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"The cost of healthcare as a percentage of the gross national product is increasing every year. If this continues, these costs will cause the economy to collapse, much as military spending in the Union of Soviet Socialist Republics did in the late 1980s." This fact was imparted to the participants during the closing keynote talk, Making Health IT Personal, by Dr. Robert Kolodner, National Coordinator for Health Information Technology at the 17th Annual Summer Institute of Nursing Informatics 2007 held July 18 to 21 at the University of Maryland School of Nursing in Baltimore. It reflected the two main messages that came from this conference: (1) informatics is not the answer to the healthcare crisis, but without the informed use of informatics, there will not be a solution, and (2) there must be interoperability of systems to make this happen.
The opening keynote speaker was Dr. Gail Wolf, professor and program director of nursing informatics at the University of Pittsburgh, who looked at the future in healthcare. She pointed out that as we move from an industrialization paradigm to one of automation, there will be life-altering changes in our healthcare system in terms of patients, providers, medicine, and technology.
Changes we will see include patients who are older and more ethnically diverse. They will come to providers with knowledge gained from the Web. In some cases, this knowledge will be more than the provider has. Additionally, patients will expect more and tolerate less.
Other changes will involve the quality issues of too much care, too little care, and the wrong kind of care. The safety issue was under Other changes will involve the quality issues of too much care, too little care, and the wrong kind of care. The safety issue was under scored by Dr. Wolf, who pointed out that we are 10,000 times safer in an airplane than in a hospital.
In many places, there is an oversupply of physicians, particularly specialists. This will result in role changes for physicians, such as some becoming clinical investigators, managers, or chronic disease managers. The shortage of nurses will be exacerbated by the changes in patient demographics, with a resultant drop in quality care. Additionally, hospitals operating beyond capacity will increase the likelihood of adverse events. Changes also will occur in financing, such as pay for performance, to save the half a trillion dollars expended due to poor quality of care.
Changes in technology that will affect healthcare include business automation, the electronic health record, telemonitoring, and data mining. The end result will be better underdecision making, better prediction of future illness, and better financial risk adjustment. One main challenge we must meet is to provide patients what they really need. Instead of labeling a patient as "uncompliant," we will be asked to see things from the patient's perspective. Patients want a provider they can trust who will provide care that is evidence based and who will be a partner in their care, not the authority. To do this, we need to overcome inertia and transform our profession.
Planning for the Future-It's Not About the Technology was the title of the Thursday morning keynote address by Stephanie Reel. Stephanie L. Reel, vice provost for information technology and chief information officer for Johns Hopkins University, is also vice president for information services for Johns Hopkins Medicine. The goal is safety-focused, patient-centric, technology-enabled healthcare. To reach this goal, Johns Hopkins focuses on seven strategic goals: safety, savings, security, scientific innovation, service excellence, satisfaction, and simplicity. Ms. Reel meets with her staff every 2 weeks to renew their focus on these seven points. Additionally, each of her staff is encouraged to adopt a unit and spend 1 day a month there to identify the real challenges and risks.
Although the hospital of 2010 will be similar to the hospital of today, there will be an introduction of technologies not yet invented, the expectation for ubiquitous and pervasive access, improved communication support by information technologies, collaboration and decision making to create safer healthcare delivery, and outcomes that are more effectively measured and reported. The hospital of the future will not always be a place, but rather a patient experience that will encourage patient involvement and empowerment.
This scenario poses many challenges including the cost, the overwhelming amount of information, the need to be more productive, the management of security, a disconnect between strategic planning and information technology, and a lack of clarity about who is responsible. Robust infrastructures put in place now must be able to support many technologies. There must be provisions for radiofrequency identification that will allow tracking of devices, supplies, and patients; teleconferencing; telemonitoring; video conferencing; and collaboration tools to support teaching, learning, and research as well as centralized, remote monitoring technologies. Challenges include less time with patients yet more complex interventions, workforce shortages, environmental complexity, and broken work flow and processes.
Technology, Ms. Reel pointed out, is risky business! Sometimes the product does not perform as de-signed. The vendor may not always be your partner. The design may have been wrong, and the system may complicate not simplify work. Users are not always ready. The change may be greater than imagined, and the product or device may be obsolete before it is implemented. Implementation may fail because there is no sense of urgency, an undercommunicated vision, an inability or unwillingness to remove obstacles or empower others to do so, a premature declaration of victory, or an inability to anchor the changes into the culture. To meet these challenges we need to keep our focus on excellence. To achieve this goal we must "blow it [the system] up" instead of applying Band-Aids. This means creating a culture of change that forgets the past, learns from mistakes, and learns from other industries. Of the many things needed to redo the system, the hardest job of all will be work flow redesign.
"The Seoul National University hospitals are paperless; in fact nurses are not allowed to carry any paper; they use PDAs and laptops" reported Dr. Hyeoun-Ae Park, a Professor and Visiting Professor from Seoul National University and the University of Maryland who spent the past year as a Visiting Scholar at SNOMED. She added that all medical devices such as heart monitors are interfaced with the hospital information system. There are kiosks that allow patients to pay their bills, print their prescriptions, make an appointment, and print out a list of services for tax purposes.
These hospitals are completely electronic and feature an electronic nursing record system (ENRS). The underpinning for the ENRS is the International Classification of Nursing Practice (ICNP) which required translating into Korean. This created an extended Korean ICNP with the addition of new concepts by cross-mapping of existing nursing terminologies and nursing documents. The resulting terms are used to populate the user interface for the ENRS.
A feature of the ENRS is a printout of the discharge nursing record given to the patient to take home. When nursing interventions are performed, a record is sent to billing, and the patient charged for the actual nursing care rendered instead of nursing care being bundled into room and board as though it were equal for all patients.
Dr. Park reported that nurses have been very satisfied with the system and find it helpful in using the nursing process. When they enter a nursing problem (nursing diagnosis), the system provides decision support by generating a list of possible interventions. The ENRS has increased direct nursing care time and decreased indirect nursing care time. Additionally, the quantity and quality of nursing documentation has increased, with 60% of the nurses documenting in patient rooms. Data collected from 580,000 entries found that the Korean version of the ICNP provided domain coverage. Although they keep free text to a minimum, they do allow some. The most frequently found statement in audits of these entries was "Slept well."
The use of the ICNP in the ENRS allows nurses to discover knowledge about nursing practice. These discoveries include the success of various types of nursing interventions used for pain, the rates of various conditions, and the outcomes for nursing interventions used in the management of these nursing problems as well as the most frequent nursing diagnoses and interventions in various units.
Dr. Park also discussed the International Heath Technology Standards Development Organization, a recently formed organization housed in Copenhagen to oversee the rights and development of SNOMED and to promote the correct use of terminology products around the world. There currently are nine charter members (Australia, Canada, Denmark, Lithuania, the Netherlands, New Zealand, Sweden, the United Kingdom, and the United States).
Dr. Park also described the ICNP catalogues, which are a subset of nursing problems, interventions, and outcomes designed for a specialty, and which simplify data input. Some of the current catalogue priorities are promoting adherence to treatment, HIV/AIDS home care, ambulatory cancer care, family nursing, and women's health. The work of mapping the ICNP, version 1.0 to SNOMED to provide interoperability of nursing concepts with other healthcare concepts is currently underway, following the process developed when the other ANA-recognized terminologies were mapped. This process calls for adding new SNOMED concepts if the ICNP concept is not already present.
A topic whose time has come, Informatics for ALL Nurses, opened Saturday morning's session by Dr. Angela McBride, the Distinguished Professor-University Dean Emeritus at Indiana School of Nursing. Dr. McBride, who is not an informatics nurse, spent a year at the Institute of Medicine (IOM) studying how healthcare is being transformed by information technology. Describing her experience learning to cope with technology, she stated "Being ignorant [of informatics] is not something that you need to hide."
It is only by owning our lack of information that we can learn. Informatics is one of the five core competencies that healthcare professionals will need in the 21st century. Dr. McBride argued that the use of informatics may be the key to achieving the other four core competencies: a focus on patients, the use of quality improvement, evidence-base practice, and collaboration across disciplines.
Informatics is not just something to add to the curriculum, but the wave of the future. To achieve safety, there needs to be seamlessness between transitions. This will require that we nurses use standardization, although we may have to sacrifice a little of our autonomy. Standardization in nursing documentation will allow the use of nursing data to shape healthcare decisions at the local, regional, national, and international levels. Dr. McBride wants to see both general and specialty nursing organizations incorporate informatics into their agendas. Her parting thought was that the relationship of healthcare professionals to informatics is like their relationship once was to research (i.e., placed in a separate course), but that it now is being integrated into the curriculum. The end result, she believes, is the need to integrate informatics into all courses in the nursing curricula.
A description of a patient Web portal from Vanderbilt University Medical Center (VUMC) that provides services for 24,000 patients was the focus of Dr. Jim Jirgis' Saturday presentation. Dr. Jirgis is the chief medical information officer for VUMC.
Patient portals, although technically possible a decade ago, have been enabled by the growing number of people who use the Internet, and their importance in everyday life is increasing. Patients want a Web portal for test results, messaging, explanations, appointments, prescription refills, and payment of bills. There are, however, many challenges, both from an information system perspective and culturally. When providing lab results via this portal was first proposed at VUMC, some physicians stated that patients cannot handle the truth. The physicians also feared that they would be barraged with calls after patients saw the results. With adequate planning and consideration, these fears never materialized.
There are, however, many things that need to be planned before such an all-inclusive system is implemented. It must be a win for patients, providers, and staff. There must be plans for handling e-mails so there are no dropped messages and patients are answered within 24 hours. This was solved at VUMC with a system of routing messages and separating critical ones from others, similar to what is done today with phone calls. Situations requiring someone to cover for providers when they are on vacation also must be accommodated.
What lab tests should be reported and when was solved by the creation of three groups. Group 1 includes routine lab tests, the results of which are made available practically within the hour. Radiologic exams, group 2, are not reported in the portal for 7 days to give the doctor time to read and make decisions on how to handle them. Tests in group 3, such as those for HIV, are never reported online.
One of the best outcomes of the Web patient portal has been the involvement of the patient in quality care. As support for patient viewing of lab reports, Dr. Jirgis told participants about a situation in which a patient caught something on an x-ray report that the physician had missed when looking at the results: a tumor that turned out to be cancerous. Under normal conditions, this situation could easily have ended up being missed for several years, with the patient dying and a lawsuit resulting. Instead, treatment was instituted, and the ending was positive.
Gaining acceptance for physician use of the system was helped by using positive means such as publicizing the names of those who had zero unanswered messages left in their in-boxes. This made others ask how they could be added to this list.
The closing session of this year's SINI was a presentation by Dr. Robert Kolodner, the National Coordinator for Health Information Technology. His talk, Transforming Health and Care: Health Information Technology Approaches the Tipping Point, provided a national perspective on healthcare technology. He stated that we currently are not getting value for our healthcare dollar. The most expensive healthcare device is the nurse, who under the current environment spends only one-third of her time in direct patient care. Instead, the nurse is burdened with tasks such as asking redundant questions, making duplicate data entries, and obtaining and providing information to physicians. The forces that currently are driving health information technology include an increased awareness of the benefits, the clinical and political leadership, and industry leaders. The latter face healthcare costs for their workers that are making them noncompetitive in the market place. The cost of healthcare for General Motors is more than the cost of steel.
A key component for implementing health information technology is robust, interoperable systems that require standards for data, security, and interoperability. The ultimate reason for achieving a solid national health information system is the realization that you are a potential patient. What quality and value services do you want? Currently, we have a sick care system. It is a fact that 75% of healthcare spending occurs in the last year of life.
The future of healthcare needs patients to manage their own care as well as a focus on populations in addition to individuals. Healthcare must move from treatment to prevention to prediction. The cornerstones to achieve this are connecting the systems, measuring and publicizing quality of care, publicizing the price of care from different providers, and creating positive incentives. Information technology itself will not solve problems. The issue is not one of deemphasizing technology, but of using it intelligently with a focus on quality, safety, and cost reduction. Currently, in 2007, we are just planting seeds, but we may be almost at the tipping point for the transition. Dr. Kolodner cautioned us, however, that there will be a lag between acceptance and implementation.
Besides the keynote speakers, there were many concurrent sessions, with participants wishing they could be in more than one place at a time! Friday afternoon also featured poster presentations. The conference was rounded out by chances to network at the many social activities including a night at the Maryland History Museum and "A Taste of Baltimore" dinner at the School of Nursing.
Linda Q. Thede, PhD, RN-BC
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