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"
Not everything on the Internet should be considered "social media." You are probably not surprised that this blog is considered a social media website. Would you be surprised to learn that the online shoe retailer Zappos' use of Twitter is considered a form of social media? Well then, you ask, are all Internet websites forms of social media? No, as the main purpose of Zappos.com is to sell shoes and other retail items, not to provide for social interactions or communications - which social media does. Zappos does have a strong social media presence on Twitter, Instagram and Facebook (social media websites) as part of its highly publicized marketing strategy. Social media's main purpose is to allow for, promote and provide a forum for social interaction and communication. Social media unlike static webpages, is characterized by an immediacy and interaction between users. It has gained popularity due to its ability to allow user-generated content. Facebook allows people to "share" posts and pictures. YouTube provides communities for vlogging, movie-making, video and music sharing. Nursing, health and medical social media sites such as Advance for Nurses, AllNurses.com, Ozmosis.org and medXcentral community all provide social media networking between like clinicians, interdisciplinary peers or those who work in a specific healthcare domain.
Wikipedia defines social media as: "the social interaction among people in which they create, share or exchange information and ideas in virtual communities and networks. Media is defined as "tools used to store and deliver information or data." Printed media (newspapers and magazines) and broadcast media (TV and radio) are all forms of "media" or communications. Traditional media - newspapers, TV, magazines and radio are all forms of one way communication. One-way, in that you cannot communicate back or interact with (in real time) or while reading a paper magazine article or watching a TV show. Additionally, not all media communications delivered via digital (digital media) or electronic (electronic media) formats allow for two-way, bidirectional communication exchanges.
Although social media can be categorized into a few types, many social media sites have functionality and features that can also be considered a category. As an example both medicalmingle and YouTube can be categorized as Media Sharing and have features that allow for users to post comments similar to social media characterized as Blogs and Forums - Examples: Tumblr, Advance for Nurses' Blogs and NurseZone.com's Forums. Additional social media categories include Social Networks (Examples: Google+, LinkedIn, Facebook and Snapchat); Social News (Examples: reddit.com for medical and Digg); Bookmarking sites (Examples: doctorbookmarks.com, StumbleUpon, Delicious), and Microblogging sites such as Twitter and Vine.
Another reason for social media's rise in popularity is it's ability to allow for real time, two-way, bidirectional communication exchange between users. Other than marketing of healthcare organizations, what are the other implications for the use of social media in patient care, clinical practice and nursing/healthcare informatics? Do you have questions or comments about this or the previous social media blog post? Or do you want to comment on the content? Please post your comments. I'd LOVE to hear input from this community on this topic! Next Blog Post: Organizations' Social Media Policy & Procedures and the rational for implementing same.
The National Council of State Boards of Nursing (NCSBN) released in August 2014 the findings of its research, "The NCSBN National Simulation Study: A Longitudinal, Randomized, Controlled Study Replacing Clinical Hours with Simulation in Pre-licensure Nursing Education."
The core finding: When nursing educators substitute high-quality simulation experiences for up to half of traditional clinical hours, nursing students achieve educational outcomes comparable to those achieved by students with educational experiences that feature a majority of traditional clinical hours.
Both simulation and traditional clinical hour methods can create nursing graduates who are prepared for clinical practice in hospitals, health systems, ambulatory clinics and other facilities along the expanding continuum of care. Educators, nursing graduates and healthcare employers stand to benefit from the blending of simulation with clinical hours:
- Nursing educators gain added flexibility and autonomy in the design, development and evaluation of learning experiences and curricula.
- Graduate nurses can integrate the immediacy and real-word quality of simulation with the discipline and rigor of traditional clinical hours. A big advantage of simulation is that students can work in high-risk situations they don't often get to participate in during traditional clinical experiences.
- Hiring organizations know for sure that nursing graduates possess the knowledge, skill and competence to perform in varied clinical settings.
The NCBSN research focuses on the role and use of simulation in the pre-licensure nursing curriculum. Large, comprehensive and national in scope, the study zeroes in on incoming nursing students from 10 pre-licensure programs across the U.S.
Researchers randomized students in one of three study groups. The control group featured a traditional clinical experience where simulation could take up to 10 percent of clinical time. A second group permitted 25 percent simulation in place of traditional clinical hours, while a third group allowed for 50 percent simulation in place of traditional clinical hours.
Launched in fall 2011 with the first clinical nursing course, the study continued through a number of core clinical courses to the time of nurses' graduation in May 2013. Researchers evaluated the 688 participating nursing students on both clinical competency and nursing knowledge while students offered feedback on how well the simulation and clinical hour experiences met their learning needs.
Researchers discovered that nursing educators could substitute simulation for 50 percent of traditional clinical experiences in core courses in the pre-licensure nursing curriculum. Equally important, researchers discovered that educators' use of up to 50 percent simulation did not affect NCLEX pass rates.
Researchers also followed the graduate nurses who participated in the study for the first six months of clinical practice. Nurse managers rated graduate nurses at six weeks, three months and six months after being hired into a clinical position. They gave both groups of graduate nurses comparable scores on the dimensions of critical thinking, clinical competency and readiness for practice.
Implications and Recommendations
The NCBSN study has multiple implications for graduate nurses, nursing educators and trainers, and nurse managers and executives. Following are just some of the lessons already learned:
- Train nurse educators. Nurse faculty and educators need ongoing training in simulation, including how to design, develop, implement, monitor and evaluate simulation experiences. Equally important is tracking the use of simulation technologies in the learning environment within and outside of healthcare.
- Prepare for regulatory change. Just as nurse educators were unsure of the role of simulation in graduate nurse education, some state regulators insisted that nursing students experience no more than 25 percent of nurse education via simulation. The NCBSN study is a game changer, offering legislators, policy makers, regulators and opinion leaders proof of the power of simulation in nurse education and training.
- Embrace the era of "just in time: simulation." While nurse educators and trainers can rely on simulations to teach burn care, they can also tap simulation to remediate actual or likely errors. Equally important, they can rely on simulation to prepare for unlikely occurrences such as natural or manmade disasters. For the first time, nurses who are terrified by the prospect of cardiac arrest can participate in simulations designed to build cognitive and "muscle memory." To that end, simulation is as valuable to hospitals, health systems, ambulatory care centers and physician practices, as it is to colleges, schools and universities.
- Vary the experience. Professionals who believe in the power of simulation will also want to invest in simulation software packages that provide varied scenarios for nurses in nurse specialties. However, keep in mind that not all nursing simulation software is created equal. Evaluate potential software subscriptions against criteria of realism, content accuracy and timeliness and choice of multiple, pre-constructed scenarios.
The NCSBN study opens doors for nurse educators and future nurses as clinical space and time becomes limited for training. Think ahead to the possibilities of simulated nursing education and how it can supplement your current curriculum.
What are the first thoughts that come to mind when you read the term: "social media"? Do you think about your tween's Myspace page or your own LinkedIn account? Maybe when you hear the term, visions of unending kitten videos posted to Facebook come to mind? Perhaps you drew a blank when you read the term because you still refuse to even own a cell phone and associate "tweeting" with something birds do. For some, the term may conjure up everything from the Internet, to Google's search engine, to recipes for zucchini bread "pinned" on Pinterest boards.
Is it possible to utilize social media as a clinical practice tool? Perhaps social media is just a fad or only something for those of Generation X, Y or Z? Is it a way to communicate, socialize or just a marketing strategy for organizations?
Regina Wysocki, BSN, RN, school nurse, wrote that social media "is a way for nurses who work in the informatics field as well as nurses who might be interested in informatics to network with one another." Svea Welch, M.A., LPC - MHSP, clinical therapist believes: "Social media is a great networking tool ... utilized by most people in and out of the [healthcare] field. It becomes dangerous when the incorrect information or too much information is shared." Is social media HIPAA compliant, a safe or appropriate venue for clinician-patient interactions?
Were you aware that blogs (like this one) are considered a form of social media? What's the connection between social media and healthcare? How are patient care, nursing informatics and social media related? Recently the American Nursing Informatics Association (ANIA) formed a work group to examine the organization's "social media presence."
Although a great deal has been written about social media outside of healthcare, in this and my next several blog posts I'd like to explore the above questions, discuss what social media is, what it isn't, what its implications are for patient care, clinical practice and nursing/healthcare informatics and, most importantly, I'd like to hear input from this community on the topic. To prime the pump here are a few more questions.
1. What are the FIRST thoughts that come to mind when you hear/read the term social media?
2. How would you define social media?
3. How have you seen social media utilized in clinical practice and or clinical informatics?
4. Does your organization have an official social media Policy & Procedure? If so why/what was the rational for implementing same?
Big data promises to have a big impact on nurse education and training, including the performance and success rates of nurse learners, whether they happen to be young Millennials or retirees who've just re-entered the workforce.
But it will take time before big data and analytics transform the experiences of learners, educators and trainers and reshape how learners develop skills, knowledge and competencies. Nursing has just started to notice how nurse learners generate digital footprints, opening the door for nursing to collect and leverage data and information about educators and learners. Once nurse educators and trainers discover how to analyze data and control the way data works to fulfill a purpose, they'll see the impact of big data on nursing practice.
Until recently, big data and data analytics would surface in functions like application processing and course management. Much of the data was "siloed" and limited to specific functions. Now, however, educators and trainers are zeroing in on individual learner data in the quest to improve learner service and support. Big data offers nurse educators and trainers the opportunity to ask more and better questions - not only about specific learners, but also about small and large groups of learners overtime and within diverse locations.
Understanding nurse learners demands that nursing identifies preferences, perceptions, attitudes, beliefs, values, strengths, weaknesses, goals and/or desires - facts that educators and trainers can integrate like never before with big data. While some nurse educators and trainers will collect data directly from nurse learners, others will observe nurse learner behavior or document and review learner choices.
No matter what strategy educators and trainers use, they'll be able to tap big data analytics to create enhanced learning experiences for individual learners. As they collect and analyze big data across cohorts and organizations, they can apply what they've learned to nurse education and training available via colleges and universities, online courses and provider organizations.
The more data educators and trainers collect about more learners, the more they can enhance the experience of nurse learners. In other words, they can offer more customized, personalized experiences and choices to help learners meet their learning, education and training goals and objectives.
The promised outcome of big data analytics thrills the nursing profession. Educators and trainers will be able to predict learner success, improve graduate and course completion rates and track learner behavior, including learners' level of engagement. They'll also receive alerts if nurse learners become bored, distracted or frustrated.
Organization and profession-level transformation will also occur. Organizations will see the results in highly personalized learning experiences, more satisfied and successful learners and less administrative work. Nurse educators and trainers will get the input they need to revamp content and measure learner performance beyond simple test scores.
Colleges, universities and provider organizations already realize that nurse learner and educator data is stored, manipulated and shared electronically. In the quest to ensure data integrity and privacy, some organizations may need to hire a professional - or even a team of professionals - to secure and protect learner and educator data.
Big data involves big change, but it also suggests big challenge. Organizations must find ways to contain personally identifiable data and forge a culture of transparency regarding data capture, storage, use and sharing. Also important is informing educators, trainers and learners about the power, function, scope and risks of big data. Among the frequently asked questions the merit answers are the following:
- Data type: What kind of learner data do you plan to collect?
- Data purpose: What do you plan to do with the learner data? Why?
- Data value: What is the value or benefit of learner data collection and analysis? How will the learner, educators, trainers, organization and nursing profession use this data?
- Data risk: What could possibly go wrong as you collect, analyze and store this data? How do you plan to handle a crisis?
Nurse educators and trainers must enlist the support of nurse managers, executives and other members of the C-Suite to support big data literacy. Nurse learners must know how to use devices -f rom laptops, tablets and Google Glass, to smartphones, smart watches and desktop units. But they also need to develop digital literacy - the ability to access, analyze and use data and information available via data analytics systems, the Web and even social media.
Only by understanding the capabilities, uses, benefits and liabilities of big data and big data analytics can nursing fully integrate it into nurse education, training and clinical practice. Nurses owe it to themselves and the profession to become part of the big data conversation.
Empowering Nurses with Data
Unlocking Big Data to Improve Care
Nursing Knowledge: Big Data Research for Transforming Healthcare
Mother Lodes and Mining Tools: Big Data for Nursing Science
Nursing Informatics: A Specialty on the Rise
Big Data and Disruptive Innovation in Wound Care
The med/surg unit is an operationally intense care environment with typically two out of three hospitalized patients residing in this area. The acuity of patients in this setting is escalating, along with rising co-morbidities and patient age. In parallel, the hospital's patient population is shifting more toward outpatient care, increasing the number of short-stay patients. Short-stay patients are those who stay in the hospital for approximately 23 hours or less and are then discharged to go home. Often, these patients are placed in med-surg units and require a heightened level of observation to assess for subtle changes in their condition. As acuity increases, so do the number of devices at the bedside, along with the requirements for entering data into a patient's record.
Despite these conditions the nurse-to-patient ratio in med-surg units has not changed. This results in more work and immeasurable stress. Add to that the regulatory, legal and hospital compliance efforts for higher degrees of documentation, as well as pressure to discharge patients as soon as possible, and you can see that there is a "perfect storm" of increased workflow requirements that could lead to errors putting patients at risk.
The environment wherein med-surg nurses work has become incredibly complex and demanding. The result is that they must provide increased effort, energy, and attention just to perform their normal, daily activities. Many are close to the breaking point; they simply cannot take on any more work or responsibility without significantly impacting patient care.
One responsibility that steals substantial time from patient care is documentation. The increasing complexity of patients seen in the med-surg unit means that nurses are constantly moving (between one and five miles during a typical 10-hour shift), making decisions on the fly, and multitasking, all of which takes a high toll on performance and work processes.1 Given all this, nurses view documentation as a lower priority item on their list, choosing to document in batch mode when they have a few minutes rather than in the real time.
In fact, studies find that it takes between two to twelve hours after collecting data from patients' monitors before nurses enter it into medical record. The manual entry of data leads to error rates as high as 17%.2 Yet documentation is taking up an increasing amount of nursing time, with studies finding that 35% of a nurse's time is spent on documentation (147 minutes in a 10-hour shift), while less than 20% is spent on patient care and education, and just 7% on assessment and surveillance.3
The focus on quality in today's healthcare environment means the EMR must be fully integrated into clinical care and decision making. Among the benefits when used properly, for instance, are better decisions and better coordinated care. With physician order entry, physicians need an ‘information rich' record with real-time data. Ancillary departments such as respiratory, physical, occupational and speech therapy also require access to an up-to-date medical record so they may immediately know a patient's state. Such information is equally important for pharmacy, infection control and discharge planning.
However, while EMRs can bring numerous benefits to the hospital environment and improve patient care, they are impractical and even dangerous if the data is not accurate, timely, and complete. So, therein lies the paradox: much of the data entered into an EMR is on the shoulders of med-surg nurses. Yet med-surg nurses are forced to place this task towards the bottom of their list because of their patient care priorities.
The current system relies on the nurse to function as a "human bridge" between medical devices and the EMR. The med-surg unit is no exception. Med-surg nurses capture patient data throughout the day from a number of devices, manually writing the data on a clipboard, sticky pads, paper towels or even alcohol wipes. At a later time during the shift, they key the data into each of their patients' electronic record. The danger of this approach is the increased likelihood of errors and potential for omissions. Moreover, valuable time slips by - time during which critical decisions are made based on data that could be hours old. Just as important, all of this activity of capturing data from various bedside devices and manually keying it into a record takes the clinicians away from direct patient care and surveillance, which can affect outcomes. Very simply, under the current system, clinicians doing both clinical documentation and patient assessment simultaneously is ... well ... incompatible, to put it lightly.
There are solutions to this "human bridge" problem that can remove the nurse as the "middleman". There is increased focus on the automation of clinical documentation, that is: the electronic transfer of data from a medical device to the EMR, and other clinical systems. The integration of data in med-surg is even more critical as the patient acuity rises along with the number of number of bedside devices to assist in monitoring. Due to the fundamental nature of vital signs, devices that take these measurements are typically among the first to be targeted for automation. Integration, however, is not limited to devices measuring vital signs. Other types of devices that can be integrated in med-surg include (but not limited to) scales, smart beds, infusion pumps, etc. By not having to record and transcribe information into the EMR, a considerable amount of time can be saved. And, automating the collection of data ensures that all desired information is accurately collected. This eliminates the possibility of accidentally omitting essential data during documentation. Recording patient data at a higher frequency allows for catching subtle changes in a patient status much sooner.
In an environment where information is recorded automatically into the patient's record, there is no need for a physician and the interdisciplinary team to wait on the med-surg nurse to complete rounds and transcribe the data.
In the end, bringing a flexible, documentation automation system into med-surg can help reinvest nursing time to direct patient-care activities, improve nursing productivity and satisfaction, enhance the completeness of the medical record, and ultimately, improve the delivery of safe, high quality care.
My question to you is, why do hospitals choose not to automate device documentation in med-surg when the evidence is clear?References
1. Potter P, Boxerman S, Wolf L, et al. Mapping the nursing process. J Nurs Adm. 2004; 34(2):101-109
2. Wager KA, et al. Comparison of the Quality and Timeliness of Vital Signs Data During a Multi-Phase EHR Implementation Computers in Nursing. CIN: Computers, Informatics, Nursing. 2010; 38(4):205-212
3. Hendrich A, Chow M, Skierczynski B, Zhenqiang L. A 36 hospital time and motion study: How do medical-surgical nurses spend their time? The Permanente Journal. 2008;12(3):25-34
Video games aren't just for kids anymore. The earliest gaming consoles kept players stationary and sedentary, and became an object of concern in a world of rising obesity rates, diabetes and other health scares. But then came games that required players to move - to participate with their physical bodies. That opened up a whole new world of gaming that is quickly morphing into something more. It's been called the "gamification" of healthcare, and it is showing up everywhere - on computers, on smartphones and in the doctor's office.
Gamification makes a lot of sense on all ends of the healthcare spectrum. Games are fun, and that means instead of being "boring," healthcare can become more engaging and enjoyable. Games are also immediate, as they can be accessed on smartphones and other mobile devices. Value-based care focuses on prevention, and prevention often happens through changing behaviors, is something that games can help players do. The Millennial generation has grown up with gaming, making it much more likely that the use of healthcare games will increase as that generation ages and needs more medical care.
As with any new venture, the market is already brimming with hopeful startups. Games, invented by health insurers and a host of technology startups, are marketed directly to consumers, who use them to track their progress and record key health metrics such as blood sugar and pounds shed. Players of these games can win rewards, perhaps even cash, if they hit their health goals. Using motivational techniques from games is a big part, as is creating engaging experiences for people. These days, anyone with a smartphone can download a variety of games designed to make them healthier, whether that means helping them stick to an exercise routine, lose weight or manage a chronic illness.
In healthcare, however, gamification presents a distinctive set of challenges. Healthcare providers that want to offer games to their customers must do so without violating federal patient privacy regulations - a requirement that can make it difficult to target games to the patients who will benefit most from them. Even companies that are not subject to those regulations are finding themselves under pressure to protect players' most personal data. Insurers, hospitals and other health providers are bound by the Health Insurance Portability and Accountability Act (HIPAA), which requires them to conceal personal health information related to all patients in their care.
Then, there is the problem of the games themselves: How can companies make them engaging enough to keep customers interested? It can sometimes be challenging to build a game that's sufficiently serious and on topic, but also fun. But it all depends on the game, and how it's put to use. As Gartner put it in a 2012 report on the phenomenon - which predicted that, by this year, as many as 80 percent of gamified apps would be doomed by poor design - "gamification is currently being driven by novelty and hype." The verdict is still out on gamification, however as our demand for more mobile and smartphone apps increase, they are likely to continue to be utilized by healthcare consumers.
The topic of meshing the art and science of nursing with healthcare technology has come to the forefront recently. A video by National Nurses United features a patient whose care becomes compromised under the watch of "algorithms" dictated by a computer. Throughout most of the encounter, the patient is not seen by a nurse, because care by computer was deemed more cost efficient by administrators and bureaucrats, who are more interested in the patient's wallet than his well-being. Only in the last-minute, perhaps even unauthorized, intervention of a nurse saves the patient from certain doom.
The strong message is that healthcare technology takes clinicians out of the picture and force-fits patients into standardized, low-cost treatment plans without considering their individual situation. The video references a study that suggests technology is harming rather than helping the patient. Overall, the series sounds an alarm that both nurses and patients are threatened by "the rise of the machines."
Such sensationalism fails to highlight either the benefits of EMRs or the role that nursing informaticians have played in the development, training and implementation of EMRs. Nursing informatics was developed to empower nurses to combine the best of technology and nursing, while safely and effectively providing patient care. Nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge and wisdom in nursing practice (Nursing Informatics: Scope and Standards of Practice, ANA 2008).
Properly designed and utilized healthcare technology can indeed benefit patients. A study in the Journal of General Internal Medicine and another conducted by the Robert Wood Johnson Foundation, show EHRs to be associated with improved care. A recent literature review reported in Annuals of Internal Medicine found that clinical decision support systems were associated with quality improvements in 85 studies reviewed.
Healthcare technology is here to stay, but tools are only useful in the hands of those who know how and when to apply them. Nurses are best positioned to shape, to incorporate and to utilize technology to maximize the efficiency and the outcomes of frontline, hands-on patient care. Nursing and technology must work and grow together to address the needs and to fulfill the promises of healthcare.