Nursing Informatics: Challenges and Opportunities in the 21 st Century Thomas R. Clancy, MBA, PhD, RN, FAAN Clinical Professor and Assistant Dean School of Nursing The University of Minnesota Objectives 1. Describe the emerging challenges of information technology in health systems today. 2. Review nursing informatics (NI) competencies required of students and practicing nurses. 3. Describe challenges faced by nursing programs in providing NI education 4. List opportunities to collaboratively enhance and improve NI education to students and practicing nurses. Over the last 50 years we have seen: An explosion in biomedical knowledge, Dramatic innovations in therapies and surgical procedures and, Management of conditions that were previously viewed as fatal. 1
Cancer Survival Rates FDA Approved HIV Drugs Smith, M., Saunders, R., Stuckhardt, L., and McGinnis, M. (2012). Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Institute of Medicine, National Academies Press Dramatic progress has been made in identifying patient safe practices. These five practices alone have been shown to significantly reduce medication errors and adverse outcomes at a minimum of cost. Intervention Results Provider order entry Pharmacist Rounding Rapid response teams Team training in labor and delivery Reconciling medications upon hospital discharge 81% decrease in medication errors 78% reduction in preventable ADE s 15% decrease in cardiac arrests 50% reduction in adverse outcomes 90% decrease in medication errors Leape, L. and Berwick, D. (2005). FIVE YEARS AFTER TO ERR IS HUMAN: WHAT HAVE WE LEARNED? In the Literature, The Commonwealth Fund. 293 (19): 2384 90 Despite this, national health expenditures as a share of gross domestic product (GDP) are currently at 17.6% and projected to rise to 20% by 2020. 2
American healthcare continues to fall short on basic dimensions such as quality, cost, outcomes, and equity Institute of Medicine (2012). Best Care at the Lowest Price. National Academies Press, Washington DC Despite finding small improvements at the margins, it is harder to see the overall, national impact of Too Err is Human on patient safety. Leape, L. and Berwick, D. (2005). FIVE YEARS AFTER TO ERR IS HUMAN: WHAT HAVE WE LEARNED? In the Literature, The Commonwealth Fund. 293 (19): 2384 90 Over 30 years ago the IOM estimated that up to 98,000 Americans die each year from medical errors in hospitals Current estimates for 2013 are: 210,000 440,000! Journal of Patient Safety: September 2013 Volume 9 Issue 3 p 122 128 Bleich, S (2005). Issue Brief in The Commonwealth Fund, 1 East 75th Street,New York, NY 10021 2692 3
Despite the progress in information technology to improve the speed and effectiveness of communication, we have seen a 2800% increase in medical errors resulting from electronic health records. Pennsylvania Patient Safety Authority, December 2012 Decades of rapid innovation and technological improvement have created an extraordinarily complex healthcare system. So much so that healthcare often falls short of its potential. Typical chronic disease pt. 79 years old, Osteoporosis, Osteoarthritis, Type 2 diabetes, Hypertension, COPD, Smith, M., Saunders, R., Stuckhardt, L., and McGinnis, M. (2012). Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Institute of Medicine, National Academies Press. Typical Patient See 7 doctors across 4 practices 27 different health providers (surgery patient) 19 medications per day Smith, M., Saunders, R., Stuckhardt, L., and McGinnis, M. (2012). Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Institute of Medicine, National Academies Press. 4
Typical Physician Interacts with 229 other physicians in 117 different practices. Typical ICU Nurse Manages 180 activities per patient per day! Smith, M., Saunders, R., Stuckhardt, L., and McGinnis, M. (2012). Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Institute of Medicine, National Academies Press. Most physicians, nurses, and other health care professionals work diligently to care for their patients, but they often are contending with: challenges of a system that is poorly configured, for the current complexity of treatments, technologies, and clinical science. Smith, M., Saunders, R., Stuckhardt, L., and McGinnis, M. (2012). Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Institute of Medicine, National Academies Press. 5
Institute of Medicine These problems point to the need for a transformation in how the health care enterprise generates, processes, and applies information to further patient care. Key Imperatives To manage the health care system s everincreasing complexity, and To curb ever escalating costs. Opportunities exist to address these problems opportunities that did not exist even a decade ago: 1. Vast computational power that is affordable and widely available; 2. Connectivity that allows information to be accessed in real time virtually anywhere; 3. Human and organizational capabilities that improve the reliability and efficiency of care processes; and 4. The recognition that effective care must be delivered by collaborations between teams of clinicians and patients, each playing a vital role in the care process. Moores Law First described in 1965 by Gordon Moore, the number of transistors on integrated circuits doubles approximately every two years. Calculations per second Processing speed Size of devices Accessed at Wikimedia on October 27, 2013 at http://en.wikipedia.org/wiki/file:pptmooreslawai.jpg 6
85% of adults own a cellphone. 76% own a computer 80% have access to the Intranet Mobile device growth is estimated at 30% per year. 10 billion users by 2020 86% of providers use the Intranet to gather clinical information The 3 rd most popular use of the Intranet is looking up health information by individuals BENEFITS of EHR Quality, Safety & Education Data integrity readable, accurate, organized and complete. Clinical decision support Care coordination, EBG s and population mgt. Patient safety Alerts, drug interactions 7
ACCESS Simultaneous access to patient records Security and privacy Graphs, charts, trending that facilitate comparison of current and past data. Access to drug information, decision support tools, and literature searches, EHR Dashboard Accessed at AHRQ website: http://www.ahrq.gov/legacy/about/annualconf09/middleton.htm on November 4, 2014 Cost and Revenue Increased productivity, Improved billing and reimbursement rates, faster turnaround for accounts, lower medical record costs, Improved revenue cycle, enhanced regulatory, requirement compliance, President Bush s goal in 2004 an Electronic Health Record for every American by the year 2014. By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care. - State of the Union address, Jan. 20, 2004 Executive order established the Office of the National Coordinator for Health Information Technology (ONCHIT) as part of the Dept of Health & Human Services (HHS) Dr. David Brailer appointed the first National Coordinator Courtesy of Murphy, J. (2012) QSEN Nursing Informatics Deep Dive Workshop 8
President Obama s goal in 2009 To lower health care cost, cut medical errors, and improve care, we ll computerize the nation s health records in five years, saving billions of dollars in health care costs and countless lives. - First Weekly Address Jan. 24, 2009 February 17, 2009 the American Reinvestment and Recovery Act (ARRA Stimulus Bill) is signed into law HITECH component of ARRA provides an incentive program to stimulate the adoption and use of HIT, especially EHR s Dr. David Bluementhal appointed the new National Coordinator HITECH ACT The 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. Taken from: Blumenthal, D. Launching HITECH, posted by the NEJM on 12 30 2009. 27 9
Meaningful Use as a Building Block Utilize technology Access to information Care coordination Patient informed Transform health care Data utilized to improve delivery and outcomes Patient self management Care coordination Evidenced based medicine Improved population health Enhanced access and continuity Data utilized to improve delivery and outcomes Patient engaged, community resources Patient centered care coordination 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 Amount Paid per Month (Millions) $900 $800 $700 $600 $500 $400 $300 $200 $100 $0 Payments to All Eligible Professionals and Hospitals Under the Medicare or Medicaid EHR Incentive Programs $22 $16 Source: CMS EHR Incentive Program Data as of 7/31/2012 $26 $31 $109 $80 $116 $276 $236 $387 $607 $836 $563 $619 $659 Cumulative Total $6,597 $619 $583 $428 $384 $8,000 $7,000 $6,000 $5,000 $4,000 $3,000 $2,000 $1,000 $0 Cumulative Amount Paid (Millions) Projections are for 90 percent of providers to have access to a fully operational electronic health records by 2019, up from 34 35 percent in 2011. 10
Competency in Health Information Technology (HIT) is critical for nursing: Largest number of health care providers in the US. 19.6% of all healthcare workers or over 3 million nurses. 1988 Nursing Informatics: Where Caring and Technology Meet (Ball, Hannah, Newbold, and Douglas). 1981 International Medical Informatics Association Nursing Working Group 1982 Computers in Nursing (1 st journal) 1984 Council on Computer Applications in Nursing (ANA) and National Forum on Computers in Health Care (NLN). 1988 1 st master s program, U of Maryland. 1992 ANA specialty recognition, nursing informatics 1995 Standards of Practice, nursing informatics NURSING INFORMATICS The goal of Nursing informatics (NI) is to improve the health of populations, communities, families, and individuals by optimizing information management and communication. Nelson, R. and Staggers, N. (2013). Health Informatics: An Interprofessional Approach. Elsevier, St. Louis. 11
NURSING INFORMATICS The design and use of informatics solutions and technology to support all areas of nursing; Direct provision of care, Establishing effective administrative systems, Designing useful decision support systems Managing and delivering educational experiences, Supporting lifelong learning, and supporting nursing research. Nelson, R. and Staggers, N. (2013). Health Informatics: An Interprofessional Approach. Elsevier, St. Louis. INTERPROFESSIONAL American Medical Informatics Association (AMIA) Healthcare Information and Management and Systems Society (HIMSS) American Health Information Management Association (AHIMA) College of Healthcare Information Management Executives NURSING Alliance for Nursing Informatics (ANI) American Nursing Informatics Association (ANIA) COMPETENCIES IN NI ANA Scope and Standards of Practice http://www.nursingworld.org/homepage Category/NursingInsider/Archive_1/2008 NI/Jan08NI/RevisedNursingInformaticsPr acticescopeandstandardsofpractice.aspx AACN American Association of Colleges of Nursing Essentials for BSN, Masters and Doctoral students http://www.aacn.nche.edu/educationresources/essential series TIGER Technology Informatics Guiding Educational Reform http://www.tigersummit.com/about_us. html 12
Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice. Apply safeguards and decision making support tools embedded in patient care technologies and information systems to support a safe practice environment for both patients and healthcare workers. Use telecommunication technologies to assist in effective communication in a variety of healthcare settings. 13
Understand the use of CIS systems to document interventions related to achieving nurse sensitive outcomes. Use standardized terminology in a care environment that reflects nursing s unique contribution to patient outcomes. Evaluate data from all relevant sources, including technology, to inform the delivery of care. 14
Recognize the role of information technology in improving patient care outcomes and creating a safe care environment. Uphold ethical standards related to data security, regulatory requirements, confidentiality, and clients right to privacy. Apply patient care technologies as appropriate to address the needs of a diverse patient population. http://news.brown.edu/pressreleases/2012/05/braingate2 15
Recognize that redesign of workflow and care processes should precede implementation of care technology to facilitate nursing practice. Participate in evaluation of information systems in practice settings through policy and procedure development. 2006 National League for Nursing Survey Five hundred deans and 1,557 faculty Only 50 to 60 percent of respondents said that informatics was integrated into the curriculum. Clinical experience with information systems was provided during clinical experiences. 16
SCHOOL OF NURSING FACULTY SURVEY 28 Nursing Schools 2013 94.7 % did not provide course content regarding theories of nursing informatics and key terms. 53.3% did not provide content on how to use data gathered through the Electronic Health Record (EHR) to improve patient care. 70.8% did not provide content on how to monitor and analyze data on nurse sensitive quality indicators through electronic dashboards and other tools. 40% did not provide content on the application and benefits of EHR s in enabling the use of evidence based practices (For example: developing evidence based care plans and executing electronic order sets, using standardized nursing languages, decision support, links to resources or other) SCHOOL OF NURSING FACULTY SURVEY 28 Nursing Schools 2013 40% did not provide content on how the EHR can be used as a bridge for interdisciplinary learning (for example: the integration of information systems for nursing, pharmacy, lab, radiology, medicine and other). 83% did not require students to demonstrate use of a mobile device (smart phone, ipad, laptop) to access real time information. 50% did not provide content on consumer informatics in a course (For example: shared medical records, consumer health websites, virtual office visits and other) 68% did not engage with clinical sites/partners to discuss developing/enhancing nursing informatics curriculum, provide feedback on demands and priorities of each organization, hospital/regional advisory councils, etc. Only 9% of nurse informaticists are employed in academic institutions. Of the 3,179 total nursing programs in the US only 317 (10% of total) have either a certificate program or advanced degree in nursing informatics. Distribution of Nurse Informaticists HIMSS Annual Survey 2011 (660 Respondents) Workplace Percent Hospital 48% Health System 20% Academic Setting 9% Vendor Organization 10% Consulting Firm 5% Government/Military 4% Ambulatory Setting 2% Other 7% 17
SCHOOL OF NURSING FACULTY SURVEY 28 Nursing Schools 2013 Confusion on what nursing informatics is. NI is a new field and faculty must find ways to integrate the content into an already full schedule of courses. To meet the accreditation requirements for NI many Schools rely on a clinical site s EHR. It is difficult for faculty to learn the specialized field of informatics given their current demands. Distribution of Training for Nurse Informaticists by Program Type HIMSS Annual Survey 2011 (660 Respondents) Training Program Type Percent Masters/PhD (Informatics Specialty) 23% Bachelors (Informatics Courses) 2% Certificate (ANCC, CPHIMS, Other) 15% On the Job Training (courses, workshops, e-learning & other) 15% None 32% Content and teaching methods needed by nurse educators for nursing informatics is: Scattered among numerous websites Aimed primarily at professional development of working informatics professionals. 18
The goal of the workshop was to develop the content and skills of local nursing school faculty so that they would more effectively develop the QSEN informatics KSAs (Knowledge, Skill and Ability) in pre licensure students. Survey Choice Agree Strongly Agree Total A series of webinars on specific nursing informatics topics, hosted through professional organizations such as AACN and others (webinars). 92 59 151 1 2 3 4 5 6 A 10 module on line, introductory course that meets the AACN BSN Essentials and QSEN competencies for nursing informatics. The course provides access to multiple resources and an instructor manual. (modules). 71 65 136 A week long summer institute that would provide nurse educators a comprehensive review of how to meet AACN BSN Essentials and QSEN competencies for nursing informatics (institute). 59 21 80 A series of one day pre conference workshops (For example: prior to an AACN regional conference) that would provide an overview of nursing informatics and how to meet AACN Essentials and QSEN competencies for nursing informatics (conferences). 55 17 72 A customized on site consultation, provided by domain experts aimed at meeting AACN BSN Essentials and QSEN competencies for Nursing informatics (consultations). 43 23 66 A certificate program aimed at nurse educators whose purpose is to provide an in depth program of study covering the fundamentals of nursing informatics; 12 academic credits, 1 2 years to complete (certificate). 33 16 49 Regional Extension Centers - 62 to support physician adoption Health Information Exchange - 56 state programs Standards & Certification interoperability specifications Privacy and Security Beacon Communities 17 demonstration projects of EHR value SHARP Research Projects 4 HIT adoption breakthrough advances Security University of Illinois at Urbana Patient-Centered Cognitive Support University of Texas Application & Network Design - Harvard Secondary Use of EHR Data Mayo Clinic Workforce Training Programs to support HIT education University Based Programs 9 universities Consumer ehealth Community College Consortiums 5 regions Curriculum Development & Competency Exam Consumer ehealth 19
as of July 2012 7,000 6,000 5,000 Total Students Enrolled or Completed: 19,831 Attrition Rate: 21.9% 4,000 951 2,963 3,000 874 2,000 1,000 3,828 583 1,979 3,324 2,712 2,617 0 Northwest (8 Colleges) Southwest (13 Colleges ) Midwest (17 Colleges) South (20 Colleges) Northeast (22 Colleges) Commnity College Workforce Training Successfully Enrollment Completed* and Graduation Actively Enrolled 400 350 Total Students Enrolled or Completed: 1,577 Percent of Goal: 94% 300 250 225 200 150 77 165 103 100 50 0 93 64 88 148 117 65 73 99 29 62 58 67 19 47 Duke George Indiana Johns OHSU Colorado Columbia Texas State Minnesota Washington Hopkins University Based Workforce Training Enrollment and Graduation Graduated Enrolled Target Establish academic partnerships with health systems. Establish a consistent policy for access to EHR s during students clinical practicums. Co develop a standard curriculum for use of EHR in health facilities. 20
Establish academic partnerships with commercial information technology vendors: Co develop academic versions of EHR s Case studies Teaching methods Establish regular reviews with academic institutions to review; Existing curriculum New trends in IT Consumer informatics & pt. engagement emobile health Big data Robotics Virtual health Computer simulation and serious games http://www.ohsu.edu/xd/education/schools/schoolof medicine/departments/clinicaldepartments/family medicine/pcfdi/training/ Consumer Informatics and Patient Engagement Personal health records Portals ehealth literacy Patient engagement 21
emobile Health Caregiver Alerts Voice Prompts Floor Sensors Safety Features Smart Beds Video Monitors Vital Sign Monitoring Medical Condition Monitoring Robotics Big Data Virtual Experiments Standardized Nursing Languages Knowledge discovery and data mining Data Visualization http://healthpopuli.com/2013/04/08/the value of bigdata in health care 450 billion 22
Serious Games Problem solving Meaningful goals Possibility spaces Feedback and information Empowerment and reward Thank You! Thomas R. Clancy clanc027@umn.edu 23