Transcript Slide 1

Nursing, Technology and
21st Century Practice
Mark D. Sugrue, RN-BC, FHIMSS, CPHIMS
November 1, 2014
Massachusetts Society of PeriAnesthesia Nurses
Outline
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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)
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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
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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
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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.
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.
MSNBC
January 2008
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/M2 Day 1-4
What Should
Have been
Administered
What Was
Actually
Administered
Day 1
1 g/M2
4 g/M2
Day 2
1 g/M2
4 g/M2
Day 3
1 g/M2
4 g/M2
Day 4
1 g/M2
4 g/M2
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
Cumulative Capabilities
2013
Final
2014
Q1
Stage 7
Complete EMR; CCD transactions to share data; Data
warehousing; Data continuity with ED, ambulatory, OP
2.9%
3.1%
Stage 6
Physician documentation (structured templates), full
CDSS (variance & compliance), full R-PACS
12.5%
13.3%
Stage 5
Stage 4
Closed loop medication administration
22.0%
24.2%
CPOE, Clinical Decision Support (clinical protocols)
15.5%
15.7%
Stage 3
Nursing/clinical documentation (flow sheets), CDSS
(error checking), PACS available outside Radiology
30.3%
27.7%
Stage 2
CDR, Controlled Medical Vocabulary, CDS, may have
Document Imaging; HIE capable
7.6%
7.2%
Stage 1
Stage 0
Ancillaries - Lab, Rad, Pharmacy - All Installed
3.3%
3.2%
All Three Ancillaries Not Installed
5.8%
5.6%
Stage
Data from HIMSS AnalyticsTM Database © 2014
N = 5,458
SM
56%
19% (2010)
N = 5,449
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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%
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Nursing @ Lahey
1,443 Nurses
Average Age: 45
% BS or > 61.26%
Years Exp:15
RN Faculty Age>50: 60%
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.
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American Association of Colleges of Nursing
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
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Nursing Specialty Recognized by ANA
Focuses on Integration of:
– Nursing Science
– Computer Science /Communication
– Information Science
• Data, Information, Knowledge and Wisdom
Nursing Informatics
Increasing Complexity
Nelson’s: Data to Wisdom Continuum
Wisdom
Understanding, applying,
Applying with
Compassion
Knowledge
Interpreting, Integrating
Understanding
Information
Organizing,
Interpreting
Data
Naming collecting
organizing
Increasing Interactions and Interrelationships
Nursing in the Eye of the Storm !!
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ARRA
RWJF
IOM
Nursing
ICD10
PPACA
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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
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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
Medication
Management
CPOE
Core HIS
Clinical
Documentation
Emergency
Department
….but where was Nursing?
Health IT Policy Committee
• 24 Members
• 9 MD’s including Chair and
Vice Chair – all male
• 6 Females
• 1 Vendor (Epic)
• 1 RN
Health IT Standards Committee
• 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
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ICD10
PPACA
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International Classification of Disease
10th Revision
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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:
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Coding Medical Records
Health Information Management
Registration/Scheduling
Encounter Forms/Charge Tickets
Clinical Documentation
Information Systems; including EHR’s
…the entire Revenue Cycle
(1)
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
From Becker Hospital Review – February, 2014
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ICD-10 One Example !!
125 Codes
Specificity = Location, depth and stage
Pressure
Ulcer
L89.131
Pressure ulcer of right lower back, stage I
L89.132
Pressure ulcer of right lower back, stage II
L89.133
Pressure ulcer of right lower back, stage III
L89.134
Pressure ulcer of right lower back, stage IV
• 9 Codes
• 707.00 – 707.09
L89.139
Pressure ulcer of right lower back, unspecified stage
L89.141
Pressure ulcer of left lower back, stage I
• Specificity = Location
L89.142
Pressure ulcer of left lower back, stage II
L89.143
Pressure ulcer of left lower back, stage III
L89.144
Pressure ulcer of left lower back, stage IV
L89.149
Pressure ulcer of left lower back, unspecified stage
L89.151
Pressure ulcer of sacral region, stage I
L89.152
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
ICD10
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PPACA
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Health Reform
Patient Protection and Affordable Care Act
(PPACA)
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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
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Nurse-led care coordination
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Adequate compensation for care coordination
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Measuring the quality of care coordination
using “nurse-sensitive indicators.”
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Strong leadership from all healthcare
professionals.
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Inclusion of a wider segment of small, solo and
nurse-led practices.
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Measure patient satisfaction
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Nursing in the Eye of the Storm !!
ARRA

RWJF
IOM
Nursing
ICD10
PPACA
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The Future of Nursing: Leading
Change, Advancing
Health
Released
October 5, 2010
Type
Consensus Report
Topics
Health Care Workforce,
Quality and Patient Safety,
Health Services, Coverage,
and Access
Activity
Robert Wood Johnson
Foundation Initiative on the
Future of Nursing, at the
Institute of Medicine
Board
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
#
Recommendation
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Remove scope-of-practice barriers
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Expand opportunities for nurses to lead and diffuse collaborative
improvement efforts
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Implement nurse residency programs
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Increase the proportion of nurses with a baccalaureate degree to 80
percent by 2020
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Double the number of nurses with a doctorate by 2020
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Ensure that nurses engage in lifelong learning
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Prepare and enable nurses to lead change to advance health
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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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TIGER
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, patientcentered, 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
Technology Innovation
Changing Healthcare
Our Epic EHR Program Vision
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The Epic EHR will provide us with an unsurpassed level of coordinated information
and resources across all care settings.
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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.
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Fully integrated clinical and administrative data will be available to better
understand and manage quality and efficiency across all facets of the organization.
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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.
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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
Validation
• Listen and learn
current state
workflows
Discovery
• Review Epic
Foundation workflows
and collect SME and
leadership input
• Workgroup sessions will resolve
validation items with a final vote
of yellow or red
• Build, configure and test
modifications based on feedback,
& workgroup sessions
• 3 Validation waves
Build &
Testing
Content and Workflow
Design and Build:
11/15/13 thru 9/1/14
Training &
Go-live
• Provide training to
end-users and begin
using Epic
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
healthit.gov/bluebutton
• Blue Button model based on
MyHealtheVet (Veterans
Affairs).
• Take the Blue Button
Pledge !!
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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/
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Innovation: Health Trackers
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Site focuses on the everexpanding 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.
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Tyto wants to replace F2F doctor visits
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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
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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
What: Complete brain
training focused on the
five executive
functions: Memory,
attention, language,
executive functions,
and visual and spatial
skills
Cost: Some content is
free; Subscription is
$15/ month
Cost: Free for 7 days
then $15 / month.
Platform: iOS and
Web
Platform: Web
What: A memory
training program to
improve attention in
individuals with a
working memory
deficit by combining
cognitive
neuroscience with
gaming
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: Via company
contact only
Cost: Not yet
commercially
available.
Platform: Web
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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
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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
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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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