In honor of National Case Management Week,
which takes place October 9th
, we are featuring a stellar Nurse On the Move
, Ann Marie Marks RN, BSN, CCM. Markshas over 36 years of nursing experience. She started in the critical care field and eventually segued into case management at a time when this field was being developed.
Marks helped pave the way for the role of the case manager, including creating content for the first Certified Case Manager (CCM) exam in 1990. She’s helped define what case management entails and continues to serve as an advocate for patients by coordinating care across a large, interdisciplinary health care system.
Today, she serves as an RN case manager consultant and speaker; she presents at the Thomas Jefferson College of Health Population Health Academy, and was the #1 ranked speaker at NAHQ’s 2016 National Quality Summit. She recently served as the Director of Care Coordination at the Delaware Valley Accountable Care Organization where she continues to consult on post-acute services. She was previously Director of Commercial Case Management for Humana, Inc., in Louisville, Ky., and as the National Director of Integrated Care Management for Aetna’s Medicaid division. In 1999, Marks was appointed by the governor of Kentucky to serve as Deputy Secretary of Health, with oversight of Commonwealth’s Primary Care Case Management
Program (KenPAC), and programs within the Department of Medicaid Services, CCSHCN, and Office of Aging.
I was fortunate enough to sit down with Marks in our Philadelphia office to discuss what case management is, what it was, and how it’s evolved, including why it’s so important in today’s world of health care.
Read on to discover the vital role that case managers play and for more case management news:
- Subscribe to Professional Case Management , the Official journal of the Case Management Society of America (CMSA). Marks is a CMSA member and a long-time subscriber to the journal and says, “Over the years, this journal has been the source for evidenced-based studies and peer-reviewed literature for case management. It’s the most often cited and is often a source of reading materials for classes on case management. For me, this journal is one of my go-to spots when I’m attesting to the value of case management or saying a program hasn’t proved valuable.”
CMSA Core Curriculum for Case Management
- Check out these books on case management from Wolters Kluwer.
, COLLABORATE® for Professional Case Management
, Case Management
Q: You’ve been a registered nurse for nearly 40 years and specialized in critical care. What made you decide to become a nurse?
When I was 15 my father was in a horrible auto accident. He was taken to a larger city hospital about 70 miles from our small town. His jaw was wired and he had a chest tube, a feeding tube, and many injuries. He could not be left alone, and my mother needed to return to her position as a teacher. Somehow I was nominated to “stay” with him. I slept on a cot in his room and within a day the nurses and doctors started teaching me to care for him. I learned so well that they allowed me to take him home three weeks earlier than anticipated! Three years later, I was awarded a college scholarship to a college that had a Bachelor's in Nursing and knew I wanted that. But having the experience of living in a hospital for eight weeks and caring for a complex patient, my dad, certainly influenced my choice to be a nurse. It was the confidence those nurses instilled in a teenage girl.
Q: How did you enter into the case management field?
It seemed like years before what I did was called case management. When I entered in the early 1980’s, we were referred to as rehabilitation nurses. It was my encounter of a “rehab nurse” when I was working in ICU that inspired me to explore the field. A nurse arrived in our hospital to discuss a patient who had been in a catastrophic industrial accident. She was very business-like and wore a suit! I found it intriguing that she was a nurse, not providing direct medical care (treatments, medications, etc.,) but was coordinating the care. I came to learn that she was working for a company that provided services to large self-insured employers and insurance carriers. Eventually, I was able to get my foot in the door there. The president, Mary Gambosh, hired me part-time, and challenged me with expanding her business in Kentucky.
But more importantly she trained me about the principles of good case management, and shared everything she knew. Mary assigned me to a large account in the coal fields of eastern Kentucky. That was the beginning of a great career in case management and the expansion of nursing for me and a mentorship under one of the legends in this field, Mary Gambosh, RN.
Q: Can you define what a case manager is and speak to why the name, “case manager,” has changed over time from patient navigators to care coordinators, etc.?
I think the word “case” was always there because the insurance companies would “refer you a case;” I first started to hear the term “case manager” in various states’ Departments of Insurance. As long as I have known about case management, I have associated it with advocacy, care coordination, and resource management. Even when I entered the field as a ‘rehab nurse,’ I knew that the profession of case manager was evolving, and there was a need to distinguish the education and experience of the professional who did this work. In the late 1980’s, talk started to ensue among the rehabilitation nurses, the certifying agencies, and other professions with great debate about who would qualify to sit for an exam to be a ‘case manager.’ Simultaneously to this, we started to see case manager roles expand inside the hospitals, among payers, and self-insured employers themselves. Components of utilization management, hospital bill auditing, and care coordination became requests of those in this field. I have seen the new titles of care coordinators and navigators, and I am pleased when I see the job descriptions that often state, “CCM preferred.” The certification attests that you meet a certain competency and experience level to sit for the exam. We do help patients and families navigate complex systems. We do coordinate care. Case management is about making things happen!
Q: How are case managers patient advocates? What is vital about this role in the health care system?
In addition to their clinical experience, the case managers have training in the benefit systems and reimbursement systems that pay for the services. Helping patients access their benefits and manage those benefits effectively is often critical to the outcome. Advocating for quality care, access to care, and even evidence-based care, is part of the advocacy. Sometimes it’s as simple as getting people involved in the patient’s care to listen—to take a pause and think about what the patient is trying to say or wants. In a world that is stressing value-based care and quality performance measures, the case manager role becomes more vital. We are vital to driving quality health care, helping manage benefits at the right place, right time, etc., and ultimately to the cost management of large populations.
Q: Can you describe an important case you’ve worked on?
One that always stands out in my mind was a victim of a mass shooting known as the Standard Gravure Shooting in Louisville, Ky., in 1989. It’s important to me because gun violence and violence in the work place has become a weekly headline. But this event drew national publicity. Within hours of the shooting, I was being called to be the case manager for some of the victims. One was a gentleman who had worked in the plant over 40 years. This wasn’t just a patient with serious physical wounds, but one with emotional trauma. I remained a part of his case until the day he returned to work, which was his personal goal. I followed him the first year in his new job. But this patient, this case, changed my awareness of the importance of integrating physical and behavioral health into care planning.
Q: What is the biggest challenge related to case management?
Establishing trust with patients. Today we talk about “patient experience” and “patient engagement” and this applies to case managers as well. Many patients or families initially see you as the person who is coming to take something away. It takes skill to help a patient with complex issues to understand that you are there to assess the situation and can actually help. There are also challenges in health reform itself and the demand for quality case managers.
Q: I understand you helped write t sample test questions to become a certified case manager in the 1980’s. How has this specialty evolved since then?
Back when case management started, it was very episodic. Up until the early 1990’s, you would take one case, then another, and we thought that receiving a case referral six months after a diagnosis or three months after an injury was “early.” It used to be based on the idea that something had to have already happened. Now, I’m looking out across the population with predictive analytics information on a subset of that people in a community and trying to identify where I could best place a case manager.
An additional change is the growing numbers of certified case managers. The recognition of case managers in the continuum of health care has been part of the evolution. They are valued as key members of the team, in whatever setting. Case managers have started to be identified as part of the preventive services, not just a referral after a catastrophic event.
Q: Why should nurses in other practice areas pay attention to National Case Management Week and what are some ways nurses can celebrate?
National Case Management Week, like other specialty recognition weeks, affords an opportunity to learn about nurses and other professionals who are part of an integrated care team. Gaining insight into the training, the various job roles, and what a case manager can “make happen” could help other nurses collaborate with this key person on the team. It might even help nurses who are interested in the specialty of case management find an open door.
Q: What do you see for the future of nurses and case managers?
I see that the role of nurses in general has really come back to that primary care model. We want to coordinate end-to-end care for the patient, and I think the future holds more case managers taking the lead coordinating for the patient across the entire continuum of care. I see unlimited possibilities, but I certainly see an increased demand not just for nurses, but for case managers. Technology will also continue to play a big role. The skill sets have changed and over the years I’ve hired 2,000 case managers in a variety of settings, and I can tell you that the skill sets to do this work require so much knowledge about the software for the documentation and for the reporting. Plus, many of our case managers are virtual, so the settings will continue to change. A person needs to survive in a virtual workforce.
Posted: 9/23/2016 9:47:00 AM
| with 0 comments
, Nurse On the Move
Last month, I had the pleasure of collaborating with Michelle Berreth RN, CRNI®, CPP, a Nurse Educator for the Infusion Nurses Society, on a podcast discussing My Nursing Care Plan
. It’s always so interesting to speak with other nurses about their career paths and to bounce ideas around together. After breaking down the components of the care plan – Meeting My Professional Requirements
, Being a Lifelong Learner in Nursing
, and Maintaining Work-Life Balance
– we brainstormed some strategies for planning and meeting personal and professional goals, talked about how difficult it is for nurses to master work-life balance, and discussed having others contribute to our care plans. That last idea of Michelle’s is my favorite and I’ll be incorporating that into my next update of my own nursing care plan
. Thanks Michelle!
Please listen in to our conversation!
Have a question or something to add? Be sure to leave a comment!
Posted: 9/16/2016 11:11:27 AM
Lisa Bonsall, MSN, RN, CRNP
| with 0 comments
Do you have relationships with people who’ve come in and out of your life at just the right times? People who you connect with so deeply, that no matter how much time has passed, you pick up your friendship without missing a beat? That’s how I’d describe my relationship with Myrna.
In the spring of 1990, my parents and I attended an open house at the nursing school I would be attending that fall. The program consisted of separating the parents from the soon-to-be students for different sessions. When we met up again, my parents introduced me to a couple who they had become fast friends with – and who just happened to be from our same home town! It was Myrna’s mom and dad! And so it was our parents who initially introduced Myrna and I. We spent some time talking that day, amazed that we had never met before back at home. We went to different high schools, but literally lived within five miles of each other!
So we started school and became fast friends. Our nursing class was small enough that everyone got to know each other pretty well. Most of our classes were together and no other students at the university we attended had a schedule like ours as nursing students! After graduation, I remained in the Philadelphia area and Myrna had a commitment in New York City, so we were separated for several years. There was no social media at the time and we were both pretty busy starting our careers, so our contact was pretty limited.
Fast forward to 1995/1996 and Myrna moved to Philadelphia, taking a job in the same hospital I was working. She was in the Surgical ICU, I was in the Medical ICU, so our paths did cross occasionally at work, but it was that time together that really sticks with me. We were single, living in the city, meeting for dinners and hanging out together. We both returned to school and while her focus was on management and mine, women’s health, we still managed to take some of our requisite classes together --- research and statistics. You definitely need a good friend during those graduate level courses – I was so grateful for Myrna!
After we finished our degrees, over the next several years, we both settled down, got married, and started our families. I left the bedside and started working as a clinical editor. Myrna moved to Texas, and later to Colorado and explored some other non-clinical opportunities as well --- in pharmaceutical research, and, later, medical simulation.
Myrna came to Philadelphia a few years later on a work trip and we got to spend a little time together and she explained her work in simulation – I was so impressed. Shortly thereafter, she reached out to me: “Would I like to write some cases for her?” “Of course!”
Fast forward again, now to 2012, I was attending a conference in Colorado. “Hi Myrna – want to try to meet up?” “Yes, I’ll meet you at the airport!”
It had been such a long time since we’d seen each other! So we visited briefly then and a few years later, our team at NursingCenter was looking for another clinical editor to join our team. I knew just who to call.
I recall attending a reception with my parents in the spring prior to starting my Freshman year at the University of Pennsylvania (Penn), School of Nursing in Philadelphia. My mother was talking to another parent and I casually joined the conversation. We found out that she and her daughter, Lisa Morris (Bonsall) were from our same small town on Long Island. We attended different schools and therefore, had never met. Call it coincidence or fate – we became instant friends. We both enrolled in the pre-freshman program in August to prepare for the academic rigors of an Ivy League institution. At the conclusion of the program, we felt we were ready. Contrary to this belief, once the school year ramped up, I for one, found it to be extremely challenging. The course load was very heavy our freshman year and the amount of information we needed to memorize and synthesize was overwhelming at times. We managed to survive our first year, despite numerous distractions: parties, co-ed dorms, football games and sorority initiation.
Sophomore year brought with it the beginning of our clinical rotations and an end to our late night parties. While our non-nursing classmates slept until mid-morning, we were up and out the door by 6 am to get to our clinical site for a full day of patient care. I remember learning the basics of safe nursing practice, medication administration, and disease management. I’ll never forget the nursing process and writing care plans for all of our patients, each encompassing an assessment, diagnosis, planning, implementation, and evaluation. The practical, hands-on education continued through our junior and senior year with opportunities to take advantage of the many liberal arts classes that Penn had to offer. Lisa and I made it through, and we both graduated with a Bachelor of Science degree in Nursing (BSN). It was 1994 and our turn to make a difference.
Lisa decided to stay in Philadelphia and accepted a position in the Medical Intensive Care Unit (MICU) at the Hospital of the University of Pennsylvania (HUP). I headed to the Big Apple to begin my career at the New York University Medical Center as a nurse in the Surgical Intensive Care Unit (SICU). With four years of training at Penn, I confidently thought once again, that I was ready. However, I quickly realized that I had so much more to learn. Each disease and surgical procedure involved many complexities. Every patient’s recovery varied based on multiple factors and comorbidities. I honed my assessment skills and learned to think critically. It was stressful, and I loved patient care, but after a few years in the ICU at NYU, I realized I wanted to do more. I was ready to go back to school and Penn was the obvious choice.
Lisa had come to the same conclusion and had started graduate school at Penn around the same time to pursue an Advanced Nurse Practitioner degree in Women’s Health. I was intrigued by the business of health care and decided to focus my graduate studies on Hospital and Healthcare Management. We both worked full-time, and many night shifts, in our respective ICUs during graduate school. We found ourselves back in the Biomedical Library, spending countless hours studying for exams, writing papers and preparing for presentations. Upon completion of our Master’s degrees, our occupations took off in different directions. Lisa embarked on a career in publishing and writing for Lippincott Williams & Wilkins. I accepted a position in vaccine clinical research at Merck & Co., Inc.
My husband’s job uprooted us from Philadelphia to San Antonio, and we finally settled down in Denver, Colorado. After several years in pharmaceutical research and lots of travel, I took a risk, left industry and began working for a small start-up education company that provided medical simulation training to health care professionals. We developed interactive clinical scenarios around patient disease management. Given her clinical expertise in the MICU, I reached out to Lisa to author several sepsis case studies for us. These cases served as the basis for the critical care curriculum used to train thousands of practitioners across the country. It was wonderful to work with Lisa again and to reconnect after so many years.
Balancing family with a career became more difficult after the birth of my second son, and I decided to take some time off from work to raise my two boys. It was a wonderful four-year hiatus that I will always cherish. Toward the tail end of that break, Lisa had come to Denver to attend a nursing conference. We met for lunch, and I shared with her my desire to return to work. She remembered our conversation and called me a year later with a job offer, as her responsibilities and workload had grown tremendously. I was grateful to have the opportunity to jump back into the workforce, utilizing both my writing and clinical skills. Today, we collaborate on many nursing topics to provide educational resources to millions of nurses around the world.
It is hard to believe that it has been over 20 years since Lisa and I graduated with our bachelor degrees from Penn. I truly believe that it was fate for us to meet and reconnect after college. While we are not at the bedside full-time today, we are still contributing to the nursing profession in very meaningful and impactful ways. Nursing certainly opens up a world of opportunities, but it is up to each individual to take full advantage of them. Personally, there is no doubt that college provided me with an incredible education, but it is the friendships that I made that truly changed my life. For those of you going back to school this fall, enjoy every moment and cherish the people you meet as they may prove to be as important, if not more, that the lessons you receive in the classroom.
Myrna B. Schnur, RN, MSN
September 10th is World Suicide Prevention Day, hosted by the International Association for Suicide Prevention (IASP)
. According to IASP, “the World Health Organization estimates that over 800,000 people die by suicide each year – that’s one person every 40 seconds. Up to 25 times as many again make a suicide attempt.”
As nurses, you face these statistics every day and do your best to decrease these overwhelming numbers. Whether its screening suicide risks in teens
, patients with traumatic brain injuries
, elderly patients
, or cancer patients
, you consider the dangers and assess the situations.
But, what about assessing yourself and your colleagues for these same risks? As health care providers, nurses face stressful days and nights, confront poor patient outcomes, and combat the negative feelings they face to push through and carry on with the work at hand. At times, you may feel you are so busy caring for others that you forget to take a moment and to consider what’s going on inside yourself.
On NurseTogether.com, there is a sobering blog, Are Your Nursing Colleagues Suffering from Depression?
, that outlines some of the signs that indicate clinical depression and suicidal thoughts in nurses. According to the blog, “A study by Welsh found that 35% of a sample of medical surgical nurses had clinical depression. Another study from HealthLeaders Media revealed that one out of five nurses is depressed.” Nurses tend to have larger workloads than other professions, which can lead to both mental and physical stress. “Nurses perform 160 tasks in an eight hour shift with no task lasting longer than 2:45 seconds….Musculo-skeletal disorders are reported in more than 60% of the nursing workforce.” In the Clinical Nurse Specialist: The Journal for Advanced Nursing Practice
article, Depression in Hospital-Employed Nurses
, “Direct healthcare workers, including nurses, may be more vulnerable to depression as research has shown that work stress precipitates depression in working women and men. Indeed, healthcare workers were ranked third for depressive episodes of all occupations between 2004 and 2006.” Stress on the mind and the body are factors to consider when thinking about clinical depression.
According to Nightingalechronicles.com
, another reason nurses may be more prone to depression and suicidal thoughts than other professions is that when a nurse makes a mistake, it may result in the loss of a patient. “The pressure to ‘Do no harm’ sits heavy on the shoulders of all who take that oath. But what comes after ‘if harm is done’? How do we counsel the person who may have made the mistake?” Nightingalechronicles.com urges, “When a nurse or medical professional makes a mistake, immediate counseling and crisis intervention should be provided. Nurses should not have to bury themselves in grief, fear, and shame.”
Other ways to support nurses in trying times are to connect, communicate, and care
. IASP promotes these three actions as tools to support those who have encountered suicidal thoughts. You can connect by keeping an eye on yourself and your colleagues and by checking on how they are feeling. If a colleague or yourself is experiencing suicidal thoughts, communication is key. Nurses need to feel it is safe to discuss this topic without fear of being judged or reprimanded. Fellow nurses, policy makers, and managers then need to “care enough about suicide prevention to make it a priority.” Suicidal thoughts should not be swept under the rug or treated as something that can be dealt with later. The risks for nurses are just as real as the risks for the patients they are taking care of.
Posted: 9/8/2016 11:20:37 AM
| with 0 comments
You may or may not have yet noticed that we’ve begun implementing more personalized features here on NursingCenter.com. Take some time to explore your very own dashboard of content related to your area(s) of practice! Here’s how…
to your NursingCenter account. Don’t have one? Go ahead and register
– it’s FREE!
2. Click your name at the top right of the page.
3. Click “My Dashboard.”
4. See the results!
5. You can even toggle between your practice areas to see additional content!
6. Need to edit your practice area? Just click “Edit” to update your profile.
Hope you enjoy this new feature on Lippincott NursingCenter.com! And remember, you can always update your profile
to reflect your current practice area. Keep all of your selections up-to-date so we can bring you the content that best meets your needs to improve outcomes and develop professionally.
Posted: 8/31/2016 10:46:42 PM
Lisa Bonsall, MSN, RN, CRNP
| with 0 comments
With Zika virus in the news and on our minds this season, we know some of the best advice for preventing this illness is to prevent infection via mosquito bites. See the infographic below for recommendations to prevent transmission of Zika virus and other mosquito-borne illnesses.
Add this infographic to your website by copying and pasting the following embed code:
In January of 2016, we shared 5 Things Nurses Need to Know about Zika Virus
. Since that time, ongoing research and monitoring has increased what we know, and recommendations have been updated based on the latest evidence. Here are five more things that are important for nurses to understand:
1. Is there a test for Zika virus?
Early in the course of Zika virus, a serum real-time reverse transcription-polymerase chain reaction (rRT-PCR) may detect Zika virus RNA in the blood. The virus RNA may remain present in the urine longer than in the blood; the CDC recommends that urine samples be collected less than 14 days after onset of symptoms for rRT-PCR testing. Virus-specific IgM and neutralizing antibodies typically develop toward the end of the first week of illness, so Zika virus serologic testing can be done later in the course of illness. All submissions go through the state or local health department and there are specific instructions from the CDC on how to collect, prepare, and ship specimens for testing.
2. What are the current recommendations related to sexual transmission?
3. What is microcephaly?
- Men who have been diagnosed with Zika virus should use condoms or abstain from sex for at least six months.
- Pregnant women with male partners who live in or travel to areas with Zika should use condoms every time they have vaginal, anal, or oral sex, or abstain from sex for during the pregnancy.
- Both men and women should be counselled about contraceptive planning. Women with Zika virus should wait at least eight weeks after symptom onset before conceiving; men with Zika virus should wait at least six months, as it is unknown how long the virus may remain in semen. Both men and women with possible exposure to Zika virus should wait at least eight weeks after being exposed to attempt conception.
Microcephaly is a neonatal malformation in which infants are born with a head smaller than normal due to abnormal brain development. In some cases, newborns may develop normally, however, possible associated neurologic complications include developmental delay and seizures, as well as speech, hearing, and vision deficits, and feeding difficulties. Diagnosis can be made by ultrasound late in the second trimester or early in the third trimester, or after a baby is born. Microcephaly is a lifelong condition and treatment depends on the severity of the malformation and associated health problems.
4. Is Zika virus associated with Guillain-Barré syndrome (GBS)?
The CDC is investigating the link between Zika virus and GBS, as the Brazil Ministry of Health has reported an increased number of people who have been infected with Zika virus who also have GBS. GBS is an autoimmune disease which attacks the peripheral nervous system. Weakness of the arms and legs results, and flaccid paralysis often develops. In severe cases, the muscles of the face weaken and affect the eyes, swallowing, and breathing. Many patients with GBS have a history of a recent viral or bacterial infection, so it is possible that a percentage of those infected with Zika virus could develop GBS as well.
5. How should symptoms of Zika virus be managed?
At this time, there is no antiviral or other medication available to prevent or treat Zika virus. Rest, fluids, antipyretics, and analgesics are recommended for symptom management. It’s important to remember that aspirin and NSAIDs should be avoided until dengue virus is ruled out.
Centers for Disease Control and Prevention. (2016, July 14). Zika virus. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/zika/
Coyle, A. (2016). Zika virus: What nurses need to know. Nursing2016, 22-24.
O'Malley, P. A. (2016). Zika Virus: What We Know and Do Not Know. Clinical Nurse Specialist: The Journal for Advanced Nursing Practice, 194-197.
Todd, B. (2016). Zika Virus: An Unfolding Epidemic. AJN, American Journal of Nursing, 59-60.
Rounding out this blog series on mobile health applications (apps) or mHealth apps, I wanted to touch on apps specifically designed to provide educational tools and quick references for the nursing profession. According to a survey conducted by Wolters Kluwer Health, 65 percent of nurses said they currently use a mobile device for professional purposes at the bedside.1
The study also found that 95 percent of health care organizations allow nurses to consult websites and other online resources for clinical information at work.1
A major advantage of mobile apps is that they provide a variety of references in one central location, that is easily attainable, from almost anywhere there is a reliable internet connection. Nurses employed in every clinical setting stand to benefit from resources at their fingertips, particularly those in home and public health settings, where access to evidence-based information may be limited.
As discussed in Part 1
of this blog series, there are thousands of mHealth apps available to clinicians. The most common are drug manuals, tools to help evaluate lab and diagnostic studies, and differential diagnosis guides2
. Utilization of mobile devices in professional nursing practice may improve efficiency and assist clinicians to:
- Complete professional development;
- Stay up-to-date with the latest research and literature;
- Provide patient and peer education;
- Translate medical terms for patients and family members;
- Compute drug dosages;
- Calculate physiologic assessments, such as Body Mass Index (BMI), Mean Arterial Pressure (MAP), Glascow Coma Scale score, Apgar score, Stroke Scale and many more;
- Organize shift work; and
- Communicate with other health care professionals.
With an ever increasing number of mHealth apps on the market, how can nurses decipher which are useful and contain the most relevant and accurate information? In order to utilize these resources effectively, nurses should be competent in several key areas, including basic computer knowledge and use, information literacy, (IL) and information management3
. Information Literacy (IL) is defined as the ability to recognize when information is needed and to locate, evaluate, and effectively use that information. Therefore, nurses must be able to assess mHealth apps for accuracy, credibility, bias, timeliness, and breadth of information.3
A study, conducted by Arith-Kindree and Vandenbark (2014), asked nursing students to assess a variety of mobile apps for usefulness. The study found that some apps, while from reputable sources, provided recommendations that were incomplete.3
Based on the findings from this study, nurses should critically evaluate each app to ensure it is:
- Credible – verify the author’s credentials, publisher’s reputation, and peer-review status;
- Relevant – assess the intended audience, purpose, and publication date;
- Current – check that the content is consistently updated on a regular basis;
- Utilitarian – confirm the app is useful and functions as it was designed; and
- Comprehensive – establish that the information is complete and derived from a trusted source.
Health care apps can serve as useful tools for clinicians at the bedside, however, there are logistical and cultural obstacles that stand in the way of implementation and utilization. This opens up many opportunities for nurses in the field of informatics to develop policies, organizational infrastructure, and competencies for integrating mHealth solutions within health care organizations and communities.4
Several challenges, however, must be overcome which include:
- Establishing hospital administrator support;
- Overcoming staff resistance to change;
- Training to different learning styles and comfort levels with technology;
- Securing patient confidentiality;
- Cost of infrastructure and maintaining consistent internet access;
- Preventing vital machine failure or malfunction due to interference from handheld devices; and
- Ensuring that mobile devices are not a distraction in the workplace.
Digital tools can potentially make us more efficient, effective, and informed practitioners. We are fortunate to live in an age of innovation where tools are available at our fingertips, any time, and anywhere. Unfortunately, not all mHealth apps are accurate and some cannot be trusted. We, as health care providers, need to develop a critical eye when evaluating the use of new technologies and verify that they are consistent with evidence based practice prior to full integration into the health care delivery system. In addition, more research is needed in the area of mHealth to assess the true impact it could have on workflow, quality, and patient outcomes.
Myrna B. Schnur, RN, MSN
Baca K, Rico M, & Stoner M. (2015) Embracing Technology to Strengthen Care and Enhance Human Connection. Dimensions of Critical Care Nursing, 34(3), 179-80.
Airth-Kindree N & Vandenbark T. (2014) Mobile Applications in Nursing Education and Practice. Nurse Educator, 39(4). 166-169.
Austin, R. & Hull, S. (2014) The Power of Mobile Health Technologies and Prescribing Apps. CIN: Computers, Informatics, Nursing, 32(11). 513-515.
Posted: 7/19/2016 5:29:04 AM
Lisa Bonsall, MSN, RN, CRNP
| with 2 comments
In Part 1
of this series, I provided a general overview of mobile medical applications (apps) that are available on the market in the areas of general health, wellness, disease management, and hospital clinical workflow. There are many potential benefits of mobile medical apps, such as facilitating communication between patient and provider, enhancing efficiency, and advancing the overall quality of patient care. There have been recent reports in the news, however, pointing to the dangers of patients being misdiagnosed via telemedicine websites and mobile apps. Serious patient safety questions arise when mobile medical apps are designed to act as a medical device or provide patients with a medical diagnosis. Should these apps be regulated by the government? Part 2 of this blog series focuses on the current regulation recommendations* surrounding the use of mobile apps as it applies to direct patient care.
The Food and Drug Administration (FDA) is the government organization responsible for protecting the public health by assuring the safety of drugs, biological products, medical devices, food supply, cosmetics, and products that emit radiation.1
In 2015, the FDA released a document that outlines the use of health care applications and states that apps that act as either a medical device or an accessory to a medical device will need to obtain FDA approval. The intended use of a mobile app determines whether it meets the definition of a “device.” When the intended use of a mobile app is for the “diagnosis of disease or other conditions, or the cure, mitigation, treatment or prevention of disease, or is intended to affect the structure or any function of the body, the mobile app is considered a device.” 2
Intended use is communicated to the consumer through product labeling, advertising, or verbal and/or written statements made by manufacturers. All products that fall under the definition of device are subject to regulations set forth by the FDA before they can be marketed and sold to the general public.
FDA regulation will focus on mobile apps that turn a mobile platform into a regulated medical device, which could pose a risk to a patient’s safety if it did not function properly. Examples include medical apps that:
- Connect to and control medical device(s) in order to actively monitor or analyze medical device data. (i.e., an app that controls the delivery of insulin on an insulin pump);
- Turn the mobile platform into a medical device by using attachments, display screens, or sensors, or by including functions similar to those of currently regulated medical devices. (i.e., an attachment of electrocardiograph (ECG) electrodes to a mobile platform to measure, store and display ECG signals);
- Perform patient-specific analysis and provide patient-specific diagnosis, or treatment recommendations. (i.e., apps that use patient-specific parameters to calculate dosage or create a dosage plan for radiation therapy).
The following medical apps pose low risk to patient safety, and therefore, the FDA will exercise discretionary judgment with regard to regulation. Examples include apps that:
- Help patients self-manage their disease or condition without suggesting specific treatments (i.e., apps that coach patients with cardiovascular disease to maintain a healthy weight, eat nutritiously, and exercise);
- Provide patients with simple tools to organize and track their health information, without recommending a change to previously prescribed treatment or therapy (i.e., apps that log blood pressure, drug intake times, diet, daily routine, or emotional state);
- Provide easy access to information related to patients’ health conditions or treatments (i.e., apps that use a patient’s diagnosis to provide a clinician with best practice treatment guidelines for common illnesses or conditions);
- Help patients document, show, or communicate potential medical conditions to their providers (i.e., apps that serve as videoconferencing portals to facilitate communications between patients, health care providers, and caregivers);
- Automate simple calculations routinely used in clinical practice (i.e. medical calculators for Body Mass Index (BMI), Glascow Coma Scale Score, or APGAR score);
- Enable patients or providers to interact with Electronic Health Records (EHR) systems to view or download data to facilitate general patient health management and medical record-keeping;
- Transfer, store, convert format, and display medical device data, without controlling or changing the functions of any connected medical device.
Mobile apps that are not considered devices under the FDA definition and are not required to undergo regulatory requirements include apps that:
- Provide electronic copies of medical textbooks or references not intended to diagnose, treat, or prevent disease by helping a clinician assess a specific patient;
- Act as educational tools for medical training and may have more functionality than an electronic copy of text (i.e., videos, interactive diagrams), but are not intended to diagnose, treat, cure, or prevent disease by helping a clinician assess a specific patient;
- Provide general patient education and patient access to commonly used reference information;
- Automate general office operations and administrative functions (i.e., coding, billing, accounting, scheduling, payment processing);
- Act as generic aids (i.e., using the mobile platform to record audio, or send HIPAA compliant messages between health care providers in a hospital).
As more and more apps are developed in the field of health care, clinicians will play a pivotal role in how these apps are implemented in the routine care of patients. We need to have a basic understanding of app functionality, which ones are purely informational and which ones act as medical devices. More importantly, it is essential that we fully comprehend the impact these apps will have on the safety of our patients, as we are ultimately responsible for protecting them from harm.
In Part 3
of this blog series, I will provide an overview of the medical mobile educational tools available to nurses and how clinicians should evaluate which are the most reliable and relevant sources of information.
*Note: This article is a summary of the FDA guidelines and is not meant to be all-inclusive of the recommendations made by the FDA.
Myrna B. Schnur, RN, MSN
Posted: 7/10/2016 5:45:50 AM
Lisa Bonsall, MSN, RN, CRNP
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