Hospitals have dedicated tremendous resources to create an integrated clinical environment that results in better patient care and outcomes, reduces readmissions, and increases hospital utilization, in hopes of reducing the overall cost of health care.
Unfortunately, health IT projects either fall short of business and clinical goals or are completely abandoned at an astonishing rate. Studies vary, but failure-rate estimates range from 35% to 75%.
Overrun budgets and functionality problems are often cited as the primary culprits of doomed implementations. However, the failure to include direct-care clinical staff—including nurses—in the evaluation, implementation, and training of new technology should not be overlooked.
It’s easy to consider a new hardware or software solution and imagine its transformative potential. Health care trade shows brim with thousands of devices, enterprise systems, and software applications marketed as painless solutions for any clinical challenge facing a hospital or care unit. But a poorly implemented system that did not evaluate the impact to the clinical workflow can just as easily exacerbate inefficiencies and reduce the overall quality of patient care.
Equipment that doesn’t work properly or causes needless redundancies in daily tasks is enormously frustrating. The lack of sufficient training and vendor support increases the chances of mistakes or encourages direct-care staff to either work around a new solution or outright revolt at go-live.
A Shared Vision
Many of the doomsday scenarios associated with technology adoption and implementation can be mitigated with adequate planning, training, and collaboration. By listening to, engaging with, and educating front-line staff, hospitals can dramatically increase their chances of success with technology adoption.
For example, consider medical devices with alarm capabilities. Nursing staff are charged with the proper setting of the alarms and the prompt response when any of the devices send an alert. As the presence of alarm equipment continues to grow, nurses find their workflow and ability to engage with patients disrupted as they chase down hundreds of (often non-actionable) alarms. Without proper education and implementation of alarm devices, it’s all too easy to imagine clinical staff arbitrarily adjusting alarm settings—or even turning them off entirely.
Involving direct-care staff is critical to the success of any new technology. How will this new technology impact how nurses deliver patient care? What adjustments in workflow and practice need to be made—at go-live and beyond? Starting with these questions fosters buy-in from the staff who will be utilizing this equipment. If end-users are not involved in the selection, adoption, and implementation of a technology, then the likelihood that they will become owners of that product is significantly lower.
Environmental and Workflow Assessments
Hospitals each have their own unique characteristics, culture, and needs. Identifying and documenting those attributes are critical to any successful health IT implementation. To achieve measurable progress in health IT adoption requires that hospitals identify and support internal champions in all relevant departments.
For hospitals and health systems, especially those that are breaking ground on new technology integration, the first step is an assessment of needs and potential impact to workflow. The formidable task list that comes with any technology implementation requires the input and expertise of a project team, which ideally, should be comprised of leadership from myriad stakeholders, including IT networking, facilities, patient safety experts, educators, informatics nurses, laboratory staff, pharmacists, electrical engineers, biomedical engineers, quality improvement specialists, vendors, and direct-care clinical staff . This team will be responsible for every phase of deployment—evaluation, acquisition, rollout, implementation, and transition to live operations. They will determine the hospital’s objectives and integration goals, as well as vendor evaluations, business and clinical requirements, risk management concerns, patient safety goals, and costs.
The project team will also be charged with identifying the departments or units the integration will first impact. Big bang, enterprise integrations are not unprecedented, but a phased roll out in a single department or set of departments with the highest acuity, such as the surgical suite, allows more time and space for assessments, lessons learned, and best practices, which can be applied as the integration spreads to the rest of the enterprise.
One aspect of integration that is often overlooked is the value of clinical workflow, which can vary among hospitals and individual units. Workflow should not be minimized because it will largely define how data is collected, how it is displayed, and what is displayed. Hospitals should incorporate clinical workflow as quickly and as early as possible in the process.
Designating a nursing champion—or super-user—at the outset allows other nurses and direct-care clinical staff to receive information, training, and support during all phases of adoption. These super-users would be working closely with the interdisciplinary team assembled for the implementation project.
Health IT implementations can be expensive, complex, involve dozens of stakeholders, and are often up against aggressive deadlines. Technology can also be disruptive and bring new uncertainties to the entire organization. However, the quality of the relationship with the vendor supplying the solution can make a huge difference.
Any hospital or health system has business and clinical needs and cultures that make them different from other organizations. A partner with deep knowledge of the unique aspects of your organization not only will help you avoid common mistakes, but also keep you focused on detailed integration points and workflows.
A partner that knows your organization also helps other vendors get acclimated, provides guidance, and ensures everyone stays accountable. A positive and fruitful collaboration allows hospitals to establish benchmarks and ensure that configurations and interoperability are optimized and seamless.
An excellent vendor also acts as a consultant and educator, making hospital staff comfortable with new technology and uncovering strategies for optimizing workflow. The importance of evaluating the vendor as much as the product they are delivering cannot be stressed enough. Vendors that lack expertise, training capabilities and clear steps toward go-live and beyond are critical red flags.
Can the vendor explain their process? Can they share metrics? Do they offer continued training and support after the implementation is complete? Answers to these questions will give your project team keen insights into the potential challenges of a technology implementation.
If your vendor supplies references, ask their customers specifically about their specific challenges and the vendor resolved them. Setbacks are a natural part of any implementation, but the true difference maker is determining the level of support and collaboration provided to overcome it.
A team approach to health IT doesn’t guarantee that technology adoption and implementation will be a success—but it will significantly increase its chances of sustainability. Today’s nurses have neither the desire nor the option to be passive consumers of health care technology. The seamless integration of technology requires that direct-care clinical staff have influence in the design and testing of equipment and applications. Involving end-users in the early stages of system analysis and design specifications can lead to better adoption of new technology, as well as identifying how current technology can be adapted for greater user acceptance.
The pace is picking up in the movement of hospitals toward automated tracking of health records, medications, and patient care. Who better than nurses—with their intimate, on-the-ground expertise—to lead the way?
Hospitals are tapping into a variety of computer and telecommunications technologies to help improve the efficiency and outcomes of patient care. The success of these high-tech systems depends greatly on how readily the staffs adapt to them and how easily they fit into the existing workflow. Nurses with training in informatics are playing a vital role in tailoring health information technology (HIT) to meet the needs and goals of their workplaces, as well as educating fellow clinicians in how to use it.
Speedier information access
The Affordable Care Act is giving many hospitals the nudge to trade the traditional hand-scribbled chart notations for electronic records.
“It’s going to be mandated by the federal government, so the hospitals cannot be sustained without medical information systems,” notes Eun-Shim Nahm, PhD, RN, FAAN, who is an associate professor and Program Director of Nursing Informatics at the University of Maryland School of Nursing.
Hospital nurses who have been leaders in the early adoption of electronic health records (EHR) say the new systems save time and make it easier for health care providers to share information with each other and their patients.
As Chief Nursing Officer for NorthShore University HealthSystem in Illinois, Nancy T. Semerdjian, MBA, RN, CNA-BC, FACHE, was in charge of implementing the hospital’s electronic medical records system. One of the most welcome improvements to come from the system, which she and her team began installing 10 years ago, was the automatic reporting of data from doctor visits, laboratory tests, and other patient encounters throughout the hospital.
“You didn’t have to wait for a paper to print somewhere or get a fax sent to the unit,” says Semerdjian, who adds that authorized clinicians can access patient records remotely using a key fob.
At Ann and Robert H. Lurie Children’s Hospital of Chicago, families of patients can apply for access to an online portal that lets them view their records online, including their latest test results and upcoming appointments, says Karen Carroll, PhD, RN, NEA-BC, Director of Nursing Informatics and Innovations.
The EHR system at Fletcher Allen Health Care in Burlington, Vermont, has enabled the oncology department to create a seamless patient care record that includes visits to doctors’ offices, ambulatory centers, and the hospital, saysAnne Ireland,MSN, RN, AOCN, CENP, Director of Clinical Practice and Innovation.
“What we had before were disparate systems in all of those locations,” says Ireland, whopreviously led the EHR implementation across all departments at the hospital.“One place didn’t know what the other knew, because they all kept their own records.”
Medical device integration (MDI) is a technology helping to speed up and enhance the safety of data sharing. MDI systems capture information from the medical instrumentation hooked up to patients and automatically send updates to the patients’ electronic records.
“We’re automating that clinical documentation piece, so the nurse no longer has to manually transcribe the device data—therefore eliminating the risk of transcription error,” says Mary Carr, RN, Chief Nursing Officer for iSirona, a medical device integration software company headquartered in Panama City, Florida. “As a clinician, you gain more time for direct care and ultimately improve patient outcomes.”
The US Department of Veteran Affairs has become a world leader in the application of telehealth technology to improve patient care and education, and the VA aims to double its program’s reach to 825,000 veterans by the end of 2013.At the Michael E. DeBakey VA Medical Center in Houston, telehealth is part of a two-pronged HIT system that also includes secure messaging for patient emails, says Omana Simon, DNP, RN, FNP-BC, the facility telehealth coordinator. Components of the program include home telehealth, clinical video telehealth, and a store-and-forward process for relaying information to providers in remote locations.
Patients participating in home telehealth take home a device called a Health Buddy that enables them to record and send information about their vital signs and symptoms. At the hospital, several nurses and a nurse practitioner regularly review the data, and the patient’s medication can be adjusted accordingly.
The program currently focuses on the treatment of uncontrolled diabetes, uncontrolled hypertension, depression, heart failure, and COPD, and the hospital plans to add telehealth programs for smoking cessation and palliative care, according to Simon.
With clinical video telehealth, patients go to the nearest VA clinic and sit in front of a video monitor. A clinician at the Houston medical center provides long-distance consultation, while a clinical technician at the local site is on hand to assist the patient. Data from the video encounter is automatically added to the patient’s medical record.
Improving patient care
“Many studies have shown that [the telehealth programs] have improved the patients’ quality of life, patient satisfaction, and clinical outcomes,” says Simon, who notes, for example, that blood sugar and blood pressure results have improved, while the number of ER visits and unscheduled clinic visits has decreased.
NorthShore University HealthSystem puts its electronic records system to use in managing chronic illnesses, for example, by generating automatic checklists for patients admitted with congestive heart failure, Semerdjian says.
“When the patient is discharged, we make sure the patient has a follow-up visit with their physician, that they receive instructions in medications, and that they know to weigh themselves every day,” she says. “Those are the kinds of things that, in the paper world, you just didn’t have.”
The Mayo Clinic in Rochester, Minnesota, uses Fair Isaac Corporation’s Blaze Advisor® business rules management system to create pop-up warnings for the prevention of pressure ulcers.
“If certain pressure ulcer conditions are met, the Blaze rule will pick up on it and send a message to a clinical nurse specialist, who will then act upon this message—go out and see the patient and work with the nurses on the floor to come up with the best treatment process,” saysBob Kirchner, RN, MSN, MBA, an informatics nurse specialist at the Mayo Clinic.
Medication delivery is another target area for enhancement through HIT. The Mayo Clinic has been using barcode medicine administration for the past two years, and Kirchner says the evidence shows the system has prevented medication errors.
Nikita Cowan, RN, a charge nurse and the interim manager in the Acute Med Surgical Unit at Texas Health Presbyterian Hospital in Dallas, says barcoding is the most significant automation tool the hospital has implemented in the last few months. Like Kirchner, she touts the system for reducing errors.
“It just builds that extra barrier of protection and safety for the patient and for the nurse,” Cowan says.
Fletcher Allen Health Care employs programmable electronic IV pumps that are connected to the EHR system so records are updated instantly whenever medication is administered. “If I change the infusion rate on a patient’s pump, the computer knows what I’ve done,” Ireland says.
HIT is also improving the efficiency of prescription orders. Semerdjian notes that NorthShore physicians’ medication orders show up simultaneously in the pharmacy department and on the chief nursing officer’s medical administration record, speeding up the time that the medicine gets transported to the hospital unit.
Texas Health Presbyterian recently implemented an early warning score system for monitoring patients’ vital signs. The system features color-coded electronic charts that help clinicians keep track of significant changes in a patient’s condition.
“I think it has a direct impact on the number of RRTs—rapid response team calls or code blues—because the system is picking up on some subtle things that the nurse or staff may not be aware of,” Cowan says.
Nurses at the design table
Not only are nurses often in charge of implementing and managing hospital HIT projects, they also are tapped for their expertise in the planning stages.
Joyce Sensmeier, MS, RN-BC, CPHIMS, FHIMSS, FAAN, Vice President of Informatics at the Healthcare Information and Management Systems Society (HIMSS), says nurses need to get involved in the process as early as possible.
“It’s really critical to have nursing represented at the table for the decisions that are made about electronic health records and the technology systems around them, because nurses understand what patients need,” says Sensmeier, who is a co-founder andEx-Officio Chair of the Alliance for Nursing Informatics, an organization co-sponsored by HIMSS and the American Medical Informatics Association (AMIA). “They understand the importance of accuracy, consistency, and documentation.”
Semerdjian notes that when nurses partnered with HIT experts in planning the EHR project at NorthShore University HealthSystem, the working group was divided into teams with specific expertise. For example, one team dealt with an application for scheduling appointments and medical procedures, another with a system for outpatients.
Nurses at Lurie Children’s offered guidance on how to integrate the EHR system into the various hospital units, says Carroll.
“There is no such thing as an isolated system, entity, or department when you’re talking about computer records,” she says. “Everything hinges on another and has to communicate with another system.”
At Texas Health Presbyterian, Cowan has been a designated superuser of the HIT system since 2009. During monthly meetings, she and other superusers get updates on new pilot programs and planned upgrades to existing ones; then they relay the news to the rest of the staff.
Graduate-level nursing informatics studies programs are providing nurses with academic credentials for these leadership roles. For instance, Middle Tennessee State University’s (MTSU) School of Nursing in Murfreesboro offers an MSN with nursing informatics concentration and an MSPS with informatics concentration for other health professionals such as physical and respiratory therapists. A required four-hour practicum gives students hands-on experience in the field. Take, for example, the MTSU nursing student assigned to the VA hospital in Kingston, Tennessee.
“She is working on a really cool project . . . to actually integrate a medical surgical floor into the electronic medical record environment,” says Richard Meeks, MSN, RN, CPHRM, an assistant professor at MTSU.
The project includes creating concept maps and floor diagrams to help guide unit nursing leaders in adapting their workflows to an automated documentation system, Meeks adds.
Nahm, at the University of Maryland, says vendors need nurses trained in informatics to help them build better HIT systems that fit the way hospital staffers work.
“The system should correctly and accurately reflect the clinician’s workflow,” Nahm says. “If the system doesn’t work for them, it can create medical errors.”
HIT: A work in progress
One of Sensmeier’s favorite sessions at the AMIA’s Annual Symposium in Chicago last November was titled “Why is Interoperability Taking So Darn Long?” Sensmeier is a longtime advocate for interoperability in health care IT, which would involve, among other things, standardizing terminology and programming language so that different hospital systems could communicate with one another.
“Every hospital has been pretty much doing its own thing for a long time,” Sensmeier says. “To require them to standardize and begin to integrate is a huge challenge.”
As with any technology, another challenge for HIT users is coping with the glitches that crop up from time to time: sluggish or errant data flow, interpretation flaws, and equipment failures.
“When I first got into nursing informatics, I respected computers and thought that whatever comes out of a computer is probably correct,” Sensmeier recalls. “Well, during my first testing experience with a computer, I could see how easy it was for a system to misinterpret something, or for data to not get to the right place, or for printers to break.”
Nurses at Lurie Children’s continually monitor the EHR system for its efficacy in improving patient outcomes.
“We have a nursing-driven clinical informatics committee that reviews, with the staff on our front lines, what they are seeing in documenting and providing care,” Carroll says. “That is nursing’s opportunity to have input and to bring up issues and their suggestions for improvement.”
Sometimes the toughest job for the nurse informaticist is educating other clinicians about computers and getting them to embrace the technology. NorthShore University HealthSystem provided every physician with 16 hours of computer training, which helped convert a lot of skeptics among them.
“I had a physician say to me [that] he spent his first few days swearing at it,” Carroll says. “Now he swears by it.”
Fletcher Allen Health Care even offered its clinicians free typing classes, though not many signed up, according to Ireland. She notes that some found it easier to make the transition from pad and paper when they viewed the computer as a tool for interacting with patients.
Meeks says the best results come from taking an analytical approach to implementing new technology, thoroughly assessing how it will fit into the way nurses and other health care providers do their jobs.
“When we bring on this type of technology—medical records, electronic scanning of meds—we traditionally dump that stuff into an environment that hasn’t been updated since the ‘70s,” Meeks says. “That causes an imbalance in that environment, and it causes frustration and anxiety in the staff—not only nurses but other clinicians and physicians—because we’ve not done a good job integrating all of that technology into their practice.”
CPOE: it sounds like a sci-fi robot, but it’s actually the computerized physician order entry system that could revolutionize the way hospitals function. You may already be familiar with CPOE, as it’s currently used in about 30% of U.S. hospitals. If not, the system expedites processes like ordering tests and filling prescriptions. These tasks are then made instantly—and even remotely—available to authorized hospital staff. Theoretically, it reduces the margin of error, but the merits of CPOE have not been studied in depth until recently.
In early May, Pediatrics published the results of a year-anda-half-long study conducted by Stanford University and Lucile Packard Children’s Hospital in California, showing a 20% decrease in fatalities during that period. The study analyzed 100,000 Packard Children’s Hospital discharges from January 2001 through April 2009. CPOE was introduced in 2007, and between that time and the study’s conclusion, researchers observed the improvement. Researchers compared the observed mortality with the expected mortality, using data from 42 other nonprofi t pediatric hospitals comparable to Packard Children’s.
Stanford representatives say their research is the first to show a connection between the implementation of CPOE and decreased fatalities; however, they also acknowledged that one study does not serve as conclusive evidence and that other health care initiatives at the hospital could have played a role in the improved mortality rate. Critics have questioned the value of CPOE since its fi rst use during the 1970s, and one Pittsburgh hospital using the system actually saw an increase in fatalities in their pediatric ICU in 2005.
Implementing CPOE can take years and requires ample training. Perceived risks include delays in workflow due to inexperienced staff members using the system, a lack of communication between doctors and nurses, default settings that may overlook unique patient needs, and even an over-reliance on the automation and subsequent false sense of security. CPOE also offers electronic “suggestions” when it senses a potential error, and critics have argued that a barrage of such messages will eventually lose their potency as health care professionals fi nd they can usually ignore them.
However, the study’s results are still encouraging. The hospital appeared to experience an influx of children with more serious illnesses and conditions during the period, and fatalities continued to decrease. (Health care professionals might remember the 1999 Institute of Medicine report claiming medical errors caused 44,000–98,000 deaths every year in the United States, stimulating the adoption of computerized systems.)
Stanford researchers credit the hospital’s success to the carefully planned implementation of the CPOE system, and they recommend a similar approach among health care providers going forward. According to the research, Packard Children’s Hospital experienced two fewer deaths per 1,000 discharges—36 lives over 18 months.
In our last column, “Informatics: New Opportunities in Nursing,” we discussed how the expanding role of computers and technology in our lives has pervaded health care settings, creating new opportunities for professionals interested in careers in nursing informatics.
With the approval of the HITECH Act in 2009 and funding toward adoption of electronic health records (EHR) technology, the Office of the National Coordinator of Health Information Technology anticipates that 50,000 new health information technology jobs will be created within the next five years.
There is ample job growth on the horizon. Below, you will find an exploration of the various educational and experiential pathways available to students and professionals looking to enter the dynamic field of nursing informatics.
What skills make an effective nurse informaticist?
Nurse informaticists should possess strong analytical and critical-thinking skills. Having additional education and experience with information systems and databases is also an important part of the occupation. Some prior knowledge of project management is also advantageous, as it is a similar discipline. Although all these skills can be developed during nursing school and in the field as a registered nurse, having a fundamental understanding in these areas can give you a leg up over the competition as you apply for nursing programs and open positions.
What education is required?
The most favored—and direct—route toward a career as a nurse informaticist is through higher education. Formal academic preparation in nursing informatics begins at the master’s degree level with a Master of Science in Nursing (M.S.N.). There are many graduate programs that offer specialty tracks in informatics, including on-campus, online, and hybrid programs. An informatics specialty track builds the foundational skills essential to nurse informaticists, training nurses to quickly adapt to new technology and advance patient care delivery systems.
Courses may include the practice of nursing informatics, management of data and information, health care information workflow, and project management. Students learn how to interpret, analyze, and use electronic health record technology, as well as ways to provide greater efficiency and effectiveness in health care practices.
In addition to this course work, most graduate programs require a practicum experience wherein students apply their course knowledge in a real-world setting. Upon graduation, the students are prepared in both the technological side and patient side of health care: they implement innovative EHR technology in ways that set the standards for effective patient care.
Do I need an advanced degree to become a nurse informaticist?
Not necessarily. However, it is imperative that you complete an approved Bachelor of Science in Nursing (B.S.N.) program and become a registered nurse. After completing a B.S.N. program, you must complete and pass the National Council Licensure Examination (NCLEX) in order to become registered to practice nursing in your chosen state. Upon graduation, you can find ways to become more integrated with the nursing informatics profession.
For example, try to develop experience in computerized documentation or some other technological health care focus. Nurses interested in informatics often start out as “superusers,” or unit-based support persons. They serve as managers for the main user account for their departments’ IT systems. After a certain amount of time spent with IT systems, some superusers are asked to become members of a nursing informatics team or department. However, since these nurses learn about informatics while on-the-job, not through academic training, it is advised that they read relevant texts and journals and enroll in continuing education courses to enhance their formal knowledge and skills in nursing informatics.
Do nurse informaticists need to be certified?
Whether you gained experience in informatics through formal academic training at the M.S.N. level or through on-the-job training after obtaining a B.S.N., it is advised that you become certified by a nurse credentialing organization such as the American Nurses Credentialing Center (ANCC). This distinction will make you more competitive in the job market. The minimum educational requirement to become certified is a B.S.N.; a diploma or associate degree in nursing will not serve as a sufficient academic qualification to become certified as a nurse informaticist.
Where do nurse informaticists work?
Nurse informaticists are becoming key personnel in every health care setting that employs nurses. They help IT professionals better understand the practice of nursing, just as nurses become more knowledgeable with new IT capabilities affecting their practice. Nurse informaticists can be found in hospitals, long-term care, home health care, schools of nursing, IT companies, health care consulting firms, and government organizations.
How do nurse informaticists stay involved in their industry?
There are several organizations relevant to informatics. Among the top three are the American Medical Informatics Association (AMIA), the Health Information and Management Systems Society (HIMSS), and ANIA-CARING (formerly known as the American Nursing Informatics Association and the Capital Area Roundtable on Informatics in Nursing), which provide education, networking, and information resources for professionals, strengthening the role that informatics plays in health care. Additionally, all three organizations hold annual conferences, and some even host regional events and frequent smaller meetings. At these educational events, nurses learn about new technological developments affecting the health care industry and have the opportunity to network with like-minded professionals from all over the country.
The free scholarly journal, Online Journal of Nursing Informatics (OJNI), is another great resource for nurse informaticists interested in staying informed on new technology, nursing trends, and research affecting their industry.
Is it a good time to become a nurse informaticist?
Expanding roles and technological advances in health care have increased the demand for nurses to be well versed in informatics. In fact, according to the HIMSS 2011 Nursing Informatics Workforce Survey, the number of nurses taking the nurse informaticist certification exam with the ANCC has more than doubled since 2005.
Our complex health care environment requires nurses to possess advanced knowledge and understanding of new technologies to better manage information and facilitate decision making. As a nurse informaticist, you will be trusted to adapt to new challenges and embrace the many opportunities found in the ever-evolving field of health care.
New nursing technology has opened endless opportunities for superior care, says Susan R. Stafford, R.N., B.S.N., M.P.A., M.B.A., Associate Chief Nursing Officer of Nursing Informatics at the Cleveland Clinic Stanley Shalom Zielony Institute for Nursing Excellence. The Zielony Institute oversees the practice and education of more than 11,000 nurses in all aspects of the Cleveland Clinic health system, including inpatient, outpatient, rehabilitation, and home care fields. “From recently introduced innovations to those that are on the horizon, enhanced technology gives nurses the ability to integrate so we can focus on delivering quality, safe, world-class care,” Stafford says.
Nurses have always been information managers at the center of a wheel, according to Patricia Abbott, Ph.D., R.N., associate professor and Co-Director of the World Health Organization/Pan American Health Organization Collaborating Center for Nursing Knowledge, Information Management, and Sharing at The Johns Hopkins University Schools of Nursing and Medicine, and chair of the 11th International Congress on Nursing Informatics in 2012. Everybody touches base with the nurse to get the latest information on a patient, says Abbot. “We’ve always had technology in our lives.”
“Our students come in with every piece of technology known to man hooked on their belt. Sometimes it’s like Jeopardy—we’ve got the answer; now what’s the question?” Abbott says. “We’ve got the technology; now show me how to apply it.” Abbott says the younger generation was raised with technology, impacting the way they communicate and conceptualize. “It’s fundamentally changing the way you think and your belief networks,” she says. “What’s happening is a lot of people are starting to look at this and see they have to adapt or leave.”
As U.S. Secretary of Veterans Affairs General Eric Shinseki once said, “If you dislike change, you’re going to dislike irrelevance even more.”
What follows are some of the top trends in nursing technology today, from the macro-level, government-funded changes to the little gadgets you might soon find in your hand.
Nursing informatics is a growing field that supports nursing processes through technology, including telehealth, home health, ambulatory care, long-term care, education/research, acute care, outpatient settings, software development, and work flow redesign.
“Technology has been growing and work has been done for 40 years, but people didn’t know about informatics education and it was not that widely available,” says Bonnie Westra, Ph.D., R.N., F.A.A.N., associate professor and Co-Director of the International Classification of Nursing Practice Research and Development Center for Nursing Minimum Data Set Knowledge Discovery at the University of Minnesota School of Nursing. She says she’s suddenly seeing informatics classes that previously attracted three people grow into classes of 25. “Now programs are crawling out of the woodwork,” says Westra, also co-chair for the Alliance for Nursing Informatics (ANI).
The Healthcare Information and Management Systems Society (HIMSS) 2011 Nursing Informatics Workforce Survey reported that nurse informaticists play a critical role in the implementation of various clinical applications, including clinical/nursing documentation and clinical information systems, computerized practitioner order entry (CPOE), and electronic health records (EHR). The 2011 data also suggests a substantial increase in salary for nurse informaticists, which is up 17% from 2007.
Kathryn H. Bowles, Ph.D., R.N., F.A.A.N., associate professor of nursing at the University of Pennsylvania School of Nursing, says there are a few programs in the United States for nurses holding a master’s or Ph.D. She added the American Medical Informatics Association (AMIA) is doing a lot of work to promote nursing and medical education in nursing informatics, and the Technology Informatics Guiding Educational Reform (TIGER) Initiative is transforming informatics.
The TIGER Initiative aims to identify information/knowledge management best practices and effective technology to help practicing nurses and nursing students make health care safer, effective, efficient, patient-centered, timely, and equitable. “Nurses are out doing 50%–80% of all care in the globe, and many times they are in the field or in the bush,” Abbott says. “As technologies have gotten smaller, powerful, and more mobile, if we combine a huge workforce with more powerful technologies, we are enabling nurses, birth attendants, and midwives to practice better. When you do that, you improve care to an entire community.”
Telehealth promotes lower-cost health care through mobile communication and video. Laptops, tablets, and smartphones offer video conference capabilities that allow face-to-face visits without travel costs and complications, and provide vital signs and medical history for remote diagnosis and monitoring.
“Telehealth provides specialty services on the turn of a dime without the patient being shipped off to another facility,” Westra says. Telestroke robotics is one example, where practitioners use robotic technology to manage stroke victims in remote areas. Telehealth also is being used for psychiatric consults in prisons, a less expensive and equally effective treatment option.
Abbott worked on a National Institutes of Health–funded study involving implementing telehealth services for minority patients suffering from congestive heart failure. The program placed telehealth monitors in patient homes for remote monitoring, allowing patients to Skype with nurses regarding their health concerns. “Some of my patients are geriatric African American folks with heart failure, and they don’t have transportation, and they might be in the only occupied house in an area of burned-out homes,” Abbott says. Telehealth also can be a lifeline for entire communities, scaling up knowledge levels of community health workers in low-resource areas without a formally trained nurse on site.
“We know there are not enough doctors to go around, and also not enough nurses,” Abbott says. “In reality, when you start looking at the large provider groups that exist around the world, you look at ways you can reach and teach. Many of these folks, both nationally and internationally, cannot travel to the bricks and mortar model of a school to get additional training.”
Gartner Inc., a Connecticut-based information technology research and advisory company, says mobile health, or mHealth, is one of the top 10 consumer mobile applications for 2012. According to the 2009 American Academy of Nurse Practitioners (AANP) Membership Survey, 60% of respondents indicated they used a PDA or smartphone in clinical practice. Applications do not require a large, up-front investment and are simple to download. Health diaries, medication reminders, exercise tips, and applications to track food intake, pain levels, and sleeping habits are helping people monitor their own health.
Cell phones facilitating mHealth are proving to be powerful tools in the Latino and African American communities, particularly with illegal aliens afraid to participate in a formal health care system. Abbott says she’s involved in a movement surrounding texting for health, in which nurses reach out to minority populations with health tips and reminders concerning maternal health, HIV/AIDS, and drug addiction. The National Healthy Mothers, Healthy Babies Coalition text4baby’s Hispanic Outreach program, for example, supports mothers by providing 140 characters of health information and resources to a pregnant woman’s cell phone.
“They don’t have home phones—a lot don’t even have a home—but they have a cell phone,” Abbott says. “We are getting messages to them about appointments and medication refills. We let them text in questions or problems they have because they won’t come to the clinic. It’s a way to reach people through something so many people have these days.”
Over the past two years, the University of San Diego’s Hahn School of Nursing and Health Science has required an iPod Touch for incoming RN pre-licensure students. Instead of carrying multiple books to clinical sites, the iTouch provides clinical reference tools and pharmacology manuals with the tap of a finger.
“They find that having those clinical reference tools available to them very quickly while seeing patients is easier than having to look something up in a book,” says Karen Macauley, D.N.P., F.N.P.-B.C., Director of the Simulation and Standardized Patient Nursing Laboratory and clinical associate professor. The school developed an nTrack application for the iTouch with Skyscape Medical to help students document clinical experiences in hospital sites. Once they graduate, students can compile the data into an e-portfolio for potential employers.
“We decided to require it because it forces students to really embrace technology,” Macauley says. “Once they get into the hospital sites, you’re really looking at the best evidence-based practice and how to apply it to their clinical practice. Without having something at their fingertips to look at right away, they are at a loss.”
Another mobile tool growing in popularity is the electronic tablet. “The whole iPad application, how it will affect patient teaching and patient interaction, will be huge,” Westra says.
Abbott says mobile technology is especially important for nurses, who are incredibly mobile themselves. “We are running from bed to bed to bed, from unit to unit to unit, from clinic to clinic to clinic, from house to house to house,” Abbott says. “Records never seem to go with us, which has caused a lot of errors, redundancy, and wasted effort. Now when you put mobile technology in a nurse’s hand or in her pocket, it allows her to do her job, help her patient, right at the patient’s side instead of running back to the nurses’ station and grabbing a chart or looking on a computer.”
Mobile technology can also be a lifeline for remote nurses in “frontier environments” with less than seven people per square mile, Abbott says. A mini clinic with connectivity enables nurses to provide more services, find the help they need when they need it, and quickly connect through Skype with a specialist to find an answer.
Electronic health records
The federal government set aside $27 billion for an incentive program, as part of the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, to encourage hospitals and providers to adopt electronic health records systems (EHR). Policymakers continue to work toward establishing a Nationwide Healthcare Information Network to standardize EHRs, which would provide a seamless exchange of data among physicians, hospitals, laboratories, pharmacies, and other health care organizations.
At the Cleveland Clinic, electronic documentation includes computerized provider order entry (CPOE), nursing care documentation, medication dispensing and administration, and results reporting. The technology improves access to patient information at the point of care and enhances the ability to benchmark, monitor, audit, and report quality measures while offering quality data to support nursing-led research.
The Cleveland Clinic has been implementing EHR technology in stages over the past six years. The most recent implementation was the ICU nursing documentation with device integration. With this implementation, vital signs go directly from the cardiac monitor at the bedside into the EHR.
At the University of Pennsylvania, Bowles’ is examining decision making supported by information technology to improve care for older adults. Her ongoing study, funded by the National Institute of Nursing Research, focuses on the development of decision support for hospital discharge referral decisions. Using an electronic record, patients are asked a series of questions, ranging from their ability to walk to whether they have a caregiver available at home. Through statistical analysis of the answers and information already contained in the EHR, clinicians can make an informed decision regarding a patient’s needs. “Decision support, in general, is a new phenomenon,” Bowles says. “As we start using electronic records, more and more patient data will be available electronically and more developed to remind clinicians of the right thing to do.”
In May 2010, the Office of the National Coordinator for Health Information Technology (ONC) estimated an additional 50,000 health information technology workers will be needed over the next five years to satisfy meaningful use criteria. Abbott is the principal investigator on a HITECH grant to create a six-month, non-degree program for the unemployed to be qualified to build, upgrade, and maintain the implementation of health information technology programs, including EHR systems, at hospitals and clinics.
Centralized monitoring of intensive care units in remote areas is the health care delivery of the future. FHN Memorial Hospital in Freeport, Illinois, is collaborating with the University of Wisconsin e-Care team of intensivist physicians and critical care nurses in Madison, Wisconsin, on eICU care. Small microphones and cameras in each ICU patient room provide a constant link to the e-Care team at UW Hospital. Patient vital information, including heart rate, blood pressure, medications, and test results, are monitored in the FHN ICU and shared in real time with the e-Care team.
If a patient’s condition suddenly changes, the FHN physician and nurses can touch a button and activate a two-way visual and audio link for an immediate consultation with e-Care specialists.
The Mayo Clinic health guide used to be the go-to guide at everyone’s bedside. But the introduction of social media has both patients and caregivers logging onto sites like WebMD and Patients Like Me for health information, advice, and forums to share experiences.
A 2008 Edelman Health Engagement Barometer found the Internet has become the “new second opinion.” Patients with a diagnosis are barely out of the exam room door before typing status updates on their smartphones and searching for support groups via social media.
Many nurses have taken to Facebook and Twitter to promote accurate medical information to help the general population make healthy lifestyle choices, as well as to promote their profession.
Virtual reality simulations
Imagine being in the operating room and making a devastating decision that risks the life of a patient. Now imagine being given a do-over and figuring out the best way to proceed.
Such is the scenario in Second Life, a 3D virtual world becoming popular in nursing education. Westra says universities are buying islands and creating communities in which students develop avatars and run through different scenarios to see the consequences of their decisions. She’s even seen a virtual theater set up where students in their avatar personas can “attend” an author interview on a virtual theater stage. “It’s a chance to have people practice skills and make decisions and study consequences and not kill patients,” Westra says.
Radio frequency identification
Radio frequency identification (RFID) has been traditionally used for tagging equipment, but it’s starting to replace bar coding for patient identification. Westra says she is seeing RFID in nurseries to prevent kidnappings and tagging breast milk to ensure it goes to the right baby. Alzheimer’s units are using it as well to monitor patients prone to wandering.
Experimentally, it also is showing up in operating room equipment. A wand with an RFID reader is replacing X-rays to pick up any sponges or instruments left in patients before they are sewn up. Another experimental use is with intubating patients to check placement rather than using X-ray.
Judy Murphy, R.N., F.A.C.M.I., F.H.I.M.S.S., Vice President of Information Technology for Aurora Health Care in Wisconsin and co-chair of ANI, says RFID is a lot like Global Positioning System (GPS), but added there isn’t a lot of penetration of the technology at this point due to the expense. But it may be something more institutions turn to down the road.
Almost every IV these days is connected to a smart pump integrated with a computer that handles drug infusion calculating. Computerized infusion pumps with dose error reduction systems were developed to alert nurses if a programmed fusion dosage exceeds the hospital’s best practice guidelines.
Some organizations are integrating the pumps with EHRs, allowing physicians to enter information electronically and pass it along via computer to the pump, Murphy says.
Cleveland Clinic is rolling out new IV digital smart pumps designed specifically for high-volume medication infusions. This imitation will be completed and fully implemented in 2012. The Clinic will also be using new smart syringe pumps and smart pain pumps.
Wireless voice-over-IP phones
Through wireless voice-over-IP phones—voice carried over Internet protocol networks—nurses can be more easily reached when they are caring for patients in various rooms throughout a unit. This technology eliminates the need for unit secretaries to make announcements over a loudspeaker. The phone, according to the Cleveland Clinic, helps with noise control, improves efficiency in communication between staff and patients, and streamlines processes.
Electronic patient tracking boards
Similar to wireless voice-over-IP phones, electronic patient tracking boards facilitate ease of communication and coordination of patient care with a quick status display of current activity on a unit. A combination of wireless communication, barcode, and Internet technology, electronic patient tracking boards are replacing white boards in many settings.
Cleveland Clinic first used patient tracking systems in the emergency department and operating room areas. In 2010 the hospital system rolled out a new patient tracking board system to all of the main campus inpatient units.
Electronic patient tracking boards, according to Stafford, decrease the need for phone calls or meetings to find information about patients as they are coming and going. The systems give nursing units a one-stop shop for critical information on patients. A nurse, for example, can easily see if patients are at risk of falling or need extra precautions in isolation.
Point-of-care technology offers access to patient records, labs, medication information, and even second opinions, all from the patient’s bedside. A wireless network and computer allow nurses to access and receive a wide array of information without leaving the patient’s side.
Wireless point-of-care glucometers, for example, submit blood glucose results to the electronic medical record as soon as the clinician checks a patient’s blood sugar level. This technology offers completed reporting and documentation immediately upon the docking of the wireless device into its cradle. The information transaction can also be sent into the electronic medical record.
Workstations on wheels are also used for bedside and point-of-care documentation and information retrieval. Cleveland Clinic has one workstation on wheels for each caregiver working a shift on a nursing unit, providing instant access to a patient’s medical records at the bedside. The Cleveland Clinic finds the system helps nurses confirm all patient information is accurate, including medical history and medications, and improves patient safety for medication administration.
Cleveland Clinic is also rolling out a new Web-based self-scheduling platform for all caregivers. The system offers nursing caregivers convenience and flexibility through the ability to select shifts based on competencies. Nurse managers can now spend less time filling shifts and making phone calls. This technology is relatively new and still uncommon among most health systems, but it is a growing trend and anticipated to be coming to more health systems over the next few years.
“We look at the opportunities that are possible because of technological advancements,” Stafford says. “The common thread is that many of these advancements were developed to help nurses give the patient a positive experience. An enhanced patient experience is very valuable, creating a healing environment that contributes to overall positive patient outcomes.”
While all of this technology is meant to create efficiencies, improve outcomes, and ease the workload, Macauley says it all comes down to how medical professionals communicate with each other. The future of medical technology lies within professionals and students who will embrace it and create a system that lowers health care costs by reducing redundancy.
“Those people who leave the program in technology are thinking out of the box on using mobile devices and mobile technology and looking at ways of being innovative in using technology we’re all exposed to,” Macauley says.