Digital health dominated the 2014 Consumer Electronics Show (CES) (http://www.cesweb.org/home). While curved TVs, 3-D television and Ultra HD were the talk of the show, the real happening at CES was the growth in the connected space and digital health. The Consumer Electronics Association (CEA), the organization behind CES, has reported a 40% growth in digital health exhibitors over past year with over 300 exhibitors in the medtech space. Now that health and wellness are becoming increasingly consumer-oriented, a younger more health-conscious population enters the market. In addition, the Baby Boomer generation looks for better ways of managing their health.
Where medical equipment manufacturers have traditionally thought of the healthcare provider as their consumer, a new, secondary business model is opening up, one that goes directly from the manufacturer to the patient. There is an overall trend toward digital technology across multiple industries. Perhaps, this can be linked to an overarching trend, which is that every business is a digital business and every consumer, or patient, is a digital consumer.
Here are three key trends that dominated the consumer digital health space at CES this year:
#1 - Self Tracking and Wearables
It should be no surprise to anyone that wearable devices and fitness trackers would have been a big presence at CES. According to the 2014 Accenture Digital Consumer Tech Survey, 52% of consumers are interested in buying wearable health trackers. A July 2013 survey done by CEA found that one-third of mobile smartphone or tablet users have tracked some aspect of their health in the past 12 months.
Wearables are gaining popularity, as they will be more discrete and will blend into people's daily lives by being embedded in clothes and everyday products. Wearables will provide a more user-friendly experience that offers more ease when it comes to analyzing data, sharing it across the Internet and social media, and data protection. New wearable products from major companies like Sony and LG have released the Sony Core and LG Lifeband Touch - both targeted at tackling the next-gen fitness tracking market.
#2 - Aging in Place Solutions
This year the first generation of Baby Boomers will be turning 68. Most people can tell you a funny story about trying to teach your parents or grandparents how to use the Internet. Yet AARP reports that eight in 10 of its members own a computer, tablet, or e-reader. And a 2012 AARP survey of seniors over the age of 50 found that 36% of those surveyed reported being "extremely or very comfortable" with technology.
Seniors and retirees are looking for options to receive assisted care they need in a way that they don't have to overly sacrifice their independence or standard of living. And electronics companies are seeing the potential in capturing a market that is tech savvy, but also increasingly in need of healthcare solutions. CES 2014 marked the unveiling of healthcare products for supporting increased social engagement, injury prevention, even early detection and treatment of chronic diseases among seniors.
MobileHelp is introducing the Celluar DUO, a personal emergency response system targeted at seniors and is capable of automatic fall detection. The DUO operates on AT&T's cellular network, ensuring patient safety in the absence of a land line. It will also work in conjunction with MobileHelp's just-announced MobileHelp Connect online portal, which provides patients and their families and caregivers with the ability to virtually track patient activity levels, medication adherence, and trends over time. A&D Medical, a manufacturer of biometric monitoring solutions, has unveiled its Connected Wellness platform which connects A&D devices, including weight scales and blood pressure monitors, via Bluetooth Smart - enabling patients to monitor their health across multiple devices on an Android or iOS smartphone. Siemens Healthcare won an Innovations Design and Engineering Awards Honor at CES this year with its miniTek, a device that can remotely connect a patient's hearing aid to phones, TV, music players, and other audio devices via Bluetooth. An accompanying Android-based app allows users to control their hearing aid's volume
#3 - Real Time Remote Monitoring
According to a Brookings Institute analysis, remote monitoring technologies could save the U.S. healthcare system $197 billion between 2010 and 2035. Industry experts believe the combination of Internet, video, and wireless technology for inbound patients and those with chronic conditions will create an explosion of consumer products with evolving patient monitoring capabilities. They also believe we will see further evolution including implanted bioelectric sensors and options to detect a deeper range of physiological information along with sensors that can track nonlinear data like bathroom visits, coughs, and erratic behaviors. Packaged behind these more powerful sensors will be systems such as monitoring apps for smartphones and tablets, that provide two-way communication to remote healthcare consultants.
SMK Electronics demonstrated a video game for remote rehabilitation (telehabilitation). The company's platform, which was developed in coordination with the University of Manitoba, uses the Gyration Air Mouse - a motion-tracking computer mouse that can be used while held in the air - to rehab patients with arthritis and balance and gait disorders.
Vancive Medical Technologies, a division of Avery Dennison, showcased its Metria Informed Health Technology Platform - a series of disposable, adhesive, sensor-based products for health monitoring and clinical applications. Vancive's first consumer level product, the Metria IH1, is intended for "lifestyle management applications" and measures activity, sleep, calories via a sensor that sticks directly onto the body - something that could be a welcome change for consumers whose wrists are already occupied with smartwatches and fitness bands.
Growing numbers of nursing educators and trainers have come to rely on a learning model known as the "flipped classroom." Simply stated, the flipped classroom restructures how nursing students and practitioners invest their time both within and outside the traditional classroom. Even more important, the flipped classroom represents a shift in learning accountability from the nurse faculty member or trainer to the nursing student or practitioner.
Once nursing students and practitioners exit the formal classroom, they take on new responsibilities and tasks. First, they must manage the content they decide to access and use. They also must select a learning style, set a pace for learning, and identify strategies and tactics to demonstrate or verify learning.
The shift in roles goes both ways. The nurse faculty member or trainer takes on the role of learning navigator, guide or broker. Rather than dispensing nursing content from a lectern or podium, the educator or trainer adapts varied learning approaches to the needs of students and practitioners and, as much as possible, brings learners along on a personalized learning journey.
Learners who once took copious notes within the confines of the classroom now rely on multiple technologies to master nursing competencies, knowledge, skills and procedures. They watch presentation videos, listen to podcasts, review enhanced e-book content and collaborate with faculty and fellow learners within online communities. For example, a nursing student or practitioner might access nursing content through these channels:
- Participate in a webinar on implementing health assessments in primary care sponsored by the Agency for Healthcare Quality and Research;
- Listen to a series of three podcast lectures on nursing ethics;
- Consult chapters of e-books focused on evidence-based nursing care guidelines and pain management;
- Attend virtual conferences sponsored by the National Hospice and Palliative Care Association and the Oncology Nursing Society.
- Use adaptive learning systems to individually learn specific content and evaluate the ability to apply that knowledge
The flipped classroom remains a powerful learning channel. However, instead of listening to lectures punctuated by questions, nursing students and practitioners use classroom time to engage in interactive, project-based learning. For example, learners might solve real world problems related to the management of chronic disease like obesity, diabetes or congestive heart failure.
Or they might devise real-world applications of findings from a 2014 AHRQ study that reported the most common diagnoses for hospitalization are live births, pneumonia, septicemia, congestive heart failure and osteoarthritis. Or students and practitioners might identify emerging trends, implications and action steps related to research conclusions like these:
- Post-menopausal women who followed the cancer-prevention guidelines developed by the American Cancer Society were 17 percent less likely to develop cancer and percent less likely to die from cancer. Question: How should nurses share cancer prevention strategies with patients?
- The number of states with widespread flu activity increased from 25 to 35, according to the Centers for Disease Control and Prevention (CDC). Patients between the ages 18 and 64 have accounted for about 61 percent if flu-related hospitalizations nationwide. Question: How is the local community responding to the flu crisis? What's the appropriate role for hospitals, physician practices and nurses?
- According to a 2014 study from researchers at Children's Hospital at Montefiore (CHAM), only 1 of 169 adults was able to demonstrate correct use of a metered-dose inhaler. Such inhalers are commonly used to treat asthma in children. Question: How can nurses provide parents with better guidance on the benefit and use of MDIs?
By shifting the focus from formal presentations to problem analysis and resolution, nursing students and practitioners can learn more by doing more. No longer tethered to the lectern, educators and trainers can lead learners through the processes of content interpretation, analysis, evaluation, and synthesis while devoting more time to interactions with individual learners.
The flipped classroom doesn't stand alone. Instead, it functions as one component of a cluster of solutions designed to making nurse education and training more active, fluid and engaging. Such concepts have won the approval of bodies as diverse at the President's Council of Advisors on Science and Technology, and the National Council of State Boards of Nursing.
In the years ahead, nursing educators and trainers will join forces with learners to aggregate lessons learned from a variety of models, including blended and inquiry based learning. Meanwhile, nursing students and practitioners will gain access to an ever-growing array of online and offline learning resources, driving the inevitable transition to more self-directed, lifelong learning.
As learners continue to access videos, podcasts, and online content at the time and place of their choosing, nurse educators and trainers will use classroom time for hands-on exercises in problem-solving, conflict resolution, decision making and collaboration.
Other educators and trainers will turn lectures into workshops where groups of nursing students or practitioners collaborate and compete to design care plans, deliver population-specific education and counseling, integrate patient information from a wide array of tools and devices and coordinate care with multiple healthcare professionals. Still others will experiment with one-on-one coaching and mentoring, independent learning projects and real world and virtual field trips.
The future of nursing education and training is as broad as our imagination. By partnering with educators learners, technology vendors, and government, we can extend the boundaries of learning with the nursing profession.
Despite the widespread adoption of electronic medical records (EMRs), nurses still spend a large part of their shift on patient charting. This time could be better spent delivering patient care and working toward outcome and quality goals. The first thought that comes to mind regarding the time spent working with the EMR is But I thought computers are supposed to save time.
Responding to that assertion, both to providers and healthcare consumers, is a tough task. Many people watch TV programs that showcase the marvels of science with regards to forensics, as it applies to criminal justice and medical issues. Most medical professionals know that existing tools actually pale in comparison to their fictional counterparts. The computer systems used in healthcare mimic this dichotomy between reality and television entertainment. The EMR provides a wonderful toolset for providers, particularly for nurses charged with patient documentation. However, EMR systems have not yet reached the perfect level of usability. And the main reason for this is a lack of interoperability standards.
So what does interoperability mean? The basic definition of interoperability is the ability of a system to interact with all its parts, thereby producing useful and meaningful results.
Nurses know that for quite awhile now blood laboratories have had the ability to share patient test results through an electronic system, speeding their delivery and helping to improve quality of care. Doctors and nurses can now view these test results in the central patient record nearly in real-time, as soon as the tests are completed. But the ability of the EMR to do more than simply display data is where the concept of interoperability comes into play.
For example, an interoperable EMR might integrate lab results with nursing workflows. Critical lab results, like a blood sugar value less than 60, would not only be highlighted in red, but would sound an audible alert and require nursing staff nurse to acknowledge the result and document the action that was taken. This can help ensure a fast, direct patient intervention – as well as provide an audit trail for accountability of care, since the intervention can be tracked electronically.
Even more advanced interoperability might take all of this information and send the data through the mobile phone system – securely encrypted, of course – so the physician on call is immediately alerted of the situation and the actions taken.
Nurses can play a role in attaining that level of interoperability. How? They can engage the EMR administrator and assist in integrating evidence-based practice into the overall system that’s used throughout the entire facility. This daunting task for nurses is one that could potentially lead to great rewards, including reducing the need for nurses to manually input data, which in turn could allow more time for bedside care – and thereby ensure a high level quality, safety, and transparency for the patient’s dynamic health condition. Only the diligence of nursing on the front lines and promoting the interoperability of systems can meet the needs of our patients in years to come.
Recently, the question of "what's the difference between HIM and Informatics" was posed to me. At first pass, I believed I could answer this succinctly and completely. However, upon thinking about this some more, I knew I needed to describe just how interrelated the two fields were. On the surface, health informatics (HI) and health information management (HIM) may seem very similar to most people. Both fields revolve around the use of technology in the healthcare field and share some common skill sets and job responsibilities, but there are many differences between these two fields.
The key factor that distinguishes HI from HIM is that HIM typically focuses on the information technology processes needed to store and retrieve patient data accurately and complying with regulations. HI, focuses on applied technology by using information management and information technology to improve patient care.
While HI and HIM complement each other, they differ on what each of these professionals do. Health informatics professionals design and develop information systems and processes that improve the quality, effectiveness and efficiency of care. They also assess emerging technologies for healthcare applications. HI is often described as the intersection of computer science, information science and healthcare. This means that HI professionals work with both the processes and the tools used to record, store and analyze healthcare information. They have a deep understanding of data, particularly electronic health records and how it can be used to support decisions and protocols. Health informatics professionals often interact directly with clinical staff and patients in order to evaluate the impact of information technology on clinical processes, outcomes and resources.
Health information management professionals generally work with organizing and managing patient data contained in the medical record. HIM professionals are often responsible for coding health information for proper reimbursement or research. They also ensure compliance with governmental regulations regarding patient data. They must make sure patient health records are complete and accurate. It is important for them to provide access to records to staff and others, while protecting the privacy and security of patient health information.
Required skills and knowledge often is another differentiator between the two professions. Health information management careers generally require education or experience with medical records management, coding and billing and regulatory requirements. Information technology knowledge, particularly involving electronic health records is also often required. HIM careers may also require familiarity with medical terminology, medications and basic anatomy and physiology.
Careers in healthcare informatics can benefit from some of the same core skills and knowledge needed for a HIM career. However, HI roles place less emphasis on coding, billing and regulations. There is a greater emphasis on information analysis and organization and knowledge of system infrastructure design, networking, and even programming skills. HI careers often require familiarity with clinical guidelines and applications within specialty areas such as nursing, clinical care, public health and biomedical research. Since, HI positions tend to require highly specialized knowledge and an advanced skill set, HI professionals often have a Master's of Science in Health Informatics or a Graduate Certificate in Health Informatics.
Here are some resources helpful in defining health information management and health informatics:
We are witnessing the emergence of a data-powered revolution of healthcare. The digital age has broken down barriers on access, distance, socioeconomic status and time zones. In addition, devices to access digital health are affordable, mobile and intelligent (i.e., smart). As noted by Todd Park, U.S. chief technology officer, "We are beginning to see what happens when you unleash the power of American innovators and data to transform health care for the better from the ground up. It's no surprise to the doctors, hospitals, patients and entrepreneurs who have been working so hard to improve health care. But it is, indeed, great news for the nation. "
A notable trend that has emerged is that patients are "co-pilots" in their care. Traditionally, patients have had "little access to information and knowledge that could help them participate in, let alone guide, their own care. However, the Institute of Medicine design rules propose that patients have shared knowledge and free flow of information. At a minimum, they need access to information from their providers' EHRs - their own diagnoses, medications, allergies, lab test results, visit summaries, and other findings over time. A continuous healing relationship is a two-way interaction (whether electronic or face-to-face) between patients and their providers."
A convergence or coming together has also occurred, which has allowed for the explosion of digital health. While technology and data have existed for decades, it is only when various elements converged and matured that consumers could achieve increased access to digital health information. For example, the Internet, applications, and devices (personal computers to tablets) all have evolved and are utilized in daily life. Computing has become more mobile, agile, powerful and affordable. Consumer mobile devices, such as tablets have become more affordable and cell phones have morphed into smartphones, which put powerful capacity at one's fingertips.
The future is now and consumers are looking for more healthcare solutions. According to the U.S. Food and Drug Administration, there were 17,288 health and fitness apps on the market in mid-2012 along with 14,558 medical apps. " Given society's embrace of mobile devices, consumers inevitably are turning to mobile apps to manage their well-being and health care. According to the latest industry data available, there are presently 31,000 health, fitness, and medical related apps on the market today. This rise in consumer use parallels increased traction among physicians and other health practitioners. Some of the best examples are:
Social Content or Information, which can be found from several sources:
- Websites (health specific), professional health organizations, physician practices or clinics, hospitals / health systems.
- Mobile apps: American Heart Association, American Diabetes Association.
- Hospitals and health systems reacted to the proliferation of health and medical content during the late to mid-‘90s. Examples are Mayo Clinic, Intermountain Healthcare, and your local health system's website.
- Various elements of information can be found on many provider websites: blogs, risk assessment tool, health library, and request for appointment.
Wellness and Health Management- An important aspect of consumer digital health are the many applications designed to manage and monitor your own health. Sensors are now available to attach to your Smartphone or tablet (applications are free but the sensor has a price tag). Examples are:
- iHealth Wireless Blood Pressure Wrist Monitor
- Jawbone Up (sleep tracking, 24/7 activity tracking, food/drink tracking).
Nutrition- There is an abundance of nutrition-focused applications (looking to loose weight, eat gluten-free, and manage your diabetes).
Chronic Disease Management- The management of chronic disease is one of the greatest challenges to our population's health and cost of medical care. (Example, www.patientslikeme.com)
Personal Health Records - Your physician or health system may offer access to an application for personal health records that may include communication to their practice.
All these solutions sound so wonderful, but what does this all mean? On the surface consumers may have found a way to engage in their health and wellness and they also have access to vast sources of information at their fingertips. However, what about:
- Privacy (HIPAA)
- Limited access or restricted access
- Security (HIPPA)
- Data-mining without your permission
We all understand some of the potential hazards in using current technology, the Internet, websites, and applications as we know them today. However, it is unclear what other challenges that may present themselves, in what has been termed the "Wild West" of the Internet. Theft of patient data and patient identify is on the rise so caution is required!
Going forward, the ongoing challenges for consumers are:
- With a universe of available health and medical information, it can be daunting as to what will work best for you as a consumer. You will have to find the application/tool that gives you the right amount and correct information you need.
- Can each consumer understand and place into the right context what the next appropriate action might be? A specific example is the posted quality information about hospitals. Can this be deciphered by the average consumer? How can you assess whether a treatment that is recommended is your best option?
- Consumer health literacy varies. How do we evaluate how well a person understands the information that is being supplied to them? Is an online video vignette better than textual information for a particular consumer or population?
- Security and privacy may remain an open and potential issue. It is important to understand what this means for you and your family when using online sources or mobile applications.
- Consumer expectations with unrestricted access to all health information may not be realistic today from all providers. Many physicians report being inundated with the many questions that their patients bring to them upon researching on the Internet.
- Patient identify fraud is on the rise. Since HIPAA was instituted, many data breaches are documented annually. We also know there is a link between breaches and potential fraud.
The new rise in digital health can be termed a ‘Pandora's Box' (a prolific set of troubles). But, it is here to stay, as patients are the biggest stakeholders in their health.
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.