-
Aims of the National Quality Strategy (NQS):
–Better care
–Affordable care
–Healthy populations and communities
-
Role of HIT with the Patient Protection and Affordable Care Act (PPACA):
–Ensures transparency
–Increases efficiency
–Engages consumers
–Provides data to effectively manage care cost and quality
-
–Two sets of regulatory requirements to meet the meaningful use (MU) of electronic health records (EHRs)
Standard one defines the MU of EHRs
Standard two specifies how EHRs are developed and certified to meet MU criteria
-
–implemented an EHR incentive program to encourage providers and hospitals to adopt and implement certified technology
Centers for Medicare & Medicaid Services (CMS):
-
ACA Established metrics to measure success, improve quality, and create efficiency
Five performance domains:
–Patient/caregiver experience
–Care coordination
–Patient safety
–Preventive health
–At-risk population/frail elderly health
-
Three phases of meaningful use (MU)
Phase 1
–Implement a certified EHRs meeting basic requirements
-
Three phases of meaningful use (MU) Phase 2
–Consumer engagement and increases the capture and exchange of data
-
Three phases of meaningful use (MU) Phase 3
Capture and exchange more structured data, support population health management, measure outcomes, and maintain patient-centered care
-
Programs reward health care providers for adopting, implementing, and meaningfully utilizing a certified EHR
EHR Incentive Program
-
Nurse practitioners are used within which incentives program
MEDICAID
-
EHR vendors must develop products
according to specific criteria in order to be certified
-
EHR Incentive Program: Providers must adhere to
specific criteria to meet meaningful use
-
EHR Incentives program: Penalties will occur for providers who
fail to adopt EHRs or fail to meet meaningful use
-
Cornerstone of meaningful use is
patient engagement
-
Components for reformation of health care delivery:
–Technology for lowering cost and improving safety
–Assurance of patient safety and quality in a technology-driven environment
–Nursing’s diverse role as HIT advances
-
Patient Safety and Quality in Technology-Driven Environments: Rapid deployment of technology in health care environment can
inadvertently cause patient harm
-
what should be used as a guide to implement safe HIT systems for better care
The Department of Health and Human Service’s book
-
Informatics nurses should be involved in
development of EHR products and integration of the EHR with the flow of direct patient care
-
who will be involved with primary care to patients gained from the expansion of affordable health care
Advanced practice nurses
-
Nursing Education for Healthcare Informatics Model framework is targeting advanced practice care delivery is composed of what 3 main content domains
–Point-of-care technology
–Data management and analytics
–Patient safety/quality and population health
-
Relates to the first content domain (NEHI)
Reflects applied information management tools to transform data and information into improved health care delivery
Data Management and Analytics
-
Relates to the second content domain of the NEHI framework
Reflects quality improvement tools applied to individuals, as well as to public health initiatives
Patient Safety/Quality and Population Health
-
Organized according to the NEHI framework
Includes a final section on new and emerging technologies
Text Organization
-
new “buzzword”
Interprofessional team:
-
Health care and social assistance employment positions are INC or DEC in US
INC
-
Work involves the identification, definition, management, and communication of data, information, knowledge, and wisdom
Informatics Nurse Specialist
-
Support colleagues, health care consumers, patients, the interprofessional health care team, and other stakeholders
Serves as the translator between clinical and information technology personnel and sectors
Serve as translators and liaisons for health care consumers and patients
Informatics Nurse Specialist
-
ANA Identified NI as a nursing specialty in
1992
-
ANA Published the specialty’s first scope of practice statement in
1994
-
ANA Published NI standards of practice in
1995
-
–The last publication, Nursing: Scope and Standards of Practice, Second Edition includes:
Competencies describing the integration of knowledge, skills, abilities, and judgment
-
NURSING INFORMATICS Educational Standards SUPPORTED BY:
–American Association of Colleges of Nursing (AACN)
–National League for Nursing (NLN)
–Quality and Safety Education for Nurses (QSEN) project
–Technology Informatics Guiding Education Reform (TIGER) initiative
–Nursing Education for Healthcare Informatics (NEHI) model
-
Initiatives that support interprofessional teamwork in healthcare include:
–Interprofessional Education Collaborative (IPEC®)
–World Health Organization (WHO)
–Institute of Medicine (IOM)
–MIT
-
–Limits the impact of interprofessional teams by language that focuses on physician reimbursement through the Medicare/Medicaid incentive structure
Meaningful use and the HITECH Act:
-
Stages of theory development:
–serve phenomenon
–Explain the phenomenon
–Model developed
–Model tested and refined
-
LEVEL OF THEORY
–Used to test propositions within the theory
–Aid in the building of enlightenment
–Used to narratively describe complex processes
Middle range/Mid-Range:
-
–Appreciates the importance of humans and technology
–All things have the potential to interact and generate action
Socio-technical systems
-
New HIT changes the
–present social system
-
Various existing infrastructures mediate
–HIT-in-Use
-
Preexisting social systems facilitate
–reinterpretation of HIT-in-Use
-
HIT-in-Use influences and changes
–pre-established social systems
-
HIT-in-Use and social system interactions affect
overall HIT redesign
-
No single definition or value accepted
Considered a dynamic non-static construct
Can be approaches or tools
QUALITY IMPROVEMENT
-
Quality Improvement Approaches:
–Plan-Do-Study-Act (PDSA) model
–Donabedian approach: structure, process, outcome
-
Socio-Technical Perspectives
- Activity theory
- Complexity theory
- Socio-technical Systems Theory
- Actor-Network Theory (ANT):
-
–The primary socio-technical approach for QI activities
–All things in an environment are individual actors
–Actors are dynamic entities able to change the context around them
Actor-Network Theory (ANT):
-
–Human or non-human entities that perform action
Actor:
-
-
–Process of stimulating action
Translation
-
–Stabilized action network
Black Box network:
-
Can be self-limiting
Realize humans and technology are different with corresponding different responses
Focus is on how actors interact with each other and the environment
Use of ANT
-
EHR penetration rate has increased since 2010 with the implementation of the
HITECH Act
-
HIT adoption for adoption’s sake was never
the goal
-
HITECH Act included funding for six major initiatives:
–EHR Incentive Program
–EHR Certification Program
–State HIE Program
–Regional Extension Center (REC) Program
–Beacon Community Program
- –Workforce Development:
- Community College Curriculum
- University Based Training
–Strategic Health IT Advanced Research Projects (SHARP)
-
Meaningful use: defined by the
EHR incentive program
-
Office of the National Coordinator for Health Information Technology (ONC): ran out of
funds for the programs
-
EHR Incentive Program: the framework for
promoting EHR adoption
-
Creation of Health Information Exchanges (HIE)
Three designs:
–Central data repository model
–Federated model using local repositories
–Hybrid model with elements of both types
-
Changes occurred 2011 where EHRs to become certified must be capable of
Nationwide Health Information Network Direct (NwHIN Direct) or Direct
-
Designed to demonstrate clinical quality improvements possible in communities with more robust EHR adoption
Beacon Programs
-
BEACON PROGRAMS Three part aim of the communities:
–Improve population health
–Test innovative approaches
–Build health IT infrastructure
-
Knowledge gained from the Beacon programs help design
learning guides
-
BEACON Guides provide information about
community challenges with HIT implementation and how to overcome obstacles
-
RECS Direct funding tied to specific operational milestones:
–Enrollment with the REC
–Go-live on an EHR
–Provider achieved Meaningful Use
-
Awarded to Universities or research institutions
Designed to support research to address critical areas of EHR functionality:
Research and Technology Development SHARP Grants
-
Sharp S:
–Privacy and security
-
Sharp C:
–Physician cognition and decision-making
-
Sharp A:
–Health application design
-
Sharp n:
–Use of EHR data
-
Grant awarded to support medical devices
MD Sharp:
-
Four grants for workforce development:
–Community colleges
–University-based training program
–Northern Virginia Community College to develop a Competency Exam
-
Each program designed to compensate for different challenges which could derail or slow broad adoption efforts
Interlocking Programs
-
The three most critical programs: INTERLOCKING
–EHR incentive program
–REC program
–State HIE program
-
Shared decision making: process of integrating patients’ goals and concerns with medical evidence to achieve high-quality medical decisions
Patient Engagement
-
Providing patients with evidence: (PATIENT ENGAGEMENT)
–Impacts choices
–Better understanding of treatment options
–Better understanding of screening recommendations
–Higher satisfaction
–Choices resulting in lower cost
–Better health outcomes
-
Patient engagement a part of Stage 2 of the
HITECH Act
-
National Quality Strategy and National Prevention Strategy support
patient involvement in health care
-
Approaches to empower people:
–Provide with tools and information to make healthy choices
–Promote positive social interactions and support healthy decision making
–Engage and empower people and communities to plan and implement prevention policies and programs.
–Improve education and employment opportunities
-
Approaches to empower people in health care:
–Confirm understanding of health promotion and disease prevention
–Involve consumers in planning, developing, implementing, disseminating, and evaluating health and safety information
–Use alternative communication methods and tools to support more traditional written and oral communication.
–Refer to adult education and English-language instruction programs enhance understanding of health promotion and disease prevention messages
-
Patient Engagement Approaches
- Patient Engagement in Health and Health Care Framework
- Health Information Management Systems Society (HIMSS) Model
- Ensure basic needs are met
- Address health literacy
- DNA analyses
- Web sites to share health information
-
Provider Approaches/ Models/Competencies (APPROACHES)
–Interprofessional education/collaborative
–Support patient activation
-
Provider Approaches/ Models/Competencies (MODELS)
–Family Health Model
–Betty Neuman Model of health
–Family systems theory (FST)
–Patient- and family-centered care
-
Provider Approaches/ Models/Competencies (COMPETENCIES)
–Dietetics Workforce Demand Study
-
Create a learning health care system with the characteristics of: 4 THINGS
- SCIENCE & INFORMATICS
- PATIENT-CLINICIAN PARTNERSHIPS
- INCENTIVES
- CULTURES
-
Create a learning health care system with the characteristics of:
–Science and informatics:
- Real-time access to knowledge
- Digital capture of the care experience
-
Create a learning health care system with the characteristics of: Incentives
- Incentives aligned for value
- Full transparency
-
Create a learning health care system with the characteristics of: Culture
- Leadership-instilled culture of learning
- Supportive system competencies
-
computing power will double every 2 years
Moore’s Law
-
standard unit of measure in computers
BIT
-
basic whole unit of information used to form the written codes assigned to retrievable computer data archives known as “the memory”
Byte
-
–Motherboard, CPU, RAM, power supply, video card, HDD, SSD, optical drive and card reader
Hardware
-
–The field of study focused on understanding human elements of systems, where systems may be defined as software, medical devices, computer technology, and organizations
Human factors
-
processing speeds, memory requirements, interface equipment, operating system requirements, and software to run the clinical software
Hardware
-
Programming language classifications:
5 generations
-
system, application, programming tools
Software
-
EHR Software Selection
- Specific to an organization
- Cost and quality decision
- Based on the needs of the organization and the end users
- Selected after completing the 12 essential steps prior to the purchase of an EHR
-
company provides software on a server that can be accessed from the Internet
Cloud computing
-
Some elements of documentation computerized as far back as the
1960S
-
De-Centralized Hospital Computer Program used in the Department of Veteran Affairs in the
1970S
-
is the standard the exchange, integration, sharing, and retrieval of health information
Health Level Seven International (HL7)
-
Lab and patient registration were computerized WHEN?
FIRST
-
Impact of EHRs:
–Improve quality of patient care
–Increase patient participation in their care
–Improve accuracy of diagnoses and health outcomes
–Improve care coordination
–Increase efficiencies and provide cost savings
-
Automatically checks for problems with new medication prescriptions and alerts to potential conflicts
Coordinates care
Reduce operation costs
Cost avoidance of care related to delays in care or medical errors
Features of EHRs Supporting Quality and Safety
-
Three ways to make an EHR decision:
–Single-vendor
–Best-of-breed
–Combination of both
-
provide a common language and set of expectations enabling interoperability between systems and/or devices
Standards
-
Steps Before Implementation OF EHR
- Request for proposal (RFP)
- Live or virtual demos of the system
- Site visits to see the system in use in other organizations
- Budgetary review
-
System Development Life Cycle (SDLC) approach PHASES
–Initiation
–Analysis
–Design
–Implementation
–Support and maintenance
-
Workflow Analysis
Advantages:
–Staff using workflows should be involved in workflow development
–Increases standardization and reinforces policies and procedures to follow the new workflows
–Decreases variability while increasing efficiencies
-
“Use” cases
Follows Actor-Network-Theory
“Use” cases created for every workflow
Build Process
-
Informatics nurse’s role:
–Understands clinical aspects of the effects of the EHR on clinicians and patients
–Assesses and monitors the impact on patient care and clinician’s experience
–Understands workflows and system functionality
–Positioned to solve problems, establish best-practices, and adapt policies and procedures to support workflows
-
Superusers role:
–First-line resources
–Pivotal, point-person during the go-live
-
How well the EHR is used and embraced as part of routine activities
Adoption
-
Levels of adoption:
–Innovators
–Early adopters
–Early and late majority
–Laggards
-
Evaluation
- Surveys
- Questionnaires
- Focus groups
- Ethnographic observational methods
- Staff interviews
- Workflow analysis pre and post
-
Point-of-Care
- Medication administration: Barcode
- Diagnostic testing: Glucose
- Issue surrounding FDA approval because of direct use with patients
-
Ability to pull in data from source systems and integrate the data from the devices into the EHR
Can be expensive
Integration
-
Issues with legacy systems
–Functionality
–Efficiency
–Ease of use
–Cost
–Return on investment
-
Challenges With Integration
- Wi Fi access unstable or non-existent
- Data reliability and validity
- Addressing rules and alerts
- Over-reliance on technology
- Associating devices with patients
- Acting on results
-
Change management:
–Maintenance requests
–Regulatory changes
–Patient safety changes
–User requests
-
SDLC Is a process
(Must align the needs of the user with the deliverable)
Primary goal IS?
Meet or exceed customer expectations
-
SDLC Phases:
–Planning
–Analysis
–Design
–Implementation and testing
–Evaluation, maintenance and support
-
SDLC Most important tool IN PLANNING
customer site visit
-
SDLC PLANNING Outputs from this phase:
–Product concept document
–Feasibility assessment
–Product scope document
-
Role of the informatics nurse: SDLC PLANNING
create a project charter
-
Parts of the charter:
–Project Champion
–Dates
–Problem or Opportunity Statement
–Objective
–Key stakeholders
–Scope
–Target Benefits
–Budget
-
SDLC ANAYLSIS Key objectives:
–Outline end-user requirements
–Data flows, processes and workflows
–Outline detailed system specifications
–Conduct market analysis
-
“tools of the trade” for the analysis
Data flow diagrams:
-
Outputs from this phase (SDLC ANALYSIS)
–Report to stakeholders
–Interviews
–End-user requirements
-
Design strategies:
–Waterfall method
–Rapid application development (RAD)
–Agile techniques
–Object-oriented
-
Implementation, Evaluation, and Support Phase
Focus on:
–End-user acceptance
–System performance
–Ongoing maintenance and support plan
-
Implementation, Evaluation, and Support Phase Tools
–Strategy plans for go-live
–Data plans for conversion of old data into the system
–Command center
–User-support center
-
Go-live phase
Implementation, Evaluation, and Support Phase
-
Implementation, Evaluation, and Support Phase
Pilot testing approaches:
–Phased or incremental
–Big bang
–Parallel systems
-
System Evaluation METRICS
–System stability
–Strategic plan adherence
–Cost avoidance
–Risk reduction
–Long-range goals
–Improvements in quality, safety, and population health improvements
-
Types of workflow diagrams:
–Simple linear
–Swim lane or cross functional
–Spaghetti diagram
–Value Stream Map
–SIPOC
-
Used to:
–Identify areas of concern
–Opportunities to improve a process
workflow diagrams:
-
Steps to Workflow Redesign
- Identify process to be mapped
- Identify and involve individuals who perform the tasks
- Map the current state
- Assess current state workflow
- Identify opportunities for improvement
- Identify data to measure redesign outcomes
- Map future “to be” process
- Test new workflows and processes
- Train on new workflows and processes
- Go live with the new workflows and processes
- Analyze data and refine workflows and processes
-
End-user satisfaction:
–Focus groups
–Surveys
-
Return on investment (ROI):
–Technical expenses for software, hardware, networking
–Man hour costs of labor for technical, clinical, and clinician time and effort
-
Consider rip and replace:
–Vendor goes out of business
–New vendor has a superior product
–A serious problem with the EHR that fails to accommodate new technologies
–Business model shifts and changes traumatically
-
Promotes EHR-enabled improvement in patient outcomes through sharing case studies and lessons learned on implementation strategies, workflow design, best practice adherence, and patient engagement.
–“The Davies award”:
-
Measures of Success
- USEFUL
- Feasible
- Ethical
- Accurate
-
–A fundamental concept under the HITECH Act and
–Vital for establishing meaningful use (MU)
Exchange of health information:
-
Models for HIE
Centralized:
–Data sharing protected through data sharing agreements
–Data are stored for use by organizations through data repositories
-
Models for HIE Decentralized
–Federated model
–Maintains control of the source data at the originating organization
-
Models for HIE
Technical exchange:
–Direct messaging
–Query-based transactions
-
–Identify unique patients within a delivery system maintaining disparate information systems or across institutions within regions
MPI purpose:
-
–Method of creating a single record from two or more records that belong to the same person
Record linkage
-
Value of HIE With EHR
- Fewer repeat procedures
- Reduced medication errors
- Specific results from studies
-
NwHIN standards: Three areas:
- Content structure specifications
- Transport and security specifications
- Vocabulary and code set specifications
-
PHIN standards:
–Cascading alert checklist
-
Standards Development
Four basic methods:
–Ad hoc
–De facto
–Government-mandated
–Consensus
-
Standards Development Groups
–Vocabulary
–Non-vocabulary
-
Common Data Standards
- Functional Specifications of EHRs
- Messaging
- Clinical documentation standards
- Medical imaging and communication
- Code sets, vocabularies and values
- ICD and CPT code Sets
- LOINC and SNOMED-CT
-
Gaps in Standards
- Data quality
- Advanced directives
-
Process of linking interoperable components from one system to another
Involves mapping “one component to another”
An essential component for interoperability
Positive and negative consequences
Data Mapping
-
Types of map relationships:
–One to one
–One to many
–No match
-
Data Mapping determined by the distribution of the map relationships for a given map
Equivalence
-
Desired Characteristics for Controlled Medical Vocabularies
- Content
- Concept orientation
- Concept permanence
- Non-semantic concept identifier
- Polyhierarchy
- Formal definitions
- Rejection of not elsewhere classified
- Recognized redundancy
- Multiple granularities
- Multiple consistent viewsGraceful evolution
-
Evidence-based analysis of the health-related strengths, weaknesses, opportunities, and threats for a specified community
Community Health Assessment
-
Community Health Assessment Take into account input from
persons who represent the broad interests of the community served by the hospital facility
-
Community Health Assessment
CDC Voluntary Accreditation Program:Core functions
- Assessment
- Policy development
- Assurance
-
Most effective assessments are grounded in
collective impact
-
Function as a tool to rebuild communities
Assessment Process
-
Assessment Process
Data analytic strategies:
–Compile secondary data
–Inpatient utilization patterns
–Primary data collection
–New data sources
-
Assessment Process
Variables:
–Population density
–Economics
–Birth and birth-related information
–Mortality and morbidity
-Access to primary care
-
Assessment Process
- Analyze the data
- Triangulate the data
- Set priorities: Focuses on areas of most concern to the residents
-
Intervention and Evaluation Monitoring progress for actions step done how often
quarterly
|
|
