Telemedicine will emerge as a $34 billion market by 2020, according to research from Mordor Intelligence, helping care providers improve care outcomes, enhance access and manage costs.
Telemedicine's growth will also change how nurses serve patients and consumers in an environment shaped by value-based, accountable care and ongoing pressures to generate revenue, cut costs, and enhance patient satisfaction and engagement.
Among the dominant short-term telemedicine trends are the following:
Support: Government and societal support for telemedicine will escalate, allowing more nurses to get involved in the delivery of telemedicine services. Legislators introduced some 200 telehealth bills in 2015, according to a report from the National Conference of State Legislatures . Physicians can now practice telemedicine across state lines thanks to the Interstate Medical Licensure Compact from the Federation of State Medical Boards. Such compacts will touch diverse healthcare professionals, including nurses, through the Enhanced Nurse Licensure Compact.
Accreditation/Coding: Nurses involved in telemedicine will confront issues ranging from accreditation to coding. The American Telemedicine Association (ATA) offers varied levels of accreditation to telemedicine providers. Meanwhile, the Centers for Medicare & Medicaid Services (CMS) has added codes for telemedicine services-some six in 2015. Nurses will help monitor how well healthcare organizations (HCOs) comply with telemedicine standards while ensuring proper coding for telemedicine services.
Expansion: Telemedicine will surface within multiple care settings, enhancing the likelihood of nurses' involvement. Telemedicine will spread from hospitals and physician practices to retail, urgent care and on-site employee clinics. Employers plan to expand their use of telemedicine, according to a survey from Towers Watson. Meanwhile, retailers like Target, Walgreens and CVS will offer telemedicine through in-store clinics, predicts mHealth Intelligence.
Telemedicine will also expand globally, the result of partnerships between hospitals, health systems and academic medical centers in the U.S. and abroad. Experts predict that the global telemedicine market will experience a combined annual growth rate (CAGR) of close to 19 percent in 2016, according to P and S Market Research.
Technology: Telemedicine will no longer function as a stand-alone or add-on technology. Expect telemedicine vendors to pitch benefits like integration with electronic health record systems, data collection and analytics and support for multiple medical specialties and professions, according to Health Data Management. Such innovations will enable providers to use telemedicine to manage costs and improve quality, access and outcomes.
Consider, for example, how telemedicine could enhance patient and consumer experience and engagement. Providers could use telemedicine in all phases of care: prevention, including information dissemination, education and, coaching, as well as diagnosis, treatment, recovery and health maintenance.
Many questions remain unanswered, including the following:
- Who should and will pay for telemedicine? Should payers reimburse for all telemedicine or just specific services? The controversy is likely to continue.
- How could telemedicine enhance the management of chronic disease patients in rural and remote areas?
- How much will patients and consumers benefit from telemedicine? Will it remain a service for the upper middle and affluent classes? Or will an aging population accelerate widespread telemedicine adoption?
- Will telemedicine fulfill its promise and potential? How much will it improve care outcomes? Enhance patients' access to high quality specialty care? Control or reduce healthcare costs? The jury is still out, but initial reports are positive.
Despite these issues, the future of telemedicine is bright. Telemedicine use continues to grow among healthcare professionals, according to Assessing the Value of Telemedicine Devices in Today's Healthcare Landscape from Aeris, an Internet of things (IoT) and mobile-to-mobile vendor.
"As more individuals choose to ‘age in place,' adopting telemedicine is a valuable solution that gives patients the freedom to move, without disrupting their lives unnecessarily with costly hospital and doctor visits," say Janet Jaiswal of Aeris. "While barriers to adoption remain, such as investing in the technology and patient acceptance of the technology, we remain confident about the future of telemedicine."
Nurses who want to stay engaged with the trend toward telemedicine should consider the following actions:
Inform: Do everything you can to inform patients and consumers about the value and benefits of telemedicine. Forty-one percent of consumers have never heard of telemedicine, according to a survey in Healthcare Informatics.
Make the case: Counter naysayers by sharing telemedicine's positive results in terms of outcomes, access, equity, quality and cost control. For example, telemedicine helped one VA hospital save $64K a year, according to mHealth Intelligence. Widespread adoption of telemedicine could save some $6 billion annually, according to forecasts from CGI Research.
Get involved: Take part in the telemedicine decision-making process, sharing best practices like market assessments, mission alignment, clinician champions, management support, training, outcomes measurement and system integration. Investigate how you and nursing colleagues can plug into critical steps outlined by AMD Global Telemedicine or the ATA's Telemedicine Practice Guidelines.
Telehealth Nursing Fact Sheet (American Telemedicine Association)
Telehealth Nursing Practice (American Academy of Ambulatory Care Nursing)
ICU Nurses Report Telemedicine Improves Patient Care
2016: Telehealth Trends for Nurse Practitioners
How Telemedicine Is Changing the Nursing Industry
Drones are far more than toys. Drones will transform diverse areas of life, including business, defense, education, entertainment, and, of course, health and medicine. Drones will also transform the role and function of nurses and other healthcare professionals. Just consider the possibilities:
Education: Educators from diverse disciplines have incorporated drones in curricula and research projects. Building on developments by institutions like University of Pennsylvania's GRASP/Lab and Embrie Riddle, some educators have started loaning drones to students. Drones have the power to deliver books and learning resources to remote and rural areas and facilitate healthcare research and surveillance via aerial drone photography.
Look for more nursing educators and trainers to mobilize drones to support research and data gathering. Consider, for example, how drones could support research on the social determinants of health within Native American, Latino, African American and high-utilizer neighborhoods and communities.
And think of how educators could offer "birds-eye views" of complex U.S. healthcare facilities-from Ascension Health, Catholic Health Initiatives and Kaiser Permanente to Adventist Health System, Dignity Health and Trinity Health, as well as healthcare environments in countries like Vietnam, India and Cameroon.
Health, Medicine and the Environment: 2015 was a breakthrough year for humanitarian applications of drone technology. The United Arab Emirates (UAE) sponsored the first Drones for Good competition, which was won by a drone designed to rescue people in tight spaces.
Researchers in Norway have mobilized drones to measure the impact of climate change, while Nepalese professionals have mapped earthquake damage with drones. Following extensive flooding in Texas and Oklahoma, researchers from Texas A & M, Corpus Christi relied on drones for search and rescue operations. Meanwhile, rescuers in Maine used a drone to carry a lifejacket to boys stranded in the middle of a raging river.
Among the more specific healthcare applications of drones are the following:
Medications, supplies and lab tests: Drones have already begun to pick up specimens and return them to labs for analysis. Researchers from Johns Hopkins University were worried that the sudden acceleration or hard landing of a drone might destroy blood cells or cause blood to coagulate. However, research confirmed that drones could take on the delicate task.
Rural and remote healthcare/global health: Drones are likely to enhance healthcare delivery in developing countries and remote or impoverished areas of the U.S. While drones may not drop packages at the entrances of Chicago high-rises, unmanned aerial vehicles (UAVs) have delivered supplies to earthquake victims in Haiti and to places like Papua New Guinea.
Mayo Clinic predicts increased use of drones to transport blood products and drugs in response to mass casualty incidents and critical access hospital needs. Consider the benefits of drone-delivered defibrillators, organs, medications and medical supplies.
Telemedicine: Healthcare Integrated Rescue Operations (HIRO) is the first telemedical drone designed for rescue operations. Professionals could use drones to enter areas with suspected outbreaks of Ebola or Dengue fever. Within the U.S., an injured skier could call 911 to trigger the dispatch of a telemedical drone. The drone would transmit video of the skier's injuries, while a smartphone would allow the skier to communicate directly with a healthcare professional.
Fighting Fires: Drones will serve on the frontlines of fighting fires and other natural disasters that threaten our health and well-being. Federal government officials are already looking at drones to fight forest fires in the West. Others see value in wall-climbing drones that could locate the sources of fires in high-rise buildings and the individuals who are still trapped inside.
Prevention: Drones will be indispensable in injury and accident prevention. A Texas inventor is exploring how drones could prevent pool drownings while lifeguards already view drones as vital in shark-spotting and prevention of beach-related accidents.
Police departments increasingly rely on drones to clear traffic accident sites. Drones accelerate the photography of accident scenes, editing hundreds of photos into a multidimensional map. Insurance companies can also settle claims quicker and more efficiently.
Forward to the Future
As nurses look forward to a future where drones are active participants, they may witness myriad problems-from privacy, security and designated delivery spots to traffic patterns, durability and licensing. However, nurses can become part of the drone revolution if they take action on the following:
- Learn as much as possible about drones; specifically, how professionals can use them in health and medicine. Health information technology publications increasingly cover drones, including the relationship between drones and technologies like virtual reality.
- Review typical health, medical and environmental challenges. Consider how drone technology could address problems of quality, cost, access, safety, efficiency and equity.
- Avoid myths and stereotypes. Many people assume that drones look like airplanes. Drones might resemble balloons or function as manned vehicles. A Chinese company called eHang is already testing drones that can carry humans.
Susan Sportsman, PhD, RN, ANEF is the Director of the Academic Consulting Group, an innovative service of Elsevier. Sportsman is also currently the Co-Chair of the Texas Team Advancing Health Through Nursing Education Committee and a member of the Texas Board of Nursing Advisory Committee on Education. She was recently selected as a Fellow in the National League for Nursing Academy of Nurse Educators.
Educators loan drones to students: http://www.cnn.com/2014/06/21/us/college-lends-drones-to-students/
Drones deliver books to remote and rural areas: http://www.brw.com.au/p/tech-gadgets/textbook_delivery_zookal_delivers_uCptYCXykZeTqX8PMoWmRM
Drones for Good competition: http://english.alarabiya.net/en/business/technology/2015/02/07/World-first-competition-sees-drones-put-to-good-use-in-UAE.html
Drones help scientists measure the impact of climate change: https://www.climatecentral.org/news/drones-study-arctic-sea-ice-18921
Drones map earthquake damage: http://www.wsj.com/articles/nepal-aid-workers-helped-by-drones-crowdsourcing-1430483540
Drones for search and rescue operations: http://www.wtsp.com/story/news/2015/05/28/drones-search-for-texas-oklahoma-flood-victims/28131941
Drones deliver lifejacket to boys stranded in the river: http://www.usatoday.com/story/news/nation-now/2015/07/01/maine-crews-drone-rescue-2-boys-from-raging-river/29568759/
Study shows successful transport of blood samples with small drones: http://www.hopkinsmedicine.org/news/media/releases/proof_of_concept_study_shows_successful_transport_of_blood_samples_with_small_drones
Drones could prevent pool drownings: http://www.dallasnews.com/business/technology/headlines/20160122-plano-inventor-dreams-of-stopping-drownings-with-drones-over-troubled-water.ece
Drones can carry humans: http://money.cnn.com/2016/02/15/technology/drone-virtual-reality-tech-trends
Discussions about virtual reality (VR) often center on the technology; specifically, sophisticated headsets like Oculus Rift, which was showcased at the 2016 Consumer Electronics Show (CES). While VR is still in its infancy, many innovations will surface in 2016, supported by conversations about VR's health and medical applications. Experts predict that the VR market will soar to $15.89 billion by 2020, according to MarketsandMarkets. Following are just some of the ways nurse professionals may experience VR:
Education and training in nursing knowledge, skill and competencies: Look for VR to transform education and training of healthcare professionals as well as consumer and patient education. Products like Oculus Rift and Magic Leap will transport nurse learners into diverse learning environments-from a third-world country, natural disaster zone or elderly patient's home to inside the human heart, brain or nervous system. Among the applications are:
- Training for specific environments: The British government already relies on VR to train medics for battle. Nurses may rely on VR to prepare for future roles and assignments in labor and delivery, trauma, surgery or mental health.
- Making choices and taking risks: Virtual reality will allow nurses to rehearse choices as they evaluate risks and benefits. National Grid, for example, relies on Virtalis VR to facilitate decisions about tools and protective gear. VR will be a major draw for would-be nurses and Millennials who grew up in the era of the X-Box and look forward to compelling, immersive education and training experiences.
Product and service design and development. VR will accelerate and transform team-based collaboration, allowing nurses to create tools, devices, systems and care environments. The die has already been cast. Ford Motor Company already uses VR in automotive design, while Caterpillar and General Motors depend on VR to evaluate designs and re-invent products.
Nurses will likely do the same, joining forces with nurse colleagues and other healthcare professionals to develop, test and re-engineer tools, devices, equipment and care settings. By immersing themselves in 3-D models, similar to those developed by Caterpillar and General Motors, nurses will literally be able to reach in and touch to explore and test new healthcare products, systems and care environments.
Treatment of patients with PSTD, depression and anxiety. Developed by the USC Institute for Creative Technologies, Bravemind relies on VR to treat veterans with post-traumatic stress disorder (PSTD), inviting them to relive the smells, sounds and feelings of war. Meanwhile, growing numbers of mental health professionals are using video games and VR for depression and anxiety treatment. Among the more prominent interactive games for mental health treatment are Elude, Depression Quest, Actual Sunlight, and SPARX.
Rehabilitation of heart and stroke patients. VR environments are already helping patients recover from stroke, as evidenced by work done at the Rehabilitation Institute of Chicago. MindMaze uses a motion-sensing camera to project an avatar onto a patient's VR goggles. Through multiple electrodes, the patient command a virtual arm or leg to complete a task like lifting a bowl or raising a glass, for example. The technology tricks the patient's brain into reactivating damaged neurons or activating new neurons to replace damaged ones. Nurses will rely on technologies like MindMaze to work with the disabled or patients recovering from a heart attack or stroke.
VR is like any new technology. It generates questions and doubts. Nurses should remain optimistic about the impact of VR on nursing education and training and on diagnosis, treatment, recovery and prevention, while remaining somewhat skeptical of its workability, practicality and development costs. Among the questions nurse educators and professionals should pose are the following:
Virtual Life vs. Real Life: Is the virtual world presented through VR different enough from the real world that it impinges upon nurses' ability to assimilate and integrate knowledge and skill? Will nurses and other healthcare professionals become sufficiently enamored with VR that they support developers in the creation of new virtual worlds for medicine and care delivery?
Mainstream Potential: Will VR evolve to the extent that it becomes an affordable mainstream technology in health and medical education, prevention, diagnosis, treatment and recovery across every entity on the expanding continuum of care? Can we have faith in Mark Zuckerberg's 2014 statement that "this kind of immersive, augmented reality will become part of the daily lives of billions of people?"
Beyond Games: Will VR reach beyond games to embrace the essence of education, religion, business, science, entertainment and technology? Adds Facebook's Zuckerberg: "Imagine enjoying a court side seat at a game, studying in a classroom of students and teachers all over the world or consulting with a doctor face-to-face - just by putting on goggles in your home."
Who We Are: Does VR have the capacity to change us-and not in a good way? Could VR exacerbate the challenges already generated by omnipresent smartphones and wearable devices? Could it curtail low-value interactions, as described by Palmer Luckey, founder of Oculus? Or will VR expand our horizons and forge relationships and alliances few could imagine?
Virtual reality gives athletes a new view of training: http://www.sfgate.com/business/article/Virtual-reality-gives-athletes-a-new-view-on-6778059.php
Virtual reality makes real impact in medical device testing: http://www.statnews.com/2015/12/30/virtual-reality-medical-device-testing/
New virtual relaxation pod uses Oculus Rift to enhance mindfulness therapy for patients: http://www.medicaldaily.com/new-virtual-relaxation-pod-uses-oculus-rift-technology-enhance-mindfulness-370494
Virtual reality system designed for motor rehabilitation of the shoulder: http://www.healio.com/orthotics-prosthetics/health-care-updates/news/online/%7B9dd7937a-4c9e-4895-aa59-704579ad1917%7D/virtual-reality-system-designed-for-motor-rehabilitation-of-the-shoulder
Can virtual reality be the next big thing in curing blindness? http://www.bloomberg.com/news/articles/2016-01-19/can-virtual-reality-be-the-next-big-thing-in-curing-blindness-
When virtual reality becomes a life saver: http://www.psmag.com/nature-and-technology/when-virtual-reality-becomes-a-life-saver
With the Teslasuit you'll be able to feel virtual reality: http://www.topsecretwriters.com/2016/01/with-the-teslasuit-youll-be-able-to-feel-virtual-reality
Rehabilitation Institute of Chicago: http://www.ric.org/research/research-centers--programs/mars3/d2vid/
Her name is Nadine. Developed by Nanyang Technological University in Singapore, this human-like, or humanoid, robot can reveal personality, mood and emotions. Nadine's creators believe that social robots like her will soon surface in homes, offices and other environments that face worker shortages.
But should nurses live in fear that Nadine's descendants will take control of the profession of nursing? Probably not. Nurses, however, should develop a more expansive view of robotic technology and robots, which already support healthcare communications, patient monitoring, supply delivery and patient care.
Nurses must gradually uncover answers to the following questions:
- Rationale: Why robots and robotic technology are needed in healthcare?
- Performance: How do robots function?
- Rewards: What are the risks and advantages of robots?
- Results: What kinds of results have robots already generated?
- Future: What does the future hold for robots and robotic technology?
Robot as Communicator
Robots aid in patient-clinician communications. Consider the RP-VITA, or Remote Virtual Independent Telemedicine Assistant, which allows clinicians to communicate with colleagues and patients. This remote-presence solution combines autonomous navigation and mobility from iRobot with telemedicine technology from InTouch Health.
RP-VITA has the same height, weight and eye contact as the patient who participates in a clinical consultation on its screen. Once a patient contacts a clinician, the clinician is able to "talk" to RP-VITA via an iPad or laptop and send the robot to the patient's location.
Clinicians can also use RP-VITA to monitor and transmit vital signs and symptoms. The benefit: Physicians can diagnose and treat patients in remote or hard-to-reach areas without having to travel to the location.
RP-VITA doesn't stand alone in the robot universe. Clinicians, including nurses, social workers, case managers and other professionals, will rely on robots like Giraff to care for the home-bound elderly. Or they'll turn to Anybots, which bills itself as a "virtual telepresence company" to become immersed in distant environments- for example, a patient's home, skilled nursing facility or healthcare workplace.
Robot as Messenger
Nurses typically spend part of their day delivering supplies and medications. That may end with the emergence of the Aetheon TUG, which has already made more than 19 million deliveries involving food services, laboratory, pharmacy, nursing, laundry and environmental services.
Swisslog Robocourier, an autonomous mobile robot (AMR), also transmits materials from a lab, pharmacy and other departments, freeing clinicians to focus on patient-related tasks and cutting turnaround times and labor costs.
Electronic maps, sensors and magnets allow Robocourier to navigate crowded hallways, tight spaces and multiple floors. Robocouriuer is even able to plot the best routes within a facility, avoiding heavily trafficked areas and moving rapidly without disruption or injury to patients and clinicians.
Robot as Patient Care Assistant
Clinicians already rely on robots to treat patients. Surgeons, for example, use the DaVinci Surgical System for non-invasive but complicated surgeries. At the same time, researchers are working on microbots with the capacity to deliver drugs, destroy cancer cells, regulate diabetes and inspect organs without surgery.
While sophisticated microbots may emerge post 2020, clinicians already use robots to care for the elderly and disabled. The Bestic Feeding Arm, for example, gives patients with no function in their hands or arms the chance to eat meals on their own. Elderly or disabled patients in hospitals, assisted living centers or their own homes can choose which pieces of food they want and when they want to lift the food to their mouths.
Developed in Japan, a robot called RoBear literally has the strength of a bear and the heart of a caring clinician. Equipped with sensors that provide feedback on the level of force needed, RoBear can lift patients out of wheelchairs and beds with slow, gentle movements. The 309-pound RoBear will likely bring relief to nurses strained by lifting heavy patients.
Yet another type of robot supports therapy for victims of abuse, domestic violence or other traumas. Developed by students at MIT, the highly cost-effective Ollie the Otter could enhance patient-clinician interaction. Meanwhile, PARO, a cuddly robotic seal developed in Japan, provides comfort to nursing home patients while raising some ethical issues about entrusting emotional support to what some see as a medical device.
Reaching Toward the Future
Nurses are unlikely to lose their jobs to robots. Robots will continue to replace tasks and functions like cleaning, lifting, moving and drug and supply delivery. However, healthcare will always depend on the intervention, support and human touch of trained, caring nurses. Just as babies need human interaction to grow in body, mind and spirt, so patients, families and clinical colleagues need the presence and caring concern of nurses. Emergencies and crises will demand a brand of support that only nurses can provide. Robots, in turn, will offer more efficient, effective ways to deliver care. Among the action steps for nurses are the following:
- Reflect on the future impact of robots on patient care. Consider, for example, innovations like surgical robotics, prosthetics and exoskeletons, which can help disabled people walk.
- Ponder how robots could affect nurses' workloads and patient safety. Consider the future impact of pharmacy, delivery and disinfection robots.
- Think about robots in the home. By 2030, more than 20 percent of Americans will be 65 and older, increasing opportunities for robotic devices and virtual care.
- Put robotics on your reading list. Robots are regularly covered in health information technology publications as well as more popular reads like TechCrunch and CNET and conferences like the annual Consumer Electronics Show (CES).
- Zero in on how robots are likely to transform daily life-from transportation, education and food to entertainment, pharmaceuticals, media and real estate.
Nadine emotional robot: http://www.itpro.co.uk/strategy/25790/nadine-emotional-robot-debuts-in-singapore
InTouch Health: http://www.intouchhealth.com/our-solutions/patient-access/intouch-vita/
Atheon TUG: http://www.aethon.com/tug/tughealthcare/
Swisslog Robocourier: https://www.youtube.com/watch?v=zDmzcN7teu0
DaVinci Surgery: http://www.davincisurgery.com/
Medical Microbots Take a Fantastic Voyage into Reality:
The Bestic Feeding Arm: https://www.youtube.com/watch?v=KmYIoKACztc
ROBEAR: The Experimental Nursing Care Robot: https://www.youtube.com/watch?v=0LaVwDmLDLw
Ollie the Otter is a Therapy Robot: http://spectrum.ieee.org/automaton/robotics/medical-robots/mit-ollie-the-baby-otter-therapy-robot
PARO Robotic Seal: https://www.youtube.com/watch?v=Vx8mv87e6wE
Healthcare has entered a new era of collaboration; specifically, interprofessional collaboration that engages professionals ranging from physicians, nurses, dieticians, and therapists to pharmacists, physician assistants, social workers and case managers. Stories on collaboration abound in the healthcare industry news. Consider these developments:
Collaboration within healthcare organizations has also gained momentum. Professionals increasingly participate in broad-based programs like the Robert Wood Johnson Foundation's National Center for Interprofessional Education and Practice, Retooling for Quality and Safety, an initiative of the Josiah Macy Jr. Foundation, and the Institute for Healthcare Improvement.
But how can nurses use interprofessional collaboration to select, implement and optimize health information technology (HIT)? Following are several recommendations:
Join forces: Investigate marketplace realities. Collaboration works in context, which is why nurses must develop an interprofessional perspective on the following issues:
Join forces: Determine how work is accomplished, i.e., how interprofessional team members, including nurses, deliver care to patients and families. Collaboration supports care delivery by bringing the right information, at the right time, to the right professionals to make the best, most accurate clinical, financial and operational decisions. The first step is to understand how work is accomplished and how care is delivered. Then, re-engineer HIT-enabled care delivery through interprofessional collaboration.
Join forces: Design and build an organization that supports interprofessional collaboration. Interprofessional collaboration is more than an add-on that improves care quality, safety, efficiency and outcomes. Nurses can help restructure organizations by taking the following steps:
- Build and participate in interprofessional collaborative teams that improve the flow, access and use of clinical, financial and operational data and information.
- Restructure nursing jobs so nurses can make better use of data and information. Focus on roles and responsibilities, leadership traits, performance metrics and education and training.
- Support mechanisms that incentivize collaborative behavior. Recognize, reward and celebrate interprofessional collaboration on HIT issues.
Join forces: Empower fellow nurses to engage in interprofessional collaboration. Giving nurses more information-even the right information at the right time-is no guarantee of successful interprofessional collaboration. Nurses need knowledge, skill and, most importantly, the opportunity to practice interprofessional collaboration in the workplace and across the continuum of care. C-Suite executives, including chief nursing officers (CNOs) and chief nursing informatics officers (CINOs), must champion programs that educate, train, mentor and coach nurses to think and work collaboratively with other professions.
Join forces: Align systems to support interprofessional collaboration. Healthcare organizations can drive change by inviting nurses and other professionals to review and redesign the process of care delivery. They can also promote interprofessional collaboration by aligning goals, rewards and feedback mechanisms. Offering nurses incentives that reach beyond traditional compensation systems promotes interprofessional collaboration as a strategy to enhance HIT-related communication, decision making, problem-solving and conflict resolution.
Join forces: Create a culture and environment that foster interprofessional collaboration. So-called "flat" organizations invite employees to "be your own boss" and "self-organize" work. Healthcare, however, calls on individuals, groups, units, division and departments to work together. By building entrepreneurial and intrapreneurial cultures, healthcare organizations can zero in on fleeting opportunities and launch new products and services within several months to a year. These organizations wisely embrace the thinking of computer scientist Alan Kay who once said: "The best way to predict the future is to invent it."
Nurses can participate in interprofessional collaboration, but they can also lead it. That, in turn, means rethinking traditional nursing roles so that nurse leaders can support, mentor, coach and reward interprofessional collaboration for years to come.
Forward to the Future
Interprofessional collaboration takes full advantage of nurses' knowledge, skill and caring concern for colleagues, patients and families. However, interprofessional collaboration is a long journey of discovery rather than a quick trip to an isolated destination. With each step, nurses and their colleagues embrace and adapt to change, enhancing care quality, safety, efficiency and outcomes through the power of HIT.
Interprofessional Collaboration: The Nurse Perspective: https://www.discovernursing.com/nursing-notes/2015-august-interprofessional-collaboration-nurse-perspective#.VkI-e72gnIU
Interprofessional Collaboration and Education: http://journals.lww.com/ajnonline/Fulltext/2015/03000/Interprofessional_Collaboration_and_Education.26.aspx
Fostering Interprofessional Collaboration: http://campaignforaction.org/campaign-progress/fostering-interprofessional-collaboration
Viewpoint Interprofessional Collaboration and the Future of Healthcare: http://www.americannursetoday.com/viewpoint-interprofessional-collaboration-and-the-future-of-health-care/
The National Institutes of Health (NIH) describes precision medicine as "an emerging approach for disease treatment and prevention that takes into account individual variability in genes, environment and lifestyle for each person."
Also known as precision health or healthcare, precision medicine embraces e-health, pharmacogenomics, electronic family health history, targeted therapies for cancer and new approaches for addressing mysterious or rare diseases.
Precision health invites nurses and other healthcare professionals to imagine a world where clinicians could accomplish the following:
- Gauge a patient's likely reaction to a drug before that drug is prescribed,
- Use mobile devices to monitor patients' vital signs and diagnose diseases,
- Rely on genomic sequencing to identify the genetic origins of diseases,
- Identify a cancer treatment based on genetic defects within a tumor, and
- Apply a patient's family health history and genetics to diagnostic and treatment decision making.
Nurses can contribute to the evolution of precision health and medicine, but they need support from colleges, universities and provider and payer organizations. Nurses seek new ways to handle personalized health data; specifically, how to integrate genomic data into the electronic health record (EHR) and then share that data in a usable format with other professionals at the point of care.
Support for incorporating genomic data into the EHR is on the upswing. In September 2015, NIH awarded more than $48 million in grants to researchers who will learn how to integrate genomic data into the EHR. Among the lead grantees are Boston's Brigham & Williams Hospital and Baylor College of Medicine in Dallas.
The NIH grants follow long-term research conducted by the National Human Genome Research Institute (NHGRI) and Electronic Medical Records and Genomics Network (eMERGE). The goal is to determine how to apply patients' DNA to the design and evaluation of more highly personalized therapies.
The newly funded NIH projects are nothing if not practical. Some grantees will explore the root causes of highly prevalent chronic conditions like diabetes and cardiovascular disease. Others will investigate the application of data and predictive analytics to autism, drug metabolism, cancer and immune system response.
Nurses can participate in the quest to deliver precision health and medicine by implementing these strategies:
Monitor innovations: Monitor the results of genomics studies and pilot programs. The University of Cincinnati, for example, will use its NIH grant to track some 100 genes of 2,500 study participants to identify genetic roots of multiple diseases. Meanwhile, UCLA Health has launched a pilot project with Seattle-based ActX to integrate genomic data into its EPIC EHR system. The goal is to apply the principles of precision health and medicine to a large patient base.
Also in the game is the Broad Institute of Harvard and the Massachusetts Institute of Technology (MIT), which relies on data analytics to identify and store millions of genetic variants, as documented in the September 9, 2015 issue of The Atlantic.
Track issues: Track new and emerging genomics and EHR issues, including the following:
- Disclosure: How much genetic information do patients and consumers want? How, where and when should clinicians, including nurses, share this information?
- Personalization vs. Population: How can nursing achieve gains in personalized health and medicine while it pursues population and public health management?
- Safety and Security: How can nurses help ensure the security and safety of sensitive genomics data in an era dominated by costly security breaches?
- Privacy and Confidentiality: How can nurses protect the privacy and confidentiality of patients and consumers who participate in genetic testing, research, counseling and treatment?
- Market Demand Impact: How will the popularity and reduced costs of genetic testing influence the responses of providers, payers, government and patients? What, for example, is the potential for the following:
- o Misinterpretation and misuse of genetic testing results?
- o Excessive health system and consumer spending on prevention?
- o Consumer anxiety and stress over possible diagnoses and treatments?
- Cost: How should the healthcare system justify the costs of precision health and medicine against, for example, its investment in population and public health?
- Technology: How will EHR, mobile, storage and telehealth technologies contribute to the transition to precision health and medicine?
Assume leadership roles: Nurses should participate in groups that set standards and share best practices for integrating consumer perspectives into precision health and medicine. Think about monitoring the precision medicine initiative launched through NIH and the Obama administration, as well as precision health programs developed by high-profile institutions like Stanford Medicine.
Develop a positive attitude: Nurses should approach precision health with optimism and high expectations. "Embracing a national cures strategy will challenge not just regulators, but our entire system for accelerating and paying for new innovations," says Tom Corbin, who represented Oklahoma in the U.S. Senate for 10 years and how serves as advisor to the Manhattan Institute's Project FDA. "It will also enable a golden age of medicine, bringing hope to millions of patients who lack hope today."
Reflect on applications: Reflect on how the integration of genomic data into the EHR will re-engineer nursing practice. "Seminars in Oncology Nursing", which is published by Elsevier, forecasts nurses' growing involvement in communication, advocacy and support of patients and families during genetic testing, diagnosis, treatment and ongoing monitoring and decision making. Adds the journal: "Nursing education and continuing education, clinical decision support, and health systems changes will be necessary to provide personalized multidisciplinary care to patients, in which nurses play a key role."
Educate and train patients, families and colleagues on personalized, precision medicine and health: Nurses can go a long way toward educating patients, consumers and colleagues on personalized, precision medicine and health. Among the issues nurses can explore with patients and colleagues via print, online and broadcast media are the following:
Facilitate patient and family decision making: Just as nurses can educate and train patients and colleagues on personalized, precision medicine, they can also support and coach patients to make accurate, informed, evidence-based decisions on genetic testing and treatment. Among the questions nurses can address during coaching sessions are the following:
Precision Medicine Initiative: http://www.nih.gov/precisionmedicine/
Stanford Medicine Precision Health: https://med.stanford.edu/precision-health.html
National Human Genome Research Institute: https://www.genome.gov/
Electronic Medical Records and Genomics Network: http://www.genome.gov/27540473
eMERGE Network: Electronic Medical Records and Genomics: https://emerge.mc.vanderbilt.edu/
Precision Medicine Is about to Disrupt the Entire Healthcare System:
Informatics: Ethical Use of Genomics Data and Electronic Medical Records:
NIH Grants Seek Best Ways to Combine Genetic Information and EHRs:
Mining Electronic Health Records in the Genomic Era:
Matching DNA with Medical Records to Crack Disease and Aging:
The High Price of Precision Healthcare: http://genomemag.com/reimbursement/#.Vfh4jJfGvIU
Nursing Implications in Personalized and Precision Medicine:
Healthcare Is Up for a Revolution with the Rise of Personal Genomic Tests:
How Data Wranglers Are Developing the Great Library of Genetic Variation:
"Seminars in Oncology Nursing", Vol. 30, No. 2, May 2014. http://www.seminarsoncologynursing.com/
A bold new enterprise to revolutionize medicine and generate the scientific evidence needed
Nurses may have already experienced the Internet of Things (IoT) - also known as the Internet of Everything - in their personal lives as smart sensors surface in objects ranging from trash bins and refrigerators, to office supplies and slow cookers.
IoT is also poised to influence nurses' professional lives. The healthcare IoT market will surge to $117 billion by 2020, according to research from MarketResearch.com. IoT will turbocharge innovation in remote patient monitoring, telemedicine and behavior modification. It will help to control avoidable costs, surface fresh business opportunities and enhance the management of chronic conditions.
Nurses must track the promise and prospects of IoT, including its cost-saving potential, as outlined in "The Digital Revolution Comes to U.S. Healthcare" from Goldman Sachs Group Equity Research. Among the report's key messages for nurses are the following:
1. Expect digital disruptive innovation: Digital health will deliver affordable, accessible patient solutions, predicts the Goldman Sachs report. While healthcare's immediate past featured low-cost, low-access, low-tech devices, the current environment offers high-cost, high-tech, low-access devices. Tomorrow, however, will be different. Digital care will occur via low-cost, high-tech, high-access solutions. "Your smartphone could warn you that your heart and lungs are beginning to malfunction well before you start to have symptoms," predicts Eric. J. Topol, M.D.
Recommendation for nurses: Track how new and emerging digital solutions compare in terms of cost, access and technology. Evaluate the impact of devices on multiple variables, including cost control, quality, safety, outcomes, productivity, efficiency, and nursing workflow.
2. Chronic care management will remain a core challenge. The Goldman Sachs reports divides the IoT market into three promising categories: remote patient monitoring, telehealth and behavioral modification. Despite these tech innovations, nurses may struggle to manage patients' chronic conditions for two reasons:
- Chronic conditions represent $1.1 trillion in annual spending or almost one-third of the nation's healthcare expenditures, according to the National Medical Expenditure Panel Survey (MEPS).
- Three conditions-heart-related problems, asthma and diabetes-represent one-fifth of total healthcare expenditures.
Recommendation for nurses: Track the impact of chronic disease on providers, payers, patients, families, employers, communities and populations. Explore how IoT could support the prevention, diagnosis and treatment of chronic disease across the care continuum. Patients, especially the mature patient, will likely learn how to use the IoT devices to some degree, and nurses will play a key role in educating them.
3. IoT is a potential game changer for chronic disease management. If applied to the fight against heart disease, chronic obstructive pulmonary disease (COPD), asthma and diabetes, remote patient monitoring could save some $200 billion annually. If adapted to routine and psychological care, telehealth could save $100 billion annually. And if mobilized to tackle obesity, smoking and lifestyle issues, behavior modification technologies could generate unspecified but significant savings. The bottom line is IoT represents a total healthcare savings opportunity of more than $300 billion annually, predicts Goldman Sachs.
Recommendation for Nurses: Track the impact of remote patient monitoring, telehealth and behavior modification technologies on cost savings, we well as quality, safety and outcomes. Also reflect on how IoT technologies-remote patient monitoring, telehealth, and behavior modification - could address the challenges of value-based reimbursement, performance management, population health management and patient, consumer and provider engagement. Again, there will be a role for nurses in helping patients to integrate these technologies into their own lives.
Moving Forward with the IoT Evolution
And what of the future? Digital health adoption will help to reduce unnecessary, repetitive care and control wasteful spending. The nation-and perhaps the entire world-could experience significant cost savings through improvements in chronic disease management and prevention. Nurses, however, must come together to address the following issues:
- Cross-continuum collaboration: How can nurses engage in the kind of interprofessional collaboration that supports chronic disease management and prevention across the expanding continuum of care?
- Telehealth: How can nurses facilitate the adoption, implementation and use of telehealth, allowing patients to seek medical and healthcare advice without visiting a provider's office?
- Remote patient monitoring: How can nurses support the planning, adoption and use of technologies that track and respond to the highest risk, costliest patients?
- Behavior modification: How can nurses make a business and clinical case for disease prevention and readmissions avoidance via tech-facilitated lifestyle change?
- Patient training and education: How can nurses help patients integrate the IoT technology into their personal lives to take the most advantage of it?
Other issues are bound to demand the attention of nurses. Among them are the Food and Drug Administration regulation, patient and consumer adoption, provider acceptance, reimbursement and privacy.
Despite these concerns, the future is bright. "The advent of mobile and the advancement of sensors effectively allow for the miniaturization of medical equipment that formerly only a centralized institution could afford," says the Goldman Sachs report. "In this way, we envision IoT enabling a hospital of the future based almost exclusively in 'the cloud.'"
Smartphone gadgets lets you control Crock-Pot, check for sunburn
"The Digital Revolution Comes to U.S. Healthcare"
Digital Healthcare is Coming
Big Data on Internet of Things: Key Trends, Market Opportunities and Forecasts-2015-2020
Re-imagining Everyday Objects
Medical Expenditure Panel Survey
The Internet of Things: the Next Mega Trend
The global telemedicine market will be worth $34 billion by 2020, according to 2015 research from Mordor Intelligence. By 2018, more than 65 percent of interactions between patients and healthcare organizations will occur via mobile devices, predicts IDC Health Insights.
Telemedicine is a subset of the broader category of telehealth. According to the Health Resources Services Administration, telemedicine refers specifically to remote clinical services while telehealth can also refer to remote non-clinical services, such as provider training, administrative meetings, and continuing medical education.
Telemedicine will create new opportunities for nurses to improve care access, quality, safety and outcomes and squeeze out some of healthcare's avoidable costs. Nurses are already making their influence felt in the following settings:
- Nurses at a Veterans Administration hospital in Topeka, Kan., use telemedicine to supplement intensive care. A simulation lab allows nurses to train with mannequins in rooms that resemble ICUs.
- Arizona Palliative Home Care relies on telemedicine to deliver palliative care. Nurses deliver the first 45 minutes of care, with other professionals conducting video chats with patients for the remaining 10-15 minutes.
- Nurses at the John H. Dingell VA Medical Center in Detroit use telemedicine for remote monitoring of patients with chronic conditions like diabetes and high blood pressure. They rely on data generated by remote home monitoring devices.
- Nurses accompany a North Carolina orthopedic surgeon who relies on a robot to complete postoperative rounds of patients located in another city.
- Nurse educators at Duke University School of Nursing use a telepresence robot developed by Sunnyvale, Calif.-based, California-Double Robotics to create realistic clinical simulations.
Telemedicine and telehealth have a bright future. Nurses can make an impact by sharing their unique knowledge, skill, experience and insight on how telehealth and telemedicine will reduce avoidable costs and improve outcomes, quality, access and safety. Following are strategies C-suite and nurse executives can implement to ensure that nurses leave their imprint on the telemedicine revolution:
Outline benefits, challenges: Invite nurses to discuss how telemedicine can benefit the organization's consumer and patient populations. Encourage analysis of telemedicine's value proposition in terms of access to care, outreach to new markets, interprofessional collaboration, resource optimization, and reduced emergency department visits, admissions and readmissions.
Also develop strategies to overcome telemedicine barriers, including reimbursement, licensure laws, online prescribing, privacy and security and other concerns cited by the American Hospital Association in its May 2015 TrendWatch.
Share success stories: Invite nurses to build excitement around telemedicine by sharing stories of business and clinical telemedicine opportunities, implementations, results and lessons learned. Telemedicine leaders include organizations as diverse as Missouri-based Mercy Health System, New York City-based Beth Israel Medical Center, Mayo Clinic and the University of Virginia Health System.
Think big and brainstorm on channels and conditions: Consider how an organization could use telemedicine to better engage patients and consumers, providers, populations and communities via clinical services, referrals, consultations, interprofessional collaboration and digital communications. How, for example, could telemedicine improve the outcomes of patients with conditions like stroke, cancer, Alzheimer's disease, diabetes, congestive heart failure and chronic obstructive pulmonary disease?
Zero in on trends. Invite nurses to analyze, evaluate and synthesize the impact of healthcare, technology and consumer trends on telemedicine. Among the issues: How will reimbursement and industry trends influence the telemedicine market? How do telemedicine technologies rate on variables like security, integration with other systems and cost? What do payers, providers and patients need and want from telemedicine? What opportunities are likely to arise in the years ahead?
Clarify your intent: Once nurses analyze the impact of multiple trends on telemedicine, they can examine what telemedicine could mean to a healthcare organization. Before nurses hone in on telemedicine success, they should consider these steps:
- Perform a needs assessment that documents how telemedicine could close service gaps and minimize challenges like emergency department overuse, inpatient admissions and readmissions and population health.
- Evaluate how well a telemedicine program would align with organizational mission, vision and values and nurses' scope of practice.
- Assess the organization's capabilities-and the capabilities of nurses-against new and emerging market opportunities for telemedicine.
Design a telemedicine program: Working in the spirit of interprofessional collaboration, nurses can outline the varied dimensions of a telemedicine program. Consider these questions:
- Governance: Who will provide clinical, financial and operational oversight of the telemedicine program? What kinds of structures are needed?
- Reimbursement: Which telemedicine services are eligible for reimbursement from Medicare, Medicaid and private insurers? Will reimbursement be adequate to sustain the telemedicine program?
- Funding: Could the telemedicine program secure sustainable funding via government or foundation grants, alliances or vendor partnerships?
- Staffing: Who will deliver telemedicine services? Who will champion telemedicine among executives, managers, clinicians and healthcare consumers? How will the organization address issues related to education, training, licensure and credentialing?
- Process and policy: What policies, procedures and processes does the organization need to deliver high-quality, cost-effective telemedicine services?
- Technology: What kind of technology does the organization need to deliver telemedicine services? How well does the technology address service needs and gaps and requirements of the telemedicine business plan?
- Metrics: Which metrics will the organization use to evaluate telemedicine success? Examples include patients served, telemedicine consultations by service line, referrals, remote site locations, access, satisfaction, trust, adoption and use, revenues, readmissions, emergency department use, and expanded services to new populations.
- Partnerships: How could a partner or cluster of partners help the organization control telemedicine costs, manage risk, accelerate implementation and drive innovation? An organization could partner with nursing colleges and universities, health systems, academic medical centers, medical groups and payers, as well as entities along the expanding continuum of care-from imaging centers and assisted living facilities, to nursing homes and home care organizations.
Implement a telemedicine program: Implement a telemedicine program in phases via a schedule that allows adequate time to secure enterprise-wide support, purchase, install and troubleshoot equipment and provide education and training. Rather than launching a full-blown program, develop a pilot telemedicine program that zeroes in on a limited number of patients, staff, locations and specialties or disciplines. Doing so gives an organization time to adjust protocols, tweak technology and test tools that collect and evaluate patient data and measure patient and provider satisfaction.
Telemedicine allows nurses to participate in the industry-wide transition from disjointed, uncoordinated volume-based care to more integrated, patient-centric and value-based care. Through telemedicine nurses can provide care to patients, consumers and communities anytime, anywhere. Well-designed telemedicine programs help nurses operate with greater efficiency and cost effectiveness. They can improve the health status of patients and populations while generating fresh sources of revenue for healthcare organizations.
Telemedicine market: http://www.healthcareitnews.com/news/telemedicine-poised-grow-big-time
IDC Health insights: http://www.idc.com/getdoc.jsp?containerId=prUS25262514
How is telehealth different from telemedicine? http://www.healthit.gov/providers-professionals/faqs/what-telehealth-how-telehealth-different-telemedicine
A better doctor's visit through telemedicine: http://www.fastcompany.com/3048219/innovation-agents/building-a-better-doctors-visit-through-telemedicine
Telepresence robots aid Duke nursing instruction: http://wraltechwire.com/telepresence-robots-aid-duke-nursing-instruction/14798249/
Telehealth nursing fact sheet: http://www.americantelemed.org/docs/default-document-library/fact_sheet_final.pdf?sfvrsn=2
Nursing considerations and the future of telehealth: http://ca-hwi.org/freeCEUs/Chapter%205%20-%20Telehealth%20%20Nursing.pdf
The role of telehealth nursing: http://www.nursetogether.com/beyond-bedside-role-telehealth-nursing
American telemedicine association: http://www.americantelemed.org/
A patient enters a clinic with symptoms of a serious infectious disease. A nurse fails to ask the patient where she "lives, works and plays" and if she is prepared to fill a fairly expensive prescription. This is healthcare of the past-a time when clinicians addressed patients' symptoms with small regard for the consequences of the disease or condition on community, surrounding populations and public health.
Now, however, healthcare has broadened its focus from symptoms to social determinants-defined by the Centers for Disease Control and Prevention (CDC) as the "circumstances in which people are born, grow up, live, work, and age." These factors, which range from transportation, public safety and social support to crime, segregation and literacy, profoundly influence healthcare access, quality, safety and outcomes.
Nurses are the new champions of public health and navigators of social determinants of health. So vital is the role of nurses that two senators in May 2015 introduced legislation to elevate the role of the Chief Nursing Officer in the Public Health Services to the National Nurse for Public Health.
A public health mindset calls on nurses to build "a national culture of health," according to the Robert Wood Johnson Foundation (RWJF). That, in turn, requires implementation of the Core Competencies for Public Health Professionals released by the Council on Linkages between Academia and Public Health Practice.
Nurses must examine issues like healthcare associated infections (HAIs), sexually transmitted diseases, immunization and prevention from the perspective of populations and communities, not just individual patients. At the same time, nurse faculty and healthcare executives must fully integrate public health content into nurse education and training, blending coverage of the cardiovascular system, for example, with discussions of best practices for smoking cessation, stress reduction, exercise and food and diet.
Nursing schools and healthcare employers must follow the lead of public health-focused nursing programs, including those offered by Johns Hopkins University, the University of Minnesota and the University of Virginia. Other programs have already reworked nursing curricula to blend population health management with prevention, disease outbreaks and infection control.
Advancing population and public health also requires that nurses understand the inner workings of public health information system, according to the Public Health Informatics Institute. Doing so demands an understanding of informatics functions, outputs, tasks, challenges, risks, exit criteria and the entire health information technology (HIT) lifecycle.
More specifically, nurses can help build the national culture of health as described by RWJF through participation in the design, implementation and promotion of multiple campaigns using technologies, including the following:
Consumer Health: Nurses can use diverse media-from the Internet to mobile devices-to engage populations. Nearly one-third of teenagers, for example, claim that they use online information to inform health-related decisions and transition to healthier habits, according to a May 2015 study from Northwestern University. Nurses can adapt new media to meet the information education and engagement needs of seniors, Millennials, young mothers or consumer segments as defined by Deloitte:
- Casual and cautious (34%)-Not engaged, no current needs, cost-conscious
- Content and compliant (22%)-Happy with the physician, hospital, and health plan; trusting and follows care plans
- Online and onboard (17%)-Online learner, happy with care but interested in alternatives and technologies
- Sick and savvy (14%)-Consumes healthcare services and products; partners with physicians to make treatment decisions
- Out and about (9%)-Independent, prefers alternatives and wants to customize services
- Shop and save (4%)-Active, seeks options and switches for value, saves for future health costs
Disease Outbreaks: Nurses can help prevent the spread of deadly diseases by following the lead of experts who have already developed tools that use smartphones and tablets to track infectious diseases like Ebola or MERS and control outbreaks, according to Reuters. Others have discovered that clinicians can rely on simple online tools like Wikipedia to track seasonal flu activity, according to Federal Computer Week.
Quality measures: Electronic clinical quality measures (eCQM) data extracted from electronic health records (EHRs) will be invaluable as nurses monitor clinical conditions and track population health, according to the CDS' Morbidity and Mortality Weekly Report. The report confirms that reported data "could improve the timeliness and possibly completeness of data used to track issues of public health concern," says Thomas Mason, M.D., chief medical officer for the Office of the National Coordinator for Health IT, and Janet Wright, M.D., executive director of the Million Hearts® Initiative.
Environment: Climate and climate change will alter health status outcomes, according to scientists. Nurses will document how climate influences public health, reviewing, for example, how climate change could lead to more asthma attacks due to wildfires that emit soot into the air. Nurses are sure to benefit from the Obama Administration's Climate Data Initiative, which features more than 150 data sets. More than 12 technology companies have already announced plans to use the data to fight infectious diseases and combat outbreaks, according to the Washington Post.
Treatments: Nurses will rely on technology to improve treatment of chronic conditions and infectious diseases. Progress is already being made. The Center for Medicare & Medicaid Services (CMS) supports the work of VillageCare, a New York not-for-profit working to improve medication adherence among HIV/AIDS patients, according to Health Data Management. Meanwhile, the CDC and the American Medical Association have partnered to develop online tools to support patients with Type 2 diabetes, writes Health Data Management.
Nurses' burgeoning role in public health surfaces in the proposal for a National Nurse for Public Health. The future is bright. Nurses will tap the power of informatics to slow the epidemic of preventable diseases, promote health awareness, reduce disparities and increase literacy and access.
Social Determinants of Health: http://www.cdc.gov/socialdeterminants/
The National Nurse Act of 2015: http://nationalnurse.org/faq.pdf
The Top Five Issues for Nursing in 2015: http://www.rwjf.org/en/culture-of-health/2014/12/the_top_five_issues.html
Building a Culture of Health: http://www.rwjf.org/en/library/annual-reports/presidents-message-2014.html
Healthcare organizations (HCOs) will benefit from involving nurses in health information technology (HIT) planning, implementation and optimization. The process begins early. Nursing schools, colleges and universities must build students' informatics awareness, knowledge and skills, as well as their drive to innovate and transform their work in healthcare via HIT.
Some academic programs already prepare nurse graduates to use HIT in practice. Nursing informatics students build knowledge and skills in clinical information systems, strategic planning and project management, as well as implementation of new and emerging technologies. They often participate in highly individualized practicums, where experienced clinicians support completion of a nursing informatics project.
Among the programs leading the vanguard in training nurses to improve outcomes via data and technology are the University of Maryland, University of Minnesota, Duke University, Vanderbilt University, Columbia University, New York University and the University of Illinois, Chicago.
The Case for Nurse Engagement in HIT
Nurses are vital to the design and implementation of HIT systems, according to a 2011 report from the Robert Wood Johnson Foundation. The 2015 HIMSS Impact of the Informatics Nurse Survey further confirms the impact of nurses on variables ranging from workflow, patient safety and user acceptance, to system implementation and optimization and medical device integration.
If HCOs engage nurses in HIT system design and implementation early on, nurses will be able to influence the care processes that support patient-centered care. They'll spend less time in clinical documentation and more time in patient care.
Nurses need education, training, mentoring and coaching in the reasons or rationale for HIT planning, implementation and optimization. Rather than asking nurses to attend an occasional HIT meeting or react to a management decision, executives must fully involve nurses in the total HIT system process-from needs assessment, system selection and planning to education, promotion, testing, go-live, monitoring, and evaluation.
Pathways to Nurse Engagement
Executives, including chief nursing officers (CNOs) and chief nursing informatics officers (CINOs), must involve nurses in HIT planning and design before initiating conversations with HIT vendors. They should establish nurses' roles and accountabilities for each step within a HIT system project, forge consensus around implementation goals and assess nurses' readiness and willingness to move forward. Among the opportunities for nurse involvement and engagement are the following:
Identify objectives: Ask nurses to clarify upfront what they hope to achieve through HIT system implementation-from automated workflow and integration with other systems to online patient education and communication.
Evaluate the status quo: Invite nurses to assess current HIT systems, including how colleagues use and benefit from them. Equally important, get nurses to document current processes and workflows. By focusing on system problems early on, nurses can design more efficient, effective processes before and during HIT implementation.
Create protocols: Make sure nurses grasp the reasons and objectives for HIT system implementation, including why and how they must own varied elements of the process such as training, promotion, monitoring or evaluation.
Identify system requirements: Ask nurses to drill down into specific HIT system requirements. Doing so builds an RFP (request for proposal) process that ensures objective vendor comparisons and controls expenses associated with changing requirements during implementation. Be sure that nurses participate in HIT system test drives at conferences, online or at customer sites.
Evaluate costs and benefits: Secure nurses' input on HIT system cost and benefits. How, for example, does a system's functionality relate to its ease of use and cost? How does the system impact patient care? Look beyond the direct costs of hardware and software costs to productivity, efficiency and opportunity costs.
Check off boxes within vendor contracts: Engage nurses in walking vendors through "what-if" scenarios related to measurement, training or support. How well does the vendor contract ensure post-crisis and long-term HIT system performance?
Train for success: Turn to nurses for insights on HIT system education training and coaching. Nurses can help focus training on existing processes, roles and accountabilities by posing the question: "How can we ensure optimal use of the HIT system?" They can also design one-on-one or classroom experiences and learning tools guaranteed to bring other nurses on board.
Stay in for the duration: Create opportunities for nurses to stay engaged post HIT system implementation. Nurses can help ensure HIT system acceptance by tracking how clinicians and staff use and benefit from these systems. The opportunities for nurse involvement include mobilizing online surveys to zero in on processes and training barriers and implementing online checklists and dashboards to monitor system adoption, use and optimization-specifically, how well the HIT system addresses strategic imperatives like value-based care, population health and patient engagement.
Initiative on the Future of Nursing: http://www.thefutureofnursing.org/
Nursing Informatics Task Force Series: http://www.himss.org/GetInvolved/SessionList.aspx?MetaDataID=2626
Early and Often: Engaging Nurses in Health IT: http://www.rwjf.org/en/culture-of-health/2011/12/early-and-often-engaging-nurses-in-health-it.html
Special Report: Nursing, Technology and Information Systems: http://www.americannursetoday.com/wp-content/uploads/2014/07/ant11-Technology-1107.pdf
2015 Impact of the Informatics Nurse Survey: http://www.himss.org/files/FileDownloads/2015%20Impact%20of%20the%20Informatics%20Nurse%20Survey%20Full%20Report.pdf
Virtual learning environments (VLEs), typically defined as online systems that allow nurse educators and trainers to share information with nursing students and learners via the Web, are growing in popularity. The reasons are understandable. Following are just some of the benefits:
Communication: VLEs increase the number of available channels for nurses to learn through forums, discussion threads, polls and surveys. Both groups and individuals receive almost instant feedback on their performance.
Workflow: Nursing students and learners no longer need to find a trainer or instructor to hand in their assignments. Instead, they can take advantage of virtual hand-in folders with time windows.
Resource storage: Nurse educators and trainers can easily store slide presentations, checklists, tests and handouts, making these resources available to learners as needs arise.
Learning space: Nurse instructors and trainers can create virtual learning spaces that represent a classroom, course or curriculum or that showcase a subject area or topic.
Linkages: Nurse instructors, trainers and learners can access external learning resources via the VLE. Such resources can come from associations, providers, government agencies, colleges and universities or e-learning vendors.
Embedded content: Nurse instructors and trainers can easily embed content from sources as diverse as YouTube, CNN, the New York Times, or Modern Healthcare.
Podcasts and videos: Nurse instructors, trainers, students and learners can develop and share podcasts or videos that document everything from patient stories and care processes to new technologies and health policies.
Let the TIGER Roar
Technology Informatics Guiding Education Reform (TIGER) is a VLE focused on nursing informatics. Powered by the Health Information Management Systems Society (HIMSS), the TIGER VLE supports the informatics learning needs of nurse instructors, students, learners, trainers and clinical educators.
Stocked with vetted resources designed to move learners from A to Z within the discipline of nursing informatics, the TIGER VLE offers multiple benefits. Among them are personalized learning, low-cost access to online education, an expanded nursing informatics skill set and up-to-date information and knowledge on nursing informatics competencies and issues.
The TIGER VLE allows students and learners to download materials anywhere, at any time-as long as there is Internet connectivity and access. The VLE's self-paced learning environment also permits students and learners to move through modules and materials on their own timetable, at their own pace.
The TIGER VLE responds to the burgeoning need for flexibility and 24/7 access among Millennials and learners who either want to return to nursing or complete a nursing degree. The VLE is especially vital to nurse learners who already work part- or full-time jobs and care for children and family members.
The TIGER VLE also serves as an aggregator of informatics insights from diverse entities. Among them are the Office of the National Coordinator (ONC), Quality and Safety Education for Nurses (QSEN) and Health Informatics Forum Massive Open Online Course (MOOC).
Personalization is the name of the game within the TIGER VLE. Students and learners can browse available content based on specific learning needs and their current level of informatics knowledge: basic or new to health IT, intermediate or advanced.
Going forward, the TIGER VLE will invite its subscribers to attend community events and town hall meetings on nursing informatics issues, making the VLE experience even more interactive, collaborative and community-based.
Virtual Learning with a Personal Touch
The best VLEs incorporate the most powerful elements of face-to-face learning. Ideally, instructors and trainers communicate regularly with nurse students and learners, offering plenty of opportunities for collaboration with peers-either in person or online through a messaging center, discussion group or feedback and scores on assignments.
While nursing students and learners deserve flexibility, they also need clear expectations. Ideally, nurse instructors and trainers motivate and coach learners on how to participate within the VLE and make progress on learning goals and objectives.
Just as vital is analysis of learner performance. By monitoring and reviewing student and learner data, nurse instructors and trainers can guide learning and intervene in situations where learners struggle to master informatics content.
VLEs have a bright future in nursing and in all of higher and adult education. With input from nurse students and learners, nurse educators and trainers can turn nursing informatics education via VLEs into a team-based, collaborative effort.
Achieving healthcare transformation via VLEs will depend on nurses' support of initiatives like the TIGER VLE and the ongoing contributions of associations, technology vendors, government, providers and researchers.
The TIGER Initiative: http://www.thetigerinitiative.org/.
Virtual Learning Environment or Managed Learning Environment (MLE): http://whatis.techtarget.com/definition/virtual-learning-environment-VLE-or-managed-learning-environment-MLE.
Online Learning for Health Informatics Simplified: http://www.himss.org/News/NewsDetail.aspx?ItemNumber=16512.
Case Study 2: The TIGER Initiative Foundation: Technology Informatics Guiding Education Reform: http://link.springer.com/chapter/10.1007/978-1-4471-2999-8_16.
TIGER-Based Assessment of Nursing Informatics Competencies: http://link.springer.com/chapter/10.1007/978-3-319-16486-1_17.
A Sense of Urgency: Integrating Technology and Nursing Informatics in Advance Practice Nursing Education: http://www.npjournal.org/article/S1555-4155(14)00520-0/abstract.
Nursing informatics has come into own, according to the 2015 Impact of the Informatics Nurse Survey. Announced at HIMSS15 and supported by the HIMSS Nursing Informatics Community, the survey documents the impact of informatics nurses on health information technology (HIT), workflow and productivity. It also carries implications for nurse faculty, trainers and executives with the capacity to design curricula, create learning experiences and build work environments that expand nurses' roles in technology adoption, implementation and optimization. Among the key findings are the following:
Nurses emerge as health information technology leaders and guides in clinical systems implementation: More than 60% of the 600 informatics professionals surveyed believe that informatics nurses have a positive impact on quality of care. This explains why more than half of respondents report hiring a nurse informatics leader, while 20% say that they've already hired a chief nursing informatics officer (CNIO) to serve in the healthcare C-suite.
85% of survey respondents believe that nurses bring value to the implementation of clinical systems. This suggests that nurse faculty and trainers must educate nurses on systems implementation-from needs assessment, planning and system selection, to implementation, training, promotion, support, measurement and evaluation.
C-suite executives, including chief nursing officers (CNOs) and CINOs, must build models, frameworks and roadmaps that involve nurses in systems implementation. Just as executives worked to align and engage physicians in systems implementation, they must now engage every member of the clinical team. That, in turn, means offering nurses pathways to participate in systems planning, selection, design, implementation, training, and evaluation.
Nurses emerge as leaders in new technology adoption: 75% of survey respondents say that informatics nurses play a critical role in ensuring user acceptance and adoption of emerging technologies. This suggests that informatics nurses can promote the adoption and use of clinical systems and emerging technologies-from robotics and home monitoring systems, to telemedicine and health games-to providers, patients, healthcare consumers, payers, pharma and government.
Among the opportunities for nurse involvement are wearable technologies that generate data and technologies that allow consumers to share data with providers, according to Daniel Kraft, MD, Founder and Executive Director, Exponential Medicine, and Faculty Chair for Medicine, Singularity University, who addressed the HIMSS15 CIO Forum. Just as vital, says Dr. Kraft, are technologies that allow providers to connect directly with patients and apply 3-D printing to create appliances like stents.
Nurse educators, trainers and c-suite executives can guide nurses in understanding emerging technology issues, including the following:
Rationale: What need or purpose does the new technology fulfill? Why was the technology developed?
Concept: What's the essence of the emerging technology? How does it relate to more entrenched technologies?
Function: How does the technology function or perform for providers, patients, consumers and other constituencies?
Markets: Who is likely to use the technology-both now and in the future?
Benefits: How will the technology benefit users? What about results?
Future: How is the technology likely to evolve?
Nurses emerge as clinical system optimization leaders: 83% of survey respondents say that informatics nurses bring value to the optimization of clinical systems. This suggests that nurse educators and trainers must offer education and training in how to analyze the clinical systems environment, including the workflow and process environments that surround these systems. Equally important, healthcare executives must create frameworks that allow nurses to forge relationships between information technology and clinicians, implement best practices and function with a vigorous going-forward attitude.
Nurses emerge as leaders in medical device integration:70% of survey respondents say that nurses play an important role in medical device integration, defined by Healthcare IT News as "the process of taking the data from devices and integrating it to an electronic health record (EHR).
The HIMSS15 nursing informatics survey points to a bright future for nurse leaders, informatics specialists and nurses are poised to care for patients across the expanding continuum. But none of these changes will occur by adopting a wait-and-watch attitude. Nurses will extend their role and influence in health information technology only if they secure the support of diverse constituencies.
Among those positioned to shape nursing informatics' future are nursing organizations like the American Association of Colleges Nursing (AACN), health technology leaders like HIMSS, and c-suite leaders like the National Center for Healthcare Leadership and the American College of Healthcare Executives (ACHE). Equally vital are media publications whose reporters and editors have shared the function and scope of nursing informatics to their readers. Together, we can move forward to a place where nursing informatics emerges as an indispensable force for health system transformation.
Competency-based education (CBE) is in the news and on the agendas of nurse executives and educators throughout the country. This relatively new brand of education begins with the end in mind-specifically, the outcomes of learning and the demonstration of specific competencies by learners. The competency based approach may be used in a total program of study or related to competencies in a discrete area, such as informatics.
CBC models vary. Course-based approaches to CBC feature a predetermined number of courses with competencies clearly identified. Other models allow nurses to demonstrate informatics competencies at their own pace or integrated into the learner evaluation process.
Why CBC in informatics? Many experts worry that nurses will fail to meet the requirements of a changing nursing informatics environment. Studies with more positive findings reveal that learners who meet competency requirements are more confident than their peers in delivering patient care and communicating with physicians, patients and family members.
Moving forward will require that nurse educators secure management support for CBC and clarify expectations on nursing informatics competencies, including the fact that nurses must sustain the competency over time. For example, if educators integrate competencies into more traditional nursing informatics courses, they can require leaners to master one or two competencies before moving on to the next course.
One model for measuring informatics competency is the TIGER Informatics Competency Model, which consists of three parts: computer competencies, information literacy and information management. Other competencies that influence nursing informatics include interprofessional (IPE) competencies, including values and ethics, roles and responsibilities, interprofessional communication and teams and teamwork.
How can educators measure nursing informatics competencies? The majority rely on a combination of skills, simulation and actual performance. But for these methods to succeed, educators must insist on credible evaluation. That, in turn, requires advising learners of measurement criteria, ensuring inter-rater agreement so that all students are evaluated consistently and inter-rater reliability to ensure strong correlation between evaluations done by multiple evaluators. Equally important are the issues of validity and cost. There is cost associated with finding the appropriate measurement tool - or developing a rubric if none is available, and training evaluators to use it consistently.
Regardless of how the profession of nursing and nurse educators respond to shifting trends in education, CBC has an exciting future. Shifts in student and learner demographics, rising education costs and changes in technology have forced higher educational professionals to examine alternatives to traditional credit hour models.
CBC offers the potential for learners to move forward at their own pace while ensuring that they master required nursing informatics skills and content. These programs will likely reduce time to completion and the cost of a nursing or nursing informatics degree. They will also ensure that practicing nurses master informatics competencies as quickly, efficiently and cost effectively as possible.
Going forward, nurse executives and educators must learn how to structure self-paced, learner focused, outcomes-driven learning environments where they can more easily measure learner achievement. They will also need to define and refine informatics competencies, in turn developing creative strategies for learners to demonstrate these competencies.
The evolution to CBC isn't confined to nursing and nursing informatics. The American Enterprise Institute recently released a report predicting that colleges and universities are increasingly likely to offer credit in exchange for demonstration of learning and competency.
Still, optimism about the future CBC may be premature. The report concludes that "many questions about CBE (competency-based education) remain to be answered before its wide adoption, including which students and degree programs are best suited for CBE, overall cost of CBE compared to more traditional programs, and how to lower out-of-pocket costs for students."
The best approach for nurse executives, educators and learners is to maintain an open mind toward competency-based learning. Regularly review research in nursing and higher education. Reflect on how you could integrate competency-based learning into a familiar learning environment. To help conceptualize how competency-based education might be applied in your own setting, choose one or two nursing informatics competencies, then develop learning activities that would help nurses master these competencies, and finally, identify which measurement strategies you would use to determine if the nurse was competent.
Competency-Based Education Network
Experimenting with Competency
The Landscape of Competency-Based Education
All Hands on Deck: Ten Lessons from the Early Adopters of Competency-Based Education
Competency- Based Degree Programs on the Rise
Growing numbers of nurses are coming out of retirement to re-enter the healthcare workforce. Nursing informatics officers and nurse trainers must join forces to help veteran nurses understand and use the latest health information technologies and participate in technology-enabled learning.
Nurse executives and managers may need to develop formal or informal centers for nursing informatics. These centers can help returning RNs master and integrate new and emerging technologies, while guiding nurse trainers on how to deliver health IT modules and courses, engage nurse learners and manage learning environments.
Nurse trainers and instructors, in particular, must discover how to adapt traditional learning practices to technology-centered learning environments, making the most of resources like electronic learning management systems.
At Your Service
The key to the empowerment of returning RNs is offering online and print tools so they can better understand the function, scope, benefits and risks of health IT. The best approach is to develop an online self-service library that blends internal resources with those available through organizations like the Health Information Management Systems Society (HIMSS), American Medical Informatics Society and American Nursing Informatics Association.
In developing your self-service library, be sure to include syllabi, modules, course materials and videos of presentations, workshops and seminars. Also incorporate step-by-step guides on how to use a specific technology or participate in an enterprise-wide health IT initiative. For example, you could easily augment a guide focused on "Six Ways to Enhance Care Coordination" with blog posts, answers to frequently asked questions, and video clips from nurse trainers and practicing RNs.
Nurse trainers, facilitators and mentors benefit from health IT modules and course templates that showcase effective online learning. By experimenting with varied models and templates, nurse trainers can tap into the instructional strategies and techniques of others, including features like text-to-speech. They can also adapt content to specific groups like the formerly retired and integrate late-breaking medical and nursing evidence.
While nurse trainers benefit from training in course and module design, HCOs will reap the rewards of inviting returning nurses into an enterprise-wide community of health IT practice. Essential to this community is a peer-to-peer network that identifies health IT knowledge, skill and competence and zeroes in on the quality and impact of online and offline training and learning.
Begin by inviting diverse healthcare professionals-nurses, managers and executives-to join the HCOs health IT community. Be sure to involve professionals with expertise in clinical care, health IT and instruction, and other areas including young, mid-career and veteran nurses who are retiring, retired or just returned to the workforce.
While some professionals in the community will focus on improving clinical, financial or operational performance through health IT, others may decide to concentrate on research, innovation, competency development or support and re-design of health IT learning modules and courses.
Most important is taking a positive approach to health IT instruction, learning and engagement. Returning nurses are neither technophobic, "set in their ways" nor "old school." They need no extraordinary hand holding or training.
Returning nurses may not use Instagram, but they will respond to actual, real-life examples of RNs who have experienced the benefits and results of health IT. They will also embrace health IT if they understand how it can improve quality, safety and efficiency, while saving time and transforming them into more highly competent and effective RNs.
The path to turning returning nurses into health IT advocates is simple and direct. Consider the following steps:
- Offer returning nurses solid reasons to re-examine their biases, attitudes, beliefs, values and behaviors related to technology and health IT.
- Show them how to use new and emerging health IT and learning tools.
- Give them time to experiment and practice with health IT. Offer opportunities to work with mobile, electronic health records and data analytics, for example.
- Deliver plenty of encouraging feedback, coaching and mentoring. Pair returning nurses with experienced technology users and create a network of nurse professionals with expertise in specific areas of technology.
- Reward learning and change. Nothing is more engaging than a ceremony or awards program that celebrates newly acquired health IT skills and competencies.
Don't say goodbye to nurses who claim to be retiring or who have already retired. Tell them how nurses are using health IT to make a difference in the lives of patients, families and other clinicians. Invite them to special open houses and launches or new technologies. And keep them engaged with regular communications on the power and impact of nursing informatics.
"New Program Brings Retired Nurses Back to the Bedside"
"Hospitals Set Sites on Recruiting and Retraining Retired or Retiring Nurses"
"Nurses Are Delaying Retirement, Helping to Forestall Severe Shortage"
Choosing a learning management system (LMS) to monitor, measure and evaluate RNs' health IT knowledge, skill and competence calls for an evaluation of available LMS systems and identification of selection criteria. It also requires implementation of an LMS that fits the needs of the healthcare organization (HCO), nurse learners, trainers, instructors and coaches.
Growing numbers of HCOs, including colleges, universities, hospitals, health systems and providers across the care continuum, rely on an LMS to plan, implement, facilitate, assess and monitor health IT and nurse informatics education and learning. The reasons are understandable. An LMS performs these vital functions:
- centralizes health IT and nurse informatics educational content and resources;
- tracks nurse learner activities like discussion and collaboration;
- orchestrates the delivery of health IT and nurse informatics content;
- collects, aggregates and stores data on nurse learners; and
- delivers performance feedback and scores to learners and instructors.
In short, an LMS allows nurse trainers, instructors and coaches to develop courses, deliver instruction, facilitate communication, foster collaboration and assess learners. It also supports traditional face-to-face instruction and blended and online education.
Because learners value the use of an LMS, HCOs should take time to select an LMS that aligns with educational plans and strategies and integrates the perspectives of multiple stakeholders, including:
- RN learners;
- nurse instructors, trainers and coaches;
- chief nursing officers (CNOs);
- chief nursing informatics officers (CNIOs);
- chief information officers (CIOs);
- healthcare human resources executives; and
- external experts in online education and learning systems.
Involving these parties in LMS system evaluation and selection will ensure buy-in on the LMS purchase or leasing decision and prevent or minimize resistance to LMS implementation. Just as important, many of these stakeholders will emerge as champions and advocates of the LMS and the concept of a lifelong learning HCO.
Asking the Right Questions
The process of LMS evaluation and selection is far from easy. An LMS comes with many features. The central question to ask is this: Which features are most important to the HCO and its nurse learners, instructors, trainers, coaches and other stakeholders? The answer to this question will be unique to the HCO and its learning and nurse informatics priorities. Among the questions to consider in LMS selection:
- Organizational Assessment: What's the HCO's strategic direction, including s the emerging role and function of nursing within the HCO? What are the top needs and priorities of LMS stakeholders?
- LMS Features: How does the LMS compare and compete with other available systems in terms of reliability, reputation and other factors?
- Design: How well does the LMS support nurse instructors and trainers in the transfer and adaption of educational content or the development of content from scratch?
- Tools: To what extent does the LMS facilitate instruction and learning activities, including communication and collaboration?
- Assessment: How well does the LMS support the design and management of assignments and tests? Does it assess and track nurse learner activities and performance?
- Management: Is the LMS able to address security, data management and reporting? Does it support nurse instructors and trainers in administration and management of educational content?
- Technology: How well does the LMS address software, hardware and network requirements?
- Cost: What's the likely cost to acquire or lease and maintain the LMS fora specific numbers of nurse learners for each year of a multi-year contract?
- Support: Is there constant IT support (from the LMS or the HCO). Some of the users in healthcare organizations and educational institutions use systems around the clock and may require assistance with tests or other functions at times beyond the traditional workday hours.
An LMS could possess every desired feature but still be difficult to use. That's why it's vital to test the LMS in an instructional/learning environment, making sure it meets the HCO's technical requirements and needs for functionality. Think about using new and veteran trainers, instructors and learners to test the LMS against the criteria of flexibility, efficiency and user-friendliness. Rely on nurse informatics and HIT professionals to test LMS reliability, stability, scalability and security.
If the HCO already has an LMS, check to see that the HCO can transfer educational content to the new LMS. The best approach is to make every LMS user-trainers, instructors and learners-participants in each phase of LMS evaluation, selection and implementation and promotion.
Nurse learners are eager to use an LMS. Sadly, instructors tend to use just half of LMS features, according to a survey conducted by the Educause Center for Learning and Analysis. Nurse trainers, instructors and coaches need to understand LMS features and functions and how to use them to achieve learning objectives.
HCOs can take the lead by inviting nurse instructors and trainers from other organizations to share how they maximize the potential of LMS features. At the same time, HCOs and nurse associations can offer nurse instructors and trainers guidelines on how to develop content to engage nurse learners.
Who are today's nurse learners? They look forward to a future dominated by "healthcare anywhere" facilitated by anywhere, anytime access to educational content and information. They're eager to engage instructors, trainers and peers through face-to-face interactions and e-mail. And they seek classroom, online and blended learning environments made possible through an LMS that fit meets these criteria:
The LMS will achieve its potential only if nurse instructors and learners can use the LMS to engage and communicate with nurse learners and receive the guidance and support needed to develop and deliver content. In the end, an LMS must fulfill every stakeholder's needs and complement the learning and teaching priorities of the HCO and the nurses who work within it.
"The Post- LMS LMS"
"Life as a Healthcare CIO: Learning Management Systems"
"Use of an Automated Learning Management System to Validate Nursing Competencies"
ECAR Study of Undergraduate Students and Information Technology
"Developing and Reviewing Online Courses: Items for Consideration"