Transcript Slide 1
Nursing, Technology and 21
st
Century Practice
Mark D. Sugrue, RN-BC, FHIMSS, CPHIMS November 1, 2014
Massachusetts Society of PeriAnesthesia Nurses
Outline • A Look Back • Healthcare Today • Health Information Technology • Nursing Today • Nursing Informatics • A Look Forward and A Call to Action !!
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Electronic Medical Records: A Look Back
• http://www.youtube.com/watch?v=t-aiKlIc6uk
Back in the day…..
“The obedience of a patient to the prescriptions of his physician should be prompt and implicit. [The patient] should never permit his own crude opinions as to their fitness to influence his attention to them.”
AMA’s Code of Medical Ethics (1847) 4
Today
“Patients share the responsibility for their own health care….” AMA’s Code of Medical Ethics (current)
“Patients can help. We can be a second set of eyes on our medical records. I corrected the mistakes in my health record, but many patients don't understand how important it will be to have correct medical information, until the crisis hits. Better to clean it up now, not when there’s time pressure.” – Dave deBronkart (ePatient Dave)
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Doctor ratings are important to consumers
• • Survey found that
59%
said online rating sites were at least "somewhat important" when choosing a doctor.
65%
were aware that doctor rating sites like Healthgrades.com, Vitals.com and RateMDs.com existed, with
23%
seeking them to help make a decision.
•
19%
said reviews were "very important" when choosing a provider;
40%
cited them as "somewhat important." • More important are whether insurance is accepted (
89%
), location (
59%
), experience (
46%
) and word of mouth from family or friends (
38%
).
• Of those aware of the rating sites,
19%
had visited once in the past year, while
17%
had visited more than once.
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Healthcare Today
“By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care.”
President George W. Bush, State of the Union Address, January 20, 2004 7
ARRA American Recovery and Reinvestment Act (H.R.1) $787B/$19B for HIT Signed: 2/17/2009 Final Rules Published: 7/13/2010 Fed Reg: 7/28/2010 CMS Incentive Payment Meaningful Use (MU) ONC Certification Standards 8
Quality As A Driver
Health IT: The Promise “It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm.”
Florence Nightingale
Health IT Promise: Quality • Your chances of dying from an avoidable human error are
10,000
times greater in a hospital than in an airplane
Health IT Promise: Quality
High Profile Cases Transparency IOM Reports Leapfrog Group 98,000 Deaths/Year 100,000 Lives IHI Consumer Awareness
Health IT: The Promise
"Oh, they're fine," Quaid recalled a nurse telling him about 9 p.m. "They're just fine." The Quaids sued the makers of heparin last month, saying Baxter Healthcare Corp., based in Deerfield, Ill., was negligent in packaging different doses of the product in similar vials with blue backgrounds. MSNBC January 2008 Three patients, including the twins, received vials containing 10,000 units per milliliter of heparin instead of vials with a concentration of 10 units per milliliter.
Baxter spokeswoman Deborah Spak said last month the problem was “improper use of a product.” In February, the company sent a letter warning health care workers to carefully read labels on the heparin packages.
Orders Today
Health IT: The Promise
The Order That started a Quality Revolution
Cyclophosphomide 4 g/M 2 Day 1-4 Day 1 Day 2 Day 3 Day 4
What Should Have been Administered 1 g/M 2 1 g/M 2 1 g/M 2 1 g/M 2 What Was Actually Administered 4 g/M 2 4 g/M 2 4 g/M 2 4 g/M 2
The Impact
On December 3, 1994 Betsy Lehman, a Boston Globe Medical Reporter died as a result of this lethal overdose. She was 39 years old.
US EMR Adoption Model
SM
Stage Cumulative Capabilities Stage 7
Complete EMR; CCD transactions to share data; Data warehousing; Data continuity with ED, ambulatory, OP
2013 Final 2.9% 2014 Q1 3.1% Stage 6
Physician documentation (structured templates), full CDSS (variance & compliance), full R-PACS
Stage 5 Stage 4
Closed loop medication administration CPOE, Clinical Decision Support (clinical protocols)
Stage 3
Nursing/clinical documentation (flow sheets), CDSS (error checking), PACS available outside Radiology
12.5% 22.0% 15.5% 30.3% Stage 2
CDR, Controlled Medical Vocabulary, CDS, may have Document Imaging; HIE capable
Stage 1 Stage 0
Ancillaries - Lab, Rad, Pharmacy - All Installed All Three Ancillaries Not Installed Data from HIMSS Analytics TM Database © 2014
7.6% 3.3% 5.8%
N = 5,458
13.3% 24.2% 15.7% 27.7% 7.2% 3.2% 5.6%
N = 5,449 56% 19% (2010) 17
Nursing & Informatics
Putting It All Together !!
Nursing
3.1 M Nurses in the US 62.2% Hospital based Average Age: 45.5
% BS or Higher: 50% RN Faculty Age>50: 60%
Nursing @ Lahey
• 1,443 Nurses • Average Age: 45 • % BS or > 61.26% • Years Exp:15 U.S. Health Resources and Services Administration, 2008 National Sample Survey of Registered Nurses. U.S. Bureau of Labor Statistics, Occupational Outlook Handbook, 2010-2011 Buerhaus, P.I., Auerbach, D.I., & Staiger, D.O.,
Health Affairs
, July-August 2009, 28(4), 657-668.
American Association of Colleges of Nursing 19
Nursing Practice Time
From: Hendrich, Ann et al , “A 36 Hospital Time Motion Study: How Do Medical Surgical Nurses Spend Their Time?”, The Permanente Journal, 2008, Vol. 12, No. 3
Nursing Practice Location
From: Hendrich, Ann et al , “A 36 Hospital Time Motion Study: How Do Medical Surgical Nurses Spend Their Time?”, The Permanente Journal, 2008, Vol. 12, No. 3
Nursing Going the Distance !!
At Work
• 3 Miles per 10 Hour Day Shift (Median) • 2.2 Miles per 10 Hour Night Shift (Median)
Not At Work
• 2.1 Miles per 10 Hours “ The variability between individual nurses on the same unit was often greater than the variance across different hospital units.” “ Nurses travel significantly larger distances and exert more energy during daytime shifts than when away from work.” From: Hendrich, Ann et al , “A 36 Hospital Time Motion Study: How Do Medical Surgical Nurses Spend Their Time?”, The Permanente Journal, 2008, Vol. 12, No. 3
Nursing Informatics
• • Nursing Specialty Recognized by ANA Focuses on Integration of: – Nursing Science – Computer Science /Communication – Information Science • Data, Information, Knowledge and Wisdom
Nursing Informatics
Nelson’s: Data to Wisdom Continuum
Data
Naming collecting organizing
Wisdom
Understanding, applying, Applying with Compassion
Knowledge
Interpreting, Integrating Understanding
Information
Organizing, Interpreting Increasing Interactions and Interrelationships
Nursing in the Eye of the Storm !!
ARRA RWJF IOM Nursing ICD10 PPACA 25
Meaningful Use Stages
“These goals can be achieved only through the
effective use of
information to support better
decision-making and more effective care processes
that improve health outcomes and reduce cost growth.”
Stage 1
Data Capture and
Sharing Stage 2
Advanced Clinical
Processes Stage 3
Improved
Outcomes
↑
Meaningful Use Over Time
From: The Markel Foundation: Connecting for Health, “Achieving the Health IT Objectives of the American Recovery and Reinvestment Act” April 2009 26
Meaningful Use: EHR Technology
Core Hospital Functionality
Enter Rx Order e-Rx (EP) Rx Interaction checks Enter Active Rx List Enter Active Rx Allergies Enter Vital Signs (Ht, Wt, BP) Display BMI/Growth Charts Enter Smoking Status Decision Support Problem List Enter Pt Requests Provide e-Results Provide D/C Instructions Provide Clinical Summary (EP) Exchange Health Info Conduct HIPAA Security Assessment CPOE Core HIS Clinical Documentation Medication Management Emergency Department
….but where was Nursing?
Health IT Policy Committee Health IT Standards Committee
• 24 Members • 9 MD’s including Chair and Vice Chair – all male • • 6 Females • 1 Vendor (Epic)
1 RN
• 30 Members • 10 MD’s including Chair and Vice Chair – one female • • 12 Females • 1 Vendor (Cerner)
3 RN’s
3.0 Million Registered Nurses represent the largest segment of the healthcare workforce…..
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Nursing in the Eye of the Storm !!
ARRA RWJF IOM Nursing ICD10 PPACA 29
• • • •
International Classification of Disease 10
th
Revision
2015 2014
ICD-10 compliance mandated October 1,
2013
Half of US Health providers 25% or less done with ICD10 Implementation (1) Most providers were opposed to a delay…… Impact is expected to include: – Coding Medical Records – Health Information Management – Registration/Scheduling – Encounter Forms/Charge Tickets – Clinical Documentation – Information Systems; including EHR’s – …the entire Revenue Cycle
Every ICD-9 diagnosis code and every ICD-9 procedure code will be impacted and every system, form, Department, etc where these codes are in use will be impacted as well (1) From Becker Hospital Review – February, 2014
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ICD-10 One Example !!
Pressure Ulcer • 9 Codes • 707.00 – 707.09
• Specificity = Location L89.131
L89.132
L89.133
L89.134
L89.139
L89.141
L89.142
L89.143
L89.144
L89.149
L89.151
L89.152
125 Codes
Specificity = Location, depth and stage Pressure ulcer of right lower back, stage I Pressure ulcer of right lower back, stage II Pressure ulcer of right lower back, stage III Pressure ulcer of right lower back, stage IV Pressure ulcer of right lower back, unspecified stage Pressure ulcer of left lower back, stage I Pressure ulcer of left lower back, stage II Pressure ulcer of left lower back, stage III Pressure ulcer of left lower back, stage IV Pressure ulcer of left lower back, unspecified stage Pressure ulcer of sacral region, stage I Pressure ulcer of sacral region, stage II
…. and 113 More !!
Official CMS Industry Resources for the ICD-10 Transition
www.cms.gov/ICD10
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Nursing in the Eye of the Storm !!
ARRA RWJF IOM Nursing PPACA ICD10 32
Health Reform
Patient Protection and Affordable Care Act (PPACA)
• Signed: March 23, 2010 • Phase 1 – Control admin costs, Age 26 covered, Pre-existing • Phase 2 – 2014 – (Exchanges, Tax for those w/o insurance, etc) • 2019 – All insured • $938B over 10 years • Payment Reform, Pilot Studies, ACO’s, Medical Home models, P4P • Kaiser Summary http://healthreform.kff.org/the-animation.aspx
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ACO – An evolving definition….
ACO
A local health care organization that is accountable for 100 percent of the expenditures and care of a defined population of patients. Depending on the sponsoring organization, an ACO may include primary care physicians, specialists and, typically, hospitals, that work together to provide
evidence-based care
in a coordinated model. The three major foci of these organizations are: 1) Organization of all activities and accountability at the
local
level 2) Measurement of
longitudinal outcomes and costs
3) Distribution of
cost savings
to ACO members.
ANA Recommendations for ACO’s
Nurse-led care coordination Adequate compensation for care coordination Measuring the quality of care coordination using “nurse-sensitive indicators.” Strong leadership from all healthcare professionals.
Inclusion of a wider segment of small, solo and nurse-led practices.
Measure patient satisfaction
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Nursing in the Eye of the Storm !!
ARRA RWJF IOM Nursing ICD10 PPACA 36
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The Future of Nursing: Leading Change, Advancing Health
Released Type Topics Activity Board October 5, 2010 Consensus Report Health Care Workforce, Quality and Patient Safety, Health Services, Coverage, and Access Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine Studies under the IOM Executive Office
http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx
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8 Key Recommendations
5 6 7 8 3 4 # 1 2 Recommendation Remove scope-of-practice barriers Expand opportunities for nurses to lead and diffuse collaborative improvement efforts Implement nurse residency programs Increase the proportion of nurses with a baccalaureate degree to 80 percent by 2020 Double the number of nurses with a doctorate by 2020 Ensure that nurses engage in lifelong learning Prepare and enable nurses to lead change to advance health Build an infrastructure for the collection and analysis of interprofessional health care workforce data
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Scope of Practice Barriers
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Technology, Informatics, Guiding Educational Reform “Our vision is to enable nurses to use informatics tools, principles, theories, and practices to make health care safer, more effective, efficient, patient centered, timely, and equitable by interweaving enabling technologies transparently into nursing practice and education, making
information technology the stethoscope for the 21st century .
“
www.tigersummit.com
TIGER
Technology Innovation
Changing Healthcare
Our Epic EHR Program Vision
• The Epic EHR will provide us with
an unsurpassed level of coordinated information and resources
across all care settings. •
Providers will have access to the most up-to-date information about a patient
, which will help enable the highest levels of patient care and safety while also minimizing the potential need for unnecessary procedures or diagnostic testing. •
Fully integrated clinical and administrative data will be available
to better understand and manage quality and efficiency across all facets of the organization.
•
Evidence based practices will be consistently delivered
through advanced clinical decision support capabilities at the point of care, enhancing our ability to manage the care of all patients including those with chronic disease and other targeted patient populations.
•
Care team collaboration and patient engagement will be greatly improved
through the delivery of secure communication channels that will result in greater wellness for our communities
Our Epic EHR Project Life-Cycle
Business Owners Prepare to Operationalize the Epic System
• Listen and learn current state workflows
Discovery Validation
• Review Epic Foundation workflows and collect SME and leadership input • 3 Validation waves • Workgroup sessions will resolve validation items with a final vote of yellow or red • Build, configure and test modifications based on feedback, & workgroup sessions
Build & Testing Training & Go-live
• Provide training to end-users and begin using Epic Content and Workflow Design and Build: 11/15/13 thru 9/1/14
The Blue Button
• Patients have a RIGHT to have access to THEIR health information.
– Current medications you are taking – Allergies you may have – Medical treatment information from your doctor or hospital visits – Your lab test results – Your health insurance • Blue Button model based on MyHealtheVet (Veterans Affairs).
• Take the Blue Button Pledge !!
healthit.gov/bluebutton
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Google Glass
• Beth Israel Deaconess, Boston, MA • Used in the ED • Can show patient info and physicians can operate a variety of functions with voice commends (eg. Page RN).
Link: http://boston.cbslocal.com/2014/04/09/beth-israel-doctors-using-google-glass-in-er/ 46
• • • • Site focuses on the ever expanding world of health trackers.
Device categories include fitness, sleep, weight, posture, heart, genetics, home monitoring, pregnancy, dental and more.
Users can compare prices and features of similar devices to hone in the one most suitable for them.
Site can also
integrate data
from a user's current device and track it over time.
Innovation: Health Trackers
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Tyto wants to replace F2F doctor visits
• • • • Israeli-based company raised $4 million for a device that takes temperature and examines the heart, lungs, throat, ears, skin and eyes.
Examinations can be conducted remotely via a physician or an offline self-examination guided by Tyto with results analyzed by a primary care provider.
No special training needed.
Targeting a $200 retail price with FDA clearance in early 2015.
Source:
Bioniq Health; Tech Crunch
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New tests may revolutionize cancer detection
• • • • • Guardant Health's technology utilizes a blood test rather than a biopsy to detect cancer.
Blood test will cost a few hundred dollars as opposed to a biopsy which can cost upwards of $10,000,.
Test looks for fragments of tumor DNA in the bloodstream, identifying mutations in genes that are targeted by approved drugs so a specific therapy can be recommended.
Company is focused on breast, lung, colorectal, skin and prostate tumors, which accounts for over
50%
of cancers.
Raised $10 million from Sequoia Capital.
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Cognitive Training Programs
Brain fitness apps are attracting attention despite scientific proof that they work
What:
More than 40 cognitive training exercises in a variety of categories including attention, memory, speed, and problem solving
Cost:
Some content is free; Subscription is $15/ month
Platform:
iOS and Web
What:
Complete brain training focused on the five executive functions: Memory, attention, language, executive functions, and visual and spatial skills
Cost:
Free for 7 days then $15 / month.
Platform
: Web
What:
A memory training program to improve attention in individuals with a working memory deficit by combining cognitive neuroscience with gaming
Cost:
Via company contact only
Platform:
Web
What:
A method of enhancing the brain's natural processes in Alzheimer's patients in an attempt to reverse symptoms and slowdown the degenerative progression.
Cost:
Not yet commercially available.
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Summary
Technology continues to evolve at a rapid rate.
Nursing workforce will use information and communication technology and informatics to improve the delivery of patient care. Necessary skills for nurses’ in 2014 includes
basic computer competencies, information literacy and informatics skills.
Recognize the need for Nursing Informatics experts in your organizations! Place these experts into positions of influence! Seek them out! Bring them with you to the table!
Nurse leaders will need to have a working knowledge of informatics and an understanding of the impact of technology on the clinical care environment.
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Medieval Help Desk
•
Medieval Help Desk
http://www.youtube.com/watch?v=xFAWR6hzZek 52
Leadership Skills
•
Courage
•
Judgment
•
Integrity
•
Dedication
President-elect John F. Kennedy
Massachusetts State House January 9, 1961
Change is Tough !!
"That it will ever come into general use, notwithstanding its value, is extremely doubtful because its beneficial application requires much time and gives a good bit of trouble, both to the patient and to the practitioner because its hue and character are foreign and opposed to all our habits and associations.“ from
The London Times
in 1834 commenting on . . . the stethoscope 54
Resources
• New England Nursing Informatics Consortium
www.nenic.org
• HIMSS – Health Information Management Systems Society
www.himss.org
• Alliance for Nursing Informatics
www.allianceni.org
• American Medical Informatics Association
www.amia.org
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Thank You and Questions !!
Mark Sugrue, RN-BC, FHIMSS, CPHIMS [email protected]
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