmonization Advantages Demonstration: NDNQI Dashboards Discussion/Conclusions 2

3 Best Care at Lower Cost The Path to Continuously Learning Health Care in America September 2012 iom.edu/bestcare 3

4 Why now? Quality persistent shortfalls Patient harm One-fifth to one-third of hospital patients are harmed during their stay, largely preventable. Recommended care Only about half of the recommended preventive, acute, and chronic care is actually received. Outcome shortfalls If all states matched care quality in the highest-performing states, 75,000 fewer deaths would have occurred in From Best Care at Lower Cost: The Path to Continuously Learning Health Care in America, IOM,

5 The Result? The U.S. health care system today From Best Care at Lower Cost: The Path to Continuously Learning Health Care in America, IOM,

6 The Vision Continuous Learning, Best Care, Lower Cost Transition to the Learning Health System From Best Care at Lower Cost: The Path to Continuously Learning Health Care in America, IOM,

7 Meaningful Use HITECH ACT The 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act: Provides $30 billion in Medicare and Medicaid incentive payments For the meaningful use of health information technology by clinicians and hospitals Estimated to yield savings of $93 billion between 2011 and 2019 A Remarkable Journey 7

8 Meaningful Use as a Building Block Transform health care Improved population health Access to information Data utilized to improve delivery and outcomes Enhanced access and continuity Data utilized to improve delivery and outcomes Utilize technology Patient self management Patient engaged, community resources Care coordination Care coordination Patient centered care coordination Patient informed Evidenced based medicine Team based care, case management Basic EHR functionality, structured data Structured data utilized Registries for disease management Registries to manage patient populations Privacy & security protections Privacy & security protections Privacy & security protections Privacy & security protections Stage 1 MU Stage 2 MU PCMH 3-Part Aim ACO s Stage 3 MU 8

9 EHR Adoption Has Reached a Tipping Point Meaningful Use Professionals and Hospitals Registered and Paid by Medicare or Medicaid Total Professionals Registered: 436,295 (83%) Total Professionals Paid: 335,646 (64%) 527,000 Total Eligible Professionals 500, , ,000 5,011 Total Eligible Hospitals 5,000 4,000 3,000 Total Hospitals Registered: 4,693 (94%) Total Hospitals Paid: 4,400 (88%) 200,000 2, ,000 1, Source: CMS EHR Incentive Program Data as of 12/31/2013 9

10 Amount Paid per Month (Millions) Jan-11 Total EHR Incentive Payments to All Eligible Providers and Hospitals by Month Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Cumulative Amount Paid (Millions) $1,600 $1,400 $1,200 $1,000 $800 $600 $400 $200 $0 $22 $16 $26 $31 $108 $81 $116 $276 $237 $387 $605 $831 $660 $629 $623 $564 $587 $445 $409 $576 $536 $715 $1,400 $907 $1,109 $823 $1,021 $906 $354 $723 $419 $360 $344 $342 $1,451 Cumulative Total $19,438 $797 $25,000 $20,000 $15,000 $10,000 $5,000 $0 Source: CMS EHR Incentive Program Data as of 12/31/

11 U.S. EMR Adoption ModelTM From HIMSS Analytics - Progress in 3 Years Stage Stage 7 Stage 6 Cumulative Capabilities Complete EMR; CCD transactions to share data; Data warehousing; Data continuity with ED, ambulatory, OP Physician documentation (structured templates), full CDSS (variance & compliance), full R-PACS 21% 2011 Q Q4 1.0% 2.9% 3.5% 12.5% Stage 5 Closed loop medication administration 5.9% 22.0% 53% Stage 4 CPOE, Clinical Decision Support (clinical protocols) 10.7% 15.5% Stage 3 Stage 2 Nursing/clinical documentation (flow sheets), CDSS (error checking), PACS available outside Radiology CDR, Controlled Medical Vocabulary, CDS, may have Document Imaging; HIE capable 31% 48.4% 30.3% 14.1% 7.6% Stage 1 Ancillaries - Lab, Rad, Pharmacy - All Installed 6.7% 3.3% 17% Stage 0 All Three Ancillaries Not Installed 9.6% 5.8% Data from HIMSS Analytics Database 2012, 2014 N = 5,275 N = 5,458 11

12 Health Information Technology Informatics Competency Critical for nursing: Largest number of health care providers in the US. 19.6% of all healthcare workers or over 3 million nurses. Courtesy of Clancy, T. (2013). Nursing Organization Alliance Fall Summit 12

13 Quality and Safety Education for Nurses (QSEN) Project* Based on IOM competencies Proposes knowledge, skill, and attitude targets to be developed in nursing programs Goal: To prepare student nurses with knowledge, skills and attitudes needed to continuously improve the quality and safety of healthcare systems Defines quality, safety, informatics competencies for nursing Available as guides to curricular development, certification, and continuing education * 13

14 Quality and Safety Education for Nurses (QSEN) Competencies Quality Describe strategies for improving outcomes of care in the setting in which one is engaged in clinical practice. Explain common causes of variation in outcomes of care in the practice specialty. Describe common quality measures in the practice specialty. Safety Describe best practices that promote patient and provider safety in the practice specialty. Describe processes used to analyze causes of error and allocation of responsibility and accountability. Informatics Formulate essential information that must be available in a common database to support patient care in the practice specialty. Describe and critique taxonomic and terminology systems used in national efforts to enhance interoperability of information systems and knowledge management systems. 14

15 Using Electronic Documentation to Measure Clinical Competence Clinical Competencies Quality Safety Informatics Are nurses documenting accurately? Is documentation in a structured, coded format? Does the data have integrity? Can nurses pull out data needed to engage in clinical decision-making? What are the right things that nurses need to do? Did they do them? Does a nurses documentation and their patients corresponding outcomes suggest that he/she is practicing at height of their license? Does the documentation of each individual nurse support building linkages between nursing care and patient outcomes? 15

16 Continuing Competence and the Learning Health Care System Current state of clinical documentation is a barrier to nurses demonstrating meaningful use. Strategies are needed to link nursing documentation to patient safety and quality measures, to nurse competency, and to organizational competency. Institute of Medicine Report Brief (2009). Redesigning Continuing Education in the Health Professions. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine (2011). The Future of Nursing: Leading Change, Advancing Health. 16

17 Continuing Competence and the Learning Health Care System Integration of QSEN competencies into practice settings: Ensures that all health professionals engage effectively in a process of lifelong learning aimed squarely at improving patient care and population health (IOM, 2009). Supports data integrity so that data entered for clinical documentation is available for secondary use and for building evidence from practice. Institute of Medicine Report Brief (2009). Redesigning Continuing Education in the Health Professions. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine (2011). The Future of Nursing: Leading Change, Advancing Health. 17

18 Advantages: Data Integrity Improved data quality for building evidence from practice and secondary use: Clinical decision support Populate quality/safety dashboards Populate quality measures Research Nurses are responsible for defining their practice through what is documented for their patients and by analyzing the impact of their practice on patient outcomes. Provides a means to visualize the linkage between nursing care provided, how that care is documented and patient outcomes. Structured coded data will be available across organizations benchmarking. 18

19 Demo NDNQI Quality Dashboards 19

20 Summary Adoption and meaningful use of health IT are foundational to the learning healthcare system. Competencies to ensure data integrity and harmonization are also needed. The QSEN quality, safety, and informatics competencies can address the skills needed by practicing nurses to build a digital infrastructure, but they are not used yet in practice settings. Use of quality, safety, and informatics competencies across healthcare settings will ensure that data entered once can be reused for decision support, performance improvement, benchmarking, and research. Meaningful use of health IT and integration of quality, safety, and informatics competencies into educational AND practice settings would support evidence based practice and build the foundation for a learning health care system. 20

21 AMIA Membership Education Meetings Networking Mentorship And more

22 AMIA NIWG AMIA Nursing Informatics Working Group (NIWG) Patricia Dykes, PhD, RN, FAAN, FACMI Chair Laura Heerman Langford, RN, PhD Chair-Elect AMIA s 450 nurse informaticians work as developers of communication and information technologies, educators, researchers, chief nursing officers, chief information officers, software engineers, implementation consultants, policy developers, and business owners, to advance healthcare.

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