All things mobile is a hot trend right now for personal, business and academic purposes. About 40 percent of time spent online is though a mobile device, according to a 2013 comScore report. The worldwide market for mobile learning products and services will reach $9.1 billion by 2015, reports Ambient Insight Research.
The healthcare industry has a similar story to tell. Seventy-one percent of nurses already use smartphones on the job, surpassing physician use of digital technologies, reports Manhattan Research. HIMSS Analytics labeled 2013 a banner year for mobile health, with more clinicians relying on mobile options to collect data, read barcodes, monitor data from medical devices and obtain visual representations of data. The result: Mobile devices could be the key to saving billions of dollars in healthcare costs, claim speakers at HealthBeat 2013.
And yet, mobile learning comes with more than a few constraints. While many people now own mobile devices, device use is often limited to e-mail or Web-based search. People using mobile devices to access complete courses, tests, evaluation instruments or learning activities is limited. For education vendors, trying to make mobile learning content easy to view, read and use is difficult, given the wide variety of device platforms and challenging content. Others point to the absence of learning management systems for mobile devices. Additionally, concerns exist in some health care agencies surrounding students using mobile devices in the clinical area, and the standards for taking pictures or communicating with mobile devices to protect confidentiality.
Does this mean that mobile learning is doomed? Probably not, but it won't evolve and mainstream as fast as many predict. Mobile learning has generated exuberance so intense that organizations sometimes fail to evaluate factors like readiness or content and technology barriers. Nurse educators, managers and executives must acknowledge the possibilities of mobile learning while accepting the incremental nature of educational transformation. Among the trends the nursing industry must monitor and influence are these:
- Mobile-readiness of content: As more students and professionals rely on mobile devices, developers and educators will format content for easier access, viewing, reading and interaction.
- Point-of-learning nurse education: Nurse educators and managers will increasingly share brief bursts of information, insight and motivation with students and nurses. Nurses will consume data, information and content at any time, in any location, within minutes.
- Nurse expert access: Nurse educators and managers will be able to access the right expert at the right time to share opinions and advice and collaborate on problems and analyze issues. While some experts may reside within the local nursing community, others will come from across the country and around the world.
- Nurses as producers and videographers: "Everyone will become a publisher," said pundits of the first wave of Internet empowerment. The same observation applies to nursing. Nurse educators and managers will challenge nurses to create video vignettes of events, encounters and processes, embedding face-to face interviews that offer balance, objectivity and perspective.
- Special connections: Nurse educators and managers will use mobile devices' global positioning systems (GPS) to send nurses content based on location, task, encounter, responsibilities or schedules. In the same way, educators and managers will be able to offer nurse learners audio coaching and mentoring.
- Nurse e-books expanded: As nurses benefit from highly personalized, just-in-time information and content delivered at the right location, e-books will evolve from digital versions of print publications to complex resources that blend content, collaboration, testing and evaluation.
- Aggregation of online and online learning: Look for innovations like Tin Can or Experience API which can integrate a learner's offline and online experiences, including social, collaborative and experiential learning, with games and real-world activities.
For now, nurse educators and professionals would do well to follow Clark Quinn's four Cs of mobile learning:
- Content: Invite students and professionals to read and review documents, watch videos and listen to media in a portable format
- Compute: Create opportunities to process data from student and professional users, deliver answers to queries and perform calculations
- Capture: Use devices to record sound, video and images, along with other information, for storage and sharing
- Communicate: Connect student and professional learners with others-fellow students, educators, and experts-via text, audio and video
Through trend tracking and integration of Quinn's four Cs of mobile learning into lesson, module or curriculum planning, nurse educators and managers can help nurses make the most of their mobile devices. Mobile, after all, offers something for everyone. While visual learners can benefit from photo and video applications, auditory learners can master concepts by listening to instructors, coaches, experts and fellow students.
Mobile also offers flexibility. Nurse students and managers might collaborate on a video on patient safety, followed by a recognition or memory game via images communicated on cell phones. Others might complete a text communication exercise where students and managers share, repeat and confirm data and information about a patient, issue, situation or event.
The future of mobile is bright. Educators, students and managers appreciate mobile learning's potential benefits. They are ready for incremental change and the opportunity to collaborate on fresh solutions. The best course is to monitor mobile usage by clinical and healthcare business professionals while tracking new and emerging trends in mobile learning solutions.
Blended learning is now used within the training plans of clinical information systems (CIS) implementations at countless healthcare organizations, from 700+ bed medical centers, to critical access hospitals, to outpatient surgical centers, to physician offices and home health agencies across the United States. The blended way of learning has to be a collaborative effort with clinical interdisciplinary leadership, education and clinical informatics staff to develop, deliver and achieve your organization's learning plan goals and measureable targets.
Blended learning has also proven to be among the most popular choice for learners at institutions of higher education. The majority of colleges and universities have at least one, if not more, well-established online degree programs composed of blended learning curriculum.
Research has proven that online learning alone is not enough. The evidence shows that blended learning - combining in-class, facilitated training with e-learning - is much more effective than either alone. As cited in the U.S. Department of Education's "Evaluation of Evidence-Based Practices in Online Learning: A Meta-Analysis and Review of Online Learning Studies" (Revised September 2010), "Students in online conditions performed modestly better, on average, than those learning the same material through traditional face-to-face instruction" (p. xiv) and, notably, "Instruction combining online and face-to-face elements had a larger advantage relative to purely face-to-face instruction than did purely online instruction" (p. xv). Learners perform better in blended courses.
In healthcare information systems implementations the use of the blended learning approach combines a variety of learning delivery methodologies. Additional benefits to be attained using blended learning include: allows organizations to compensate for limited classroom space; provides a transitional opportunity between online instruction and face-to-face classes and minimizes the time required for end users to train. End users report blended learning provides the convenience of online learning along with the social instructional interactions of facilitated in-person classroom courses. Later, more about facilitated courses.
A blended learning approach typically includes some (if not all) of the following components:
- 1) In-person, facilitated, just-in-time classroom training
- 2) E-learning (computer based training (CBT)
- 3) Educational materials/media
- 4) The train the trainer (TTT) model
- 5) Open labs
Facilitated classroom training is not the same as traditional instructor-led training, which puts the onus of knowledge "transfer" primary on the instructor. In order for clinical end users to become optimal users of the new information system they must be held accountable for learning, be engaged and take a proactive role in their knowledge acquisition. Learning is the responsibility of the adult student/clinical end user. During clinical information systems implementations it is imperative for clinical end users to take the initiative to perform hands on practice, practice, and practice some more in the Test system prior to go-live.
Additionally the staff development/education and clinical informatics/IT departments, in collaboration with system subject matter experts and champions are responsible for organizing and providing clinical end users with in-person, instructor facilitated classes.
In-person facilitated classes should be a combination of: 1) basic course content delivered classes; and 2) hands-on, self-paced, role-based scenario guided sessions. The role based scenarios should simulate future state workflows and performance of system tasks such as: accessing a patient census; associating yourself to a patient per your clinical role; using MAR; creating hand-off documentation; how to change a specimen collection order from lab to collect- to nurse to collect; viewing department tracking boards; trending vitals and I&O, etc. Both types of in-person training sessions should be guided by your organization's policies and procedures and focused on patient care delivery activities that support learning being implemented into practice.
Just- In - Time Training
Adult learners are particularly receptive to learning new information when it is delivered to them right when they need it. "Just-in-time" training refers to a method of providing training right when it is needed, not weeks or months too earlier or too late. Just-in-time training eliminates the need for refresher training due to knowledge loss experienced if training proceeds, over an extended period of time. Just-in-time training prevents knowledge loss because staff are soon able to put the material learned into actual use upon returning to the clinical setting.
E-Learning and Other Educational Media
In addition to in-person, facilitated classroom training, the project's education developers should not overlook creating learning materials especially for e-learning/online use. The e-learning modules should ideally be packaged into bite-sized chunks of no less than 15 minutes and no more than 40 minutes in length. E-learnings such as those developed in Captivate allow clinical end users to take full advantage of interactive features such as video, audio, animation and illustrations. Utilizing e-learning allows your clinicians the convenience of choosing where and when to undertake their learning and provides end user staff with more scheduling flexibility. Incorporating e-learning into the training plan also means clinical informatics and education staff can update online materials rapidly so clinical end users can access the most up to date course content. Unlike traditional paper based courses which become outdated quickly as system upgrades are rolled out and new clinical practice evidence emerges.
Educational materials/media should not be limited to online media or e-learnings. The original system manuals provided by the vendor are often dry, voluminous and written in non-clinical speak. The original vendor's manual(s) should be edit and revises thus customizing them into smaller versions that correlate system functionality with future state work flows, and unique organization policy and procedure. Customized your end user manuals in such a way will definitely improve their usability and value for your clinical staff.
Additionally, ensure hard copy, laminated and pocket size job aides, quick tips and cheat sheets are created and provided to staff end users prior to go-live. These types of hand outs will help to further reinforce information provide from both the e-learnings and the in-person facilitated training classes.
Train the Trainer (TTT) Model
The TTT model reflects proven research that people who train others recall 90% of what they teach and that people learn new information through trusted social networks. The train the trainer model is the standard in clinical information systems implementation and is also recommended as such by many vendors. The TTT model will also help create a team of your organization's system subject matter experts and champions who are capable of transferring solution knowledge to their peers.
Lastly if your organization has the space and equipment budget, plan for having an open lab - a space with desktops or laptops (and earphones) located away from the clinical units and departments that staff can come to for additional practice time. Remembering that some units/high volume areas in your healthcare organizations are less conducive to staff learning than are others. Think about staffing your open lab with subject matter experts and champions to give support to end users who show up to practice in the test system.
Many large hospital systems offer behavioral health services as part of their continuum of care, so, it is important to fill in the gaps that behavioral health has when it comes implementation of an EMR. Some examples of why it is important to offer behavioral care services that are supported by a robust EMR include:
- One in eight or nearly 12 million ER visits in the U.S. are due to mental health and/or substance use problems in adults. This is the most costly venue for care delivery. Mental Disorders and/or Substance Abuse Related to One of Every Eight Emergency Department Cases. AHRQ News and Numbers, July 8, 2010. Agency for Healthcare Research and Quality, Rockville, MD. h p://www.ahrq.gov/news/nn/nn070810.htm
- Major depression is considered equivalent (in terms of its burden on society) to blindness or paraplegia. Schizophrenia is equivalent to quadriplegia. Disability Adjusted Life Year, DALY, Daly 2004
The gaps that are often identified in a behavioral health EMR include:
1. Providers: Most behavioral health providers are not MDs. In fact, primary care physicians spend limited time with patients and are often hesitant to diagnose and treat behavioral concerns. Most behavioral health providers are clinicians with masters or doctorate degrees who have been licensed by their state(s) to diagnose and treat behavioral health disorders.
2. The diagnostic process and tools: Behavioral health disorders are the only serious, chronic illnesses that are diagnosed based solely on self-report. The tools used to assess the behavioral health patient's mental status and substance abuse patterns are very different than the traditional medical diagnostic tools of imaging and lab work. Behavioral health diagnostic tools are most often elaborate question and answer tools that can be both clinician-administered and self-administered. Behavioral health clinicians use tools such as the Beck Depression Inventory (BDI), Generalized Anxiety Disorder scale (GAD 7), and the Diagnostic and Statistical Manual (DSM IV). These tools need to be incorporated into the data capture and workflow built into an EMR. Additionally, behavioral health providers are required to develop elaborate treatment plans with the patient's participation. Non-behaviorally focused EMRs typically don't have tools built in for this and must be built (or ignored). If ignored, the EMR becomes nothing more than a word processor.
3. Customization will always be required: While there are multiple behavioral health specific EMR vendors in the marketplace and enterprise-wide EMRs that can be configured to cover behavioral health, customization will be required to meet multiple state specific mandates, practitoner specialty requirements and federal privacy rules that apply to behavioral health. Although there are challenges when implementing an EMR in behavioral health, the successes are growing. For example, the state of New Jersey has been successful in bridging the gap between behavioral health and EMRs.
The following recommendations help to ensure a positive implementation outcome:
- Create a small but specific implementation team that aligns with behavioral health leadership during the build and test period, so all build and testing work is completed in a collaborative manner.
- Build using the most commonly used diagnoses and their DSM IV criteria into the EMR to make it easy for providers and therapists to use drop-down lists to create the diagnostic picture of the patient.
- Build using ASAM criteria, so chemical dependency staff s can more easily complete treatment planning.
- Design within the ‘tighter than HIPAA' federal constraints that govern confidentiality of patient information for patients receiving chemical dependency treatment (i.e., CFR 42).
- Involve trainers and testers in the workflow discussions.
To avoid putting a round peg in a square hole, it's essential to understand the variances in the behavioral health setting and address them in workflow, data capture, information exchange, provider engagement, and administrative requirements and incorporate them into the EMR project plan, design, and implementation.
Nurse educators, managers and executives have turned to learning analytics in the same way healthcare has turned to data or predictive analytics. Learning analytics provides a way to evaluate the responses of nursing students and professionals, deliver rapid feedback, and tweak content and formats to meet learners' needs and industry requirements. Learning analytics has the potential to create highly personalized learning environments that complement the learning styles and behaviors of nurse students and professionals. For that reason, nursing professionals should consider how they can champion learning analytics in the years ahead.
Nursing schools, colleges and universities have turned to blended or hybrid learning that combines face-to-face classroom instruction with online learning environments and platforms where tracking tools document student behaviors, identify numbers of clicks or specify time spent on a single page. Within nurse education and training, effective learning analytics systems create practice sessions through scenarios and case studies.
Exams evaluate learners' readiness for follow-up testing, along with their ability to apply concepts. Learners can review concepts as they move through modules or courses or immediately prior to an exam. If learners fail to perform well on an exam, they can take advantage of personalized online remediation activities. Finally, a solid learning analytics system creates reports for learners, educators and managers. Learners discover how well they performed on tests, while educators and managers gain insight into individual learner and program performance.
How should educators respond to the learning analytics revolution?
Promote the value of learning analytics: By blending data analysis with how learners interact with online tools and content, learning analytics helps to create more integrated, customized learning experiences. Learners are better able to learn and apply nursing concepts. That, in turn, means a more skilled, competent and prepared nursing workforce-one capable of addressing challenges like care coordination, meaningful use, quality improvement and patient engagement.
Focus on features, functions and opportunity: Learning analytics has the capacity to predict learner performance, deliver feedback to struggling learners, personalize the learning process, offer motivation and encouragement, build on individual learners' strengths, and identify learning barriers by tracking data like time spent on a site, log-in frequency or lack of attention and understanding.
View learning analytics as a component of healthcare transformation: Just as the healthcare industry is moving away from the assumption that patients are the same, nursing professionals have abandoned the assumption that all learners start at the same point and progress at the same speed. Learning analytics bases learners' future performance on their past performance. It views learners as distinct, unique, special and deserving of full engagement via customized, personalized content and regular feedback and reinforcement.
Work with vendors that grasp learning analytics: Learning analytics demands content management, delivery and evaluation, a learner information system or data repository and a mechanism to track and store learners' completed work. Equally important are integrated predictive models that record learners' progress and forecast learning outcomes based on demographic and learning data. Systems should allow nurse educators and managers to assist and support learners while customizing content to meet learners' needs, preferences and learning styles. A dashboard or control panel should track learning trends and deliver summaries of learner and program performance to nurse educators, managers, executives and researchers.
Prepare for roadblocks and barriers: Developers of learning analytics systems still need to resolve issues related to privacy and confidentiality, ethics, access, cost, misinterpretation of data, metrics and standardization. Equally important, nurse educators and managers will require training and coaching on how their can expand and balance their roles as teachers, content developers, information brokers, coaches and mentors, group facilitators and data analysts.
Learning analytics within nurse education and training faces a bright future. Educators and managers will be better able to identify slower learners who, with specific interventions, can evolve into learning superstars. Data-driven learning will expand nurses' critical thinking skills by compelling each learner to address each question, case or scenario. Learners will receive close to real-time feedback on performance, offering them the push they need to pursue remediation. Finally, learning analytics will build learner engagement through features like self and peer evaluation and grading and collaboration. While learning analytics poses multiple challenges, nurses can help to achieve its promise and potential.
Nurses everywhere are familiar with the term HIPAA - otherwise known as the Health Insurance Portability and Accountability Act of 1996. Yet what many of us fail to realize are how many different implications have been created by the act itself and the various areas it touches upon. Patient privacy, data security, breach notifications, and the confidentiality provisions of the Patient Safety Rule affect the everyday process of gathering patient data and applying it in the healthcare workplace. (The U.S. Department of Health and Human Services provides a wealth of data regarding HIPAA and related legislation. It can be accessed online at www.hhs.gov
At any time, patients file a complaint if they feel their information is being used improperly or not being maintained in a secure fashion. healthcare workers that access this patient data for purposes of analyzing patient conditions, safety, treatment, and reporting have some legal protections, however this does not remove all liability or the need to meet legal requirements to see the patient's information. What does this mean? Nurses, for example, cannot simply review a patient's electronic records to satisfy their own curiosity or because they wish to know something about a particular patient. Although Americans are concerned about the privacy of medical records, survey data shows that the majority of Americans are aware of the benefits of electronic records and believe that they outweigh privacy concerns.
HIPAA also presents obstacles to obtaining patient information for the purpose of tracking trends and other types of analysis that typically are allowed in other industries. For example, many retailers gather and analyze consumer information to help them market goods and services based on the behaviors and choices of their customers. Although this is an accepted practice among retail businesses, healthcare organizations cannot arbitrarily obtain and share customer (i.e., patient) data solely for marketing or other non-health related purposes. Therefore, nurses using informatics must be diligent about using data ethically to meet the medical needs of the patient. Informatics nurses also need to ensure their own education provides them with the knowledge and skills necessary to recognize, interpret, analyze, synthesize and hypothesize even limited data sets after identifiers and other private information has been removed.
In a nutshell, nurses wishing to pursue a career in informatics need to strive to attain higher education and training in order to work with the ever-increasing obstacles presented by legislation, ethics and industry changes. Nursing informaticists and privacy specialists have to balance the easy access that digital record keeping provides with the need for confidentiality and privacy that is dictated by HIPAA.
The future holds great wonders and discoveries for nursing informatics. As nurses, we have to ask ourselves if we're ready for and capable of meeting these challenges. Nurses throughout history have answered these questions in a positive fashion and have continued to rise to the challenge of meeting the needs of society as a whole. The key lies in following the examples they have set for dedication, ethics, perseverance and self-growth. Nursing excellence through higher education can lead us toward the ability to fulfill the needs of patients today and in the years to come.
Planning for and providing sufficient end user training is a vital component of any successful information systems implementation. Just as vital, if not more so is assessing end users' computer competency PRIOR to providing system training. In order for information system training to be effective clinical end users must first possess basic computer skills, computer competency. If a clinical end user is not first computer literacy/computer competent they will be unable to effectively master information system training.
Computer literacy is defined as the possession of basic computer skills. Computer competency is the ability to perform simple tasks with a computer.
In most industries, the use of a computer is standard, right? Employees of banks, grocery stores, the post office and even McDonald's all utilized computers and scanning technologies for years now, right? Currently, no matter where you work, a computer is a basic tool used in the performance of your job, correct? Not necessarily so in the healthcare industry, unfortunately.
Beware of making the assumption that your clinical end users are computer competent only to discover when they show up for information systems training that they lack knowledge in computer basics such as: keyboarding, moussing, how to navigate a log-in screen, open a program from a menu option or close a window in an application.
Today's healthcare professionals are required to read, write and speak English - to be "literate" in English skills. LPNs, RNs, physical therapists, physicians (as part of their jobs) are required by law to hold valid certification and/or licensure. Being computer literate - possessing basic competency in the use of a computer is NOT a mandatory requirement for hire (or clinical practice) nor is it considered fundamentally part of a clinician's role.
Prior to EMR training (or any information systems training) make sure clinical staff's computer competency is assessed and that any needed computer basics training and education is provided.
In this day and age, computer literacy, just as being competent in basic handwashing precautions, improves the care we delivery to our patients. The minimum expectation for all clinical roles should be basic computer competency and computer literacy skills.
Computer competency does not mean a clinician needs to know how to network computers or write programs. Clinical end users DO need to possess basic computer skills AND be computer competent.
The Joint Commission defines competency as the demonstration of both the knowledge and skill in the safe performance of their job. Make sure you provide needed computer training so your clinical end users are computer competent BEFORE any information systems training begins.
Remember, inadequate or insufficient training has been noted as one of the top reasons clinical information systems implementations fail.
Nurses are indispensable to population health management, an industry-wide initiative to transition from discrete, reactive patient care encounters to an approach that forecasts needs and enhances outcomes-especially among the highest-risk patients. Nurses will rely on technology to identify and analyze these populations' most pressing health needs and, working with other care team members, design interventions to satisfy or even preempt these needs.
As nurses assume greater accountability for proactively managing patients' care, electronic information exchange will become indispensable. That's because population health management demands that health systems build a deep portfolio of organizations and disciplines-from primary care practices, preventive services, and home care, to outpatient, acute and post-acute organizations. All will need to exchange and share information patient information for population health management to achieve its goals.
Especially critical to population health management is the technology-enabled patient-centered medical home (PCMH). Focusing on prevention, early intervention and patient partnerships to manage chronic conditions, the PCMH offers team-based care coordinated by primary care providers and technology-savvy nurses functioning as care managers and data analysts. Using electronic medical records (EMRs), nurses can now look across patient populations, sort and group patients by specific characteristics, advise on evidence-based diagnoses, treatments and interventions, and measure progress in real-time.
With information systems that function much like airplane or automobile dashboards, nurses can identify which patients have booked appointments in the previous one-to-three months, along with those who may not have booked appointments in two years or more. Among those patients who fail to return for follow-up care, nurses can identify which have diabetes, along with those diabetics who would probably benefit from specific health interventions. Nurses can access similar intelligence for patients with other conditions, including asthma, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), asthma, or metabolic syndrome.
Functioning as data analysts, nurses can also generate and analyze disease registries. Data interpretation helps care team members ensure that patients receive preventive care, comply with health plans guidelines, and maintain health status with minimal complications. Because systems will soon be able to track clinical measures across networks of PCMHs, care team members will know for sure if population health management actually works. They will also learn to what degree the PCMH complies with national benchmarks like those developed by the National Committee for Quality Assurance.
Nurses who envision a career in population health management should learn how technology is able to support the implementation of best practices and protocols for managing specific diseases and conditions, identify patients who would benefit most from chronic disease or population health management programs, and develop and implement disease management activities and interventions. Equally important is using technology to collect, interpret and evaluate data on measurable outcomes of care, including quality, cost, cost savings, emergency department and hospital utilization and disease management and improvement.
The demand for nurses in population health management is already evident. Brigham and Women's Hospital created its Department of Care Coordination with 14 nurses and nine social workers to manage the needs of medically complex patients with a chronic illness or multiple comorbidities. Nurses also play critical roles in Medicare Advantage programs and in health plans like Blue Cross of Idaho.
So critical is the demand for nurses in population health management that Duke University School of Nursing has partnered with Horizon Blue Cross Blue Shield of New Jersey to create a 14-week online program in population health coordination. Nurses master continuous quality improvement, monitoring and tracking of patient goals and issues, and use of clinical registries, evidence-based alerts and reminders, along with care team leadership, health coaching and integration of community resources.
Comparable programs are likely to expand in the years ahead. A rapidly aging population and a sharp increase in patients who suffer from three or more chronic conditions will fuel the demand for nurses who can manage the health of populations in medical homes or other population-based health programs. Technology will be invaluable in helping nurses to monitor, anticipate and respond to patients' health needs.
Most countries, including the U.S., lack integrated online patient-record systems. Patients visiting new doctors' offices need to fill out paper medical-history forms. Over time, these records can become incomplete and difficult to access. This leads to both inefficiencies in the medical-record system, which costs money, and medical mistakes, which can cost lives.
Researchers and entrepreneurs hope to change that by giving each patient a smart card containing his or her complete medical history. This approach may prove difficult to implement in the U.S., as security fears and compatibility issues exist. However, the technology has the potential to transform healthcare in countries that have unified health systems, or where there's inadequate infrastructure for sharing records in other ways.
Currently, there is much debate surrounding medical smart cards. It is believed that no matter how flexible the software on the card becomes, it will not be able to automatically work with every hospital database. This is because healthcare providers will still need to cooperate to ensure compatibility. Opponents of the card-based system have deemed it "not a good fit" for the U.S. (per John Halamka, chairman of the Healthcare Information Technology Standards Panel and CIO of both Harvard Medical School and Beth Israel Deaconess Medical Center, in Boston). "We tend to be more network- and mobile-centric," he says, and "carrying around a card, which is common in Europe, is not our culture."
He is, however, more optimistic about the am alternative to card-based electronic medical records: the cloud. The U.S. needs "web-based personal health records in the cloud, available anywhere at any time without a card," he said. Such a network-based alternative may require greater changes to existing health-care networks, but it is likely to give physicians even better access to important patient information.
In addition, efforts to achieve an electronic medical-record system in the U.S., whether card- or cloud-based, are complicated by the fact that hospitals essentially compete with one another for patients. So sharing healthcare information while encouraged by the government may not be seen as an incentive for individual providers or hospital.
Feel free to share your thoughts and ideas.
The healthcare environment is changing. The industry is moving from volume to value, provider-centric to patient-centric, fee-for-service to bundled payment and delivery of extreme care to accountable care and population health management. Nurses will play a growing and vital role if they can master, adopt, use and promote technologies related to patient engagement, telemedicine and mobile health, population health management, clinical integration and performance management.
Accountable care is being touted as the framework for healthcare reform. Accountable Care Organizations (ACOs) put patients at the center of healthcare decision making and give groups of healthcare professionals the responsibility for care coordination across settings. Nurses, including advanced practiced registered nurses (APRNs) such as clinical nurse specialists, nurse practitioners and certified nurse midwives, have the knowledge, experience and skill to support ACO goals: deliver high-quality, patient-centric care to populations and communities and control or reduce costs.
Nurses can play important roles as coordinators, communicators and quality managers. Nurses deserve the opportunity to coordinate care across varied care settings, including primary care and specialist physician practices, pharmacies, imaging centers, long-term care and rehab facilities, and home care. They can also add value as communicators, explaining treatment options to patients and families and sharing insights related to disease and condition risk factors, causes, diagnoses, discharge instructions and prevention of complications and readmissions. Finally, they can improve quality through evidence based nursing practice, data analysis and evaluation of cost and quality measures.
To fulfill these vital roles, nurses must master a variety of technologies, among them:
Patient engagement technologies: Patient engagement occurs when patients and families become actively involved in their own care. It involves "actions individuals must take to obtain the greatest benefit from the healthcare services available to them, "according to the Center for Advancing Health. Nurses can support engagement through the adoption, use and further development of patient portals. Engagement happens when portals deliver access to an electronic medical record (EMR) system and personal health information, online appointment scheduling, and personalized, condition-focused alerts and reminders in the form of e-mails, automated telephone calls or text messages.
Telemedicine and mobile technologies: ACOs need to extend the boundaries of care beyond the confines of the traditional hospital or primary care practice. Telemedicine and mobile health facilitate patient engagement, while helping providers deliver more cost-effective care. While telemedicine embraces applications and services that include two-way video communications, e-mail and wireless phones, mobile health features multiple technologies integrated into the increasingly wireless and mobile healthcare delivery system. The New York Times has already reported on the growing significance of mobile devices in nurse education, while Apple developed a list of top apps for nurses now available in the iTunes store. Meanwhile, the market for remote patient monitoring topped $204 million in 2012, according to GBI Research.
Data aggregation technologies: Nurses will play a growing role in data aggregation, a process that involves data collection, analysis, use, reporting and delivery of feedback throughout the organization. ACOs will use process and outcomes data to measure what they achieve for patients and population-based communities. This means offering information to influence care decision making at the point of care through clinical decision support (CDS) and integrating responses from patient experience and satisfaction surveys. Even ACOs that aren't associated with the Medicare program will need to achieve accountability on measures like patient safety, patient/provider experience, care coordination, and preventive health. The best data aggregation technologies will support APRNs with easy access, user friendly search, and training in data collection, analysis, use and reporting.
Population health management technologies: ACOs are designed to improve outcomes, which should improve population health management. ACOs must know a population's health status and utilization patterns to develop targeted wellness and prevention programs. That, in turn calls for technologies that perform data mining, risk stratification and analysis. Nurses will engage with longitudinal tracking mechanisms that integrate with CDS system for real-time patient management, while also conducting searches for disease trends, diagnoses, procedures and missed appointments.
Other technologies will be equally vital to nurses within ACOS. Among them are clinical integration technologies that offer integration of patient medical records, clinician/physician patient care portals and notifications and reminders; performance management technologies that provides quality measures, best practices, evidence-based data, regulatory compliance, real-time reporting, and benchmarking; and reporting technologies that feature patient health record integration, standardized reporting measures, e-distribution of outcomes, information access for clinical decision making and statistical summaries and compilations. APRNs may also interface with financial technologies involving medical necessity, authorization, scheduling, billing, and image retrieval.
Although nurses with all types of preparation may practice within ACOs, the Advanced Practice Registered Nurses (APRNs), who provide care as physician extenders, deliver value to ACOs only if they learn to use the required technologies. Equally critical is removing some of the barriers that may prevent some APRNs from achieving full ACO participation. Whether ACOs survive and succeed in their current form or evolve in scope, direction, process, people and technology, APRNS can make an indispensable contribution in the quest for more accountable, value-based care and cost containment.
When nurses talk about informatics, they often focus on its applications to patient care. They discuss the technical side of nursing informatics much less often, because they're not trained to think about the inner workings of complex technology. But one topic nurses should know about is unified informatics data. The term refers to the blending of disciplines - in this case, the blending of nursing theory with computers and information science. In nursing, unified data management allows us to process the patient data we collect in ways that benefit us as nurses - which ultimately benefits our patients. It lets us harness the power of data, by putting the data we need to accomplish a specific task or objective right at our fingertips.
For example, individual patient elements are recorded when the patient is admitted and ongoing data is entered by nurses as part of their electronic medical record charting of nursing assessments and observations. These individual patient elements can be matched to a computerized database and software is programmed to run an algorithm that examines, processes, and relates this data to provide specific recommendations for treatments, interventions, and care.
Nurses must begin to bridge the gaps in the possibilities that unified data can provide. Unifying data appears to be an easy task at first - you simply send all data to one place, right? Unfortunately, this is not the case. Data can take many different forms and can come from many different providers who are observing, evaluating, or treating the patient - and prior to the electronic medical record (EMR), the disparate forms taken by this data presented a multitude of challenges.
EMRs that allow unification of data will bring many benefits. Creating a central storage repository with sharing capabilities can allow all health professions - and ultimately the public - to benefit from the data gathered. When data is unified, sharing information with public health agencies, other health care organizations, and individual providers becomes standardized and structured, allowing ease of use, portability, and unknown avenues for research and discovery to evolve. Many organizations are now attempting to collect data for different purposes, including meaningful use, syndromic surveillance (a tool to improve early detection of outbreaks), and even for hospital accreditation purposes.
So what's to be done? Nurse informaticists must continue to support and lead the way for unifying data and systems, so that real-world solutions can be derived from the patient data that many of us, as floor nurses, endeavor each day to enter into information systems. But there are challenges as well as benefits. Obstacles include HIPAA, data security issues, financial considerations, and even human rights issues, as different groups argue over ethics and protocols in the way data is collected, utilized, and accessed. It's clear that information can be used for either good or ill purposes, depending on the design of those using it. Nurses are ethically, morally, and professionally equipped to meet these challenges regarding the proper application of data for patient care - the same way we've made day-to-day judgments in caring for patients throughout the history of nursing. As with so many patient care battles that have been won in the past, nurses will be at the front of the line, facing obstacles and creating solutions. So the next time you log in to an electronic system, remember that entering data is just as important to the well-being of our patients and the public as providing traditional bedside care - and therefore should receive the attention to detail that our profession is known for.
Inadequate or insufficient training has been noted as one of the top reasons clinical information systems implementations fail. "If you fail to plan, you are planning to fail!" said Benjamin Franklin.
Your plan for training is the development of a specific strategy to ensure successful system training and adoption of the clinical information technology (CIT) being implemented. In short, it is a "plan" not to fail and instead a strategy for your end users to be trained on the new CIT effectively, efficiently and in a timely manner.
The main objective of the training plan is to provide a clearly defined strategy to assure the delivery of training on and facilitate learning of clinical information systems functionality in addition to workflow processes, and related policies and procedures sufficient to enable end users to perform their jobs as effectively as possible. Your plan should utilize a blended learning approach as its instructional/delivery strategy. The development of the training plan demonstrates a commitment by your organization's leadership to support the organization's mission and vision by utilizing the clinical information system (CIS) to transform clinical practice and care delivery.
No matter when your Go Live date is it will arrive too quickly and your time line will feel too aggressive, making the need for an organized plan for training even more critical. Consider these issues in developing your plan.
- How will each end user population be trained on individual parts of the CIS? Braking down staff by roles will make this more manageable.
- Who will be included in the scope of your training plan? Which staff from what departments will be considered users now and in the future related to new hires of these departments?
- What will the scope and major deliverables of this plan consist of? Is your plan all inclusive or will you just be training some departments/disciplines/end users and not others?
- What is in scope and out of scope for your plan? If your training plan will not address all users how will you differentiate this, and what is the plan to address anything outside the scope of your plan?
- Will your training plan include e-learning (web/computer based training) modules covering content for system basics such as signing on or access and navigation, in addition to system functionality? How will you address future state workflows, policy and procedure changes?
- What about the customization of the vendor's training manuals, creation of job aides and cheat sheets for use by end users? Have you planned for this?
- Will the training you deliver include discipline specific/role based, hands-on classroom scenarios? It should.
Most importantly: How will your plan be communicated to the project's leadership, stakeholders and end users?
In Part II: Needs and skills analysis and the value in assessing computer competency before end user training.
Obamacare (Affordable Care Act), which will require millions of businesses to provide health insurance for their workers, will change the way care is delivered and paid for. It will focus on outcomes rather than fee for service and it will reduce payments to providers who do not measure up. That is why there is a new rash of investors and entrepreneurs suddenly interested, as there is money to be made for start-ups that can quickly adapt to this new healthcare model.
A few of the latest offerings are IntelligentM, which is a company that makes a smart bracelet that help hospitals decrease acquired infections (which cost the healthcare system almost $30 billion a year). There is also AdHere Tech which monitors patients to make sure they are taking their medications. And then there is Care at Hand, which is a medical information mobile app for home care workers that uses an algorithm to spot patients who may be headed for trouble.
Another part of Obamacare challenges hospitals to reduce readmission, which the federal government says costs Medicare $26 billion annually. Under the new law, hospitals that readmit too many patients whom they've treated for pneumonia, heart failure, or heart attack will have their reimbursement rates reduced. A start-up called Health Recovery Solutions has invented a tablet-based app that connects via wi-fi to a scale and pedometer. Hospitals are now sending this home with patients to track their weight and activity. Patients also take surveys on the app to monitor their recovery and results are shared with their doctors and family members so major problems can be spotted early.
Interestingly, the Affordable Care Act has been likened to the revolution of the iPhone, as it is bringing a shock to the healthcare industry in terms of importance of the use of technology. It could also possibly bring us into the Digital Age of healthcare. Feel free to share your thoughts related to the new healthcare technologies now available and how you feel they are changing how care is delivered.
Electronic medical records (EMR) already perform a host of critical functions to streamline clinical workflows and thoroughly document patient care, but is there more that hospitals can squeeze out of them? With the extensive time and resources involved in a successful EMR implementation, hospitals are rightfully looking for even more ways to increase their EMR's productivity and overall value by integrating them with other hospital technologies.
An essential benefit of an effective EMR is that it coordinates and combines various healthcare tasks. This is often accomplished by fully integrating an EMR with a hospital's existing technology systems. Interactive patient engagement systems are like low hanging fruit when it comes to this type of effective integration. As we all know, interactive systems provide an array of services to patients and hospitals, such as on-demand education, nursing workflow efficiency, service recovery functionality, care team and hospital information as well as convenient access to various hospital services such as dietary/meal ordering and prescription fulfillment.
More and more hospitals are seeing the benefits of interactive systems and their potential interoperability with other hospitals systems; their adoption has nearly tripled since 2010. Hospitals can take the efficacy and value of their interactive a step further with a custom interface with the hospital's EMR. Seamless communication and functionality between these two systems gives hospitals the opportunity to gain remarkable advancements in clinical workflow efficiencies and documentation of critical patient care information. For example, a hospital with an interactive patient education system might wish to identify a specific segment of their patient population to automatically educate them about their rights and choices on advance directives. Based upon parameters defined by the hospital, from information obtained in the EMR, the interactive system can be triggered to push patient-specific education and information as new medications, tests, or procedures are added to the patient's plan of care. Once the patient has successfully completed his or her education and potentially completed an assessment of their understanding, their participation and assessment scores can automatically be updated to their electronic patient record.
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Nurses can also be electronically notified of such educational events or patient requests for additional consultation so that they may offer supplemental education utilizing the teach-back method. This simple process improvement can have a significant impact upon positive patient outcomes, satisfaction levels, and clinical workflows. Automations such as this allow clinicians to offer focused, follow-up education, freeing their time for other clinical tasks and offering patients a thorough approach to important health education.
Furthermore, hospitals are seeking solutions to help utilize their technology in more meaningful ways and to further their commitment to cutting-edge technologies. By streamlining certain processes such as education delivery and documentation, survey deployment, and service recovery resolution, hospitals can effectively reduce the resources and paperwork formerly required to complete these tasks. In addition to these obvious benefits, hospitals can elicit critical informatics from the systems to benchmark various quality initiatives such as safety, communication, noise control, or room cleanliness to drive various improvements.
Integrating a hospital's EMR system with their interactive patient engagement system can also aid in setting patient expectations and fostering higher levels of satisfaction. Many hospitals are using their interactive systems to deliver welcome and orientation videos, patient scheduling and care plan information as well as visitor friendly hospital information like cafeteria or gift shop hours. Providing convenient, on-demand access to patient whiteboard and care team information or nice to know facts about dining or outpatient services helps patient's feel connected and sets the tone for delivering excellence in patient care. With a partnership between a hospital's interactive patient engagement system and their EMR, hospitals can make meaningful progress towards experiencing greater efficiencies and increased value from both their EMR and interactive systems.
Health organizations increasingly are choosing medication administration technologies (MATs) to ensure the safety of patients, as well as to decrease liability for the organization. While these barcode readers are widely used and accepted, nurses must continue to strive to improve safety in medication administration. In an article that appeared in the Journal of Advanced Nursing, researchers write, "While benefits of MATs appear promising, the implementation of healthcare technologies can also produce unintended consequences and new types of errors." For example, what happens if a nurse scans a medication and the barcode reader enters that same medicine twice, recording a double dose that didn't actually occur? Software that can recognize hardware errors can make these types of problems less likely.
Although hospitals are expected to meet national patient safety goals for medication administration, few, if any allow staff to provide input into the technologies they use to enhance productivity and patient safety. As a result, many nurses struggle unnecessarily with tools like barcode readers that are supposed to improve safety, reduce workload, and improve the daily working environment of nursing staff due to tools not functioning as intended. Barcodes are not error free. The scanners can fail to scan, misread a code, or send inaccurate information to the software; and vendors frequently change barcodes for different batches, causing mishaps when new stock becomes available to floor nurses.
There is also the question of whether MATs are truly evidence-based. In a report published in the American Journal of Health-System Pharmacy, researchers conclude, "The health care industry lacks scientific studies that validate technology and, when combined with best practices, improve patient safety by reducing medication errors."
Yet resolving medication errors is paramount to providing safe, quality care for all patients. Healthcare consumers should have confidence in a medical provider's ability to treat their problems to resolution while ensuring their safety. Nurses are in the middle between the organization and the patients and therefore must advocate for better tools.
Often nurses are so overwhelmed with tasks and duties that they have little time left to effectively advocate for change - they may simply state something is "not working," while providing little or no explanation. The technical staff is then left to figure out what is wrong and search for a solution. Nurses must provide more grass roots solutions. They can improve technology outcomes by providing specifics of problems, such as "this barcode reader will not read this particular label, but it reads these other labels." Even more important is for nurses to not simply accept a tool or technology and find a workaround, but rather to be an agent of change and advocate to hospital leaders and the IT department to discover better tools, processes, or methods to achieve the goals.
As nurses, we advocate for our patients even when we know there will be opposition. Bringing change to the workplace tools and technology requires this same type of fervor and commitment. Nurses are instinctive and resourceful in finding shortcuts and workarounds, but turning that same energy toward solving an issue - rather than working around it - will result in improvements not only in safety and patient care, but in the daily work environment we all experience. Informatics cannot provide any advantage unless information is collected, processed, and analyzed correctly. The only way for this to happen is by nurses being successful in using the tools provided.
As a project manager I have had to do major damage control when the "kick off" of a project was skipped. Just as a kickoff in football puts the ball into play, so does a kick- off in clinical informatics signal the beginning of a project.
As the kick-off is often the first official meeting of the group of people who will be working together on the project it should be used to communicate a project's shared vision. More so than any other project milestone, the kick-off provides an opportunity for the project's sponsor(s) and the organization's leadership to convey commitment to the project.
One of the purposes of the kick-off is to introduce the organization's project team and the vendor project team to each other and bring all team members together to form one cohesive project team. When organizing a kick-off, don't forget to include your project stakeholders as ensuring coordination and communication will aid in making project success more likely.
During the kick-off the project charter, scope, project plan (or high level time line) should be introduced.
And last but not least: It will be a missed opportunity if leadership does not capitalize on the kick-off to connect how the project initiative will further support the organization's mission and strategic plan.