By Susan McBride, PhD, RN, professor at Texas Tech University Health Science Center School of Nursing. McBride and fellow nurse informaticists Mari Tietze and John Delaney will be blogging here on the intersection of nursing and informatics in the coming days.
By DeclanTM, via Flickr.
Everyone knows by now that the Obama administration has made electronic health records (EHRs) a high priority and is providing financial incentives to health care providers (and yes, nurses are included in that group) to adopt them. But not everyone knows it’s not just about converting records from paper to digital—its much more than that.
On July 13, the Office of the National Coordinator (ONC) for Health Information Technology (HIT) released the final rules establishing definitions for the “meaningful use” of EHRs. The final rule is 864 pages and contains critical information for nurses to understand about how electronic records will change our lives.
(No one expects every nurse to read the entire document. That’s why we’re going to be blogging about some important aspects of the topic. In the meantime, click here for a good overview of meaningful use and electronic medical records, as well as links to more exhaustive information. And for a short, useful table breaking down the rule by health outcomes policy priorities such as “improving care coordination,” have a look at this PDF: Stage 1. Meaningful Use Objectives and Associated Measures Sorted by Core and Menu Set.)
Ongoing concerns. The idea behind these rules is to establish EHRs within a National Health Information Network that will allow us to exchange health care information regardless of where we are in the nation. There are many concerns about privacy and security related to this network, and these concerns are likely to be the most difficult component to address in establishing it. But there are definite clinical advantages.
Consider the benefits of the ability to retrieve information on patients entering the ER unresponsive and critically injured, or on a child whose parents aren’t there to provide a history. The EHR provides information at our fingertips on things such as health history, medication usage, and allergies. Another practical advantage is that we will no longer need to have patients fill out form after form with the same information on it. We may also reduce the need for expensive tests such as CT scans, MRIs, and laboratory tests that we frequently rerun because the results are not available when needed. And it will be easier to track outcomes, so it will be easier to establish which quality initiatives are successful.
Making nurses part of the design. The complexity is in how this will happen. These new “meaningful use” rules are at the epicenter of “the how.” What’s important for any nurse right now is that you find out what your organization is doing to develop EHRs and make sure nursing’s voice is represented in this process. We need to be part of the design in order to make it meaningful for use at the point of care. In an upcoming issue of AJN, and in upcoming posts on this blog, we’ll go into detail on what this specifically means for nurses.
There currently is no network exchange of patient information between EHR software programs. That may be the ideal but the reality is: you must be a subscriber or licensee of an EHR to view patient information. There is currently no “information exchange.”
As the awareness of the lack of interchangability spreads, the general concensus that the need for data governance modeling will become more consolidated than it is at present. Currently, it is the wild wild west as far as the electronic health record is concerned. Everybody who wants to survive has one, but not everybody that has one, has the same level of skilled resources (like nurses in the roles of clinical informaticists, data scientists, etc.) that are required to make the best use of data generated by the EHR during the process of care. Until a data governance model is established that provides a minimum data set in a uniform standard format that all survivors that remain in business can agree to populate with their data, there simply is no way to have any “information exchange”. Until that happens, the best uniform standard “source of truth” will continue to be CMS data. But CMS data is generally one to two years after the fact, and does not represent “all payer” data (about 50% of the data is arbitrarily missing from CMS data, and it is heavily skewed to the 65 or older population). Even so, it is the best we have at the current time. Accountable Care Organizations do provide a hybrid model for “information exchange”, but when will we see ACO’s collectively putting thier data into a uniform standard format that can be pooled into the truly “vast data set” that we all expected to instantly appear with the adoption of the electronic health record? So far, no such thing is even on the horizon, as long as there is no single overarching data governance model that mandates that such a “vast data set” will both occur and be populated on a go forward basis, ad infinitum.
I completely agree with Mrs. McBride in that there is currently a need to instruct nurses about “the national health information exchange and its implications for future practice”. This can be achieved by incorporating information technology subjects into nursing curriculum. Nurses worldwide need to start thinking of information technology as a possible solution to the many problems and challenges the profession is facing at the moment. By educating nurses in new available technological advances that will significantly save them time at their jobs, current nursing shortages issues could be lessened. The increased use of information technology by nurses will further improve the safety and privacy of patients and at the same time contribute to the development and evolution of the nursing profession and the whole world of healthcare. When incorporating new technologies into the healthcare system, several aspects need to be taken into consideration. Technology should be easy to use and proven to maximize healthcare professionals’ time. Also, software systems must increase patient safety, bring positive outcomes and meet the organization’s goals.
I am so happy to be able to read and respond to this exchange. Although some months later. I have done a great deal of reading and following the national health information exchange over the years. As a nurse practitioner and educator I really appriciate both Dr. Susan McBride and practitoner Richard Gilder’s input, comments expertise and efforts to advance the need for nurse to stay actively involved in the devlopment of EHRs and the implications for practice. In 2006 I did a small pilot study to evaluate the current knowledge Advanced Practice Nurses have with regards to the “national health information exchange and its implications for future practice”. The results were presented at the National Conference for the American Academy of Nurse Practitioners. The results indicated that many APNs did not have a strong understanding of the NHIE, did not understand what a RHIO was and had no grasp for the term Interoperability for health information. Yet, several were beginning to use aspects of EHRs such as e-perscribing. Nearly all of the respondants believed there systems were “secure”. I plan to further my research by comparing those results with APN’s practicing now. What I see is very much what has occured in the past with nursing. We often leave what we perseive to be “non nursing function” to doctors or administrators…then we just follow along. Informatics (nursing) is still viewed as a function for others to figure out. As a profession, we have to admit that we really are lacking many qualified expert nurses in this area to “catch us up” with this fast moving need! There is only so many of them to go around. SnowMed…HL7…they are not enough or even (in part) applicable to the domain of nursing. Getting the taxonomy we need to represent all of us is a very big task. BUT it should be a priority in reality…not just on paper…but in action.
Richard,
You make some very compelling points on your comment to our meaningful use Blog regarding nursing’s role and the need to codify nursing’s contribution in structured data. We have made some headway in the quality arena in promoting nursing sensitive measures in the requirements by CMS to report quality indicators for reimbursement purposes, and some headway in taxonomy. You and other perioperative nursing colleagues have done some good work in the taxonomy for perioperative nursing documentation—yet as you indicate, we have a long way to go.
However, I don’t think nursing is alone in lagging efforts to move to taxonomies and nomenclatures that capture what we do in the clinical setting. Although work is moving forward on taxonomies like SNOMED, clinicians do not always look favorably to conforming to taxonomies in describing what and how they provide care. The entire industry has a great deal of work to do in figuring out how to classify and document what we do in such a way that we can structure the data and standardize it for robust interoperable electronic exchange across disparate organizations.
Although I believe nursing has a unique role to play, I also think that a great deal of the health information technology development is generating from multi-disciplinary teams. We are seeing nurses well represented on many of the teams evolving across the country to implement the Office of the National Coordinator’s plan to connect our nation by 2015. As we move around the country beginning to work virtually and face-to-face with other Regional Extension Center staff, Health Information Exchange Teams, and Vendors–there are many nurses on those teams. Nurses are providing support in numerous roles including but not limited to executive leadership, data warehouse and analytic support, project management, workflow analysis, vendor development and installation teams for electronic health records—I believe nursing is at the table in very powerful ways.
In order to meet the goal of the Meaningful Use mission, namely to “… improve health care quality, efficiency, and patient safety.”, it is immediatly apparant that active collaboration with nursing, and especially nursing informatics, is required.
Because the “… stage 1 criteria for meaningful use is focused on electronically capturing health information in a coded format,…” the need for inclusion of the nursing process should be obvious. Codification of the nursing process portion of “heatlh information in a coded format”, is sparse.
In further consideration that use of this codified information is intended to “…track key clinical conditions, communicating that information for care coordination purposes, and initiating the reporting of clinical quality measures and public health information…”, it would seem that the nursing process will continue to remain an invisible component, even though it is a significant contributor to all 49 of the 2011 objectives/measures for eligible providers and hospitals.
I would like to invite discussion about the need within the nursing profession, to assign a much higher priority to development of a uniform and standardized codification of the nursing process in order to assure that nursing will be included in future development of “meaningful use”, rather than remain on the sidelines as a spectator.
This is not to say that major and significant work is not being done within nursing, but it does need to be pointed out that in the current definition of “meaningful use” only very small portions of nursings contribution to the “…health care quality, efficiency, and patient safety.” has ever been codified and therefore even available for inclusion at the present table of negotiation.
The problem of nursing being sidelined is now, and will forever remain, a fault that nursing, and only nursing, can ever own and address.
Nursing informatics science has long been aware of this issue, and yet nursing informatics as a discipline within nursing has also been given a “fringe rather than core” priority within both nursing practice and nursing education.
That priority within nursing is hopefully changing. The current Stage 1,2, and 3 expansion of the meaningful use of electronic health record data through government mandated manipulation of Medicare and Medicaid reimbursements and financial incentives will absolutely serve to leverage the priority within nursing for a standardized codification of the nursing process, to a level that nursing alone has never been able to achieve historically. This external force will change nursing practice and education forever, and for the collborative good.
While on the one hand, if nursing can not or will not change in this regard, it will be left sidelined in the dust of history, and that would be collabortively bad for all mankind; and I do not think that will happen.
Yet on the other hand, my greatest concern is that nursing will not adapt and adopt fast enough to maintain ownership of what is defined and codified as “nursing”, and the world will suffer the effects of the “law of unintended consequences of good intentions of others made on behalf of others for their own good”.
This concern is at the heart of what drives nursing informatics. If we do not define and codify nursing, nursing will be defined and codified by those who are not nurses, or perhaps not defined or codified at all, becoming invisible and unmeasurable. As a direct result, health care quality, efficiency, and patient safety will be compromised at best.
We can do this! Much progress has been made over the past century since the pathologists first attempted to codify the cause of death on post mortem autopsy findings documented on death certificates, evenually resulting in our current ICD10; and ICD11 is under condstruction.
Will ICD12 include Clinical Modifications and codes that reflect measurable (and therefore reimbursable) nursing diagnoses, nursing procedures, and nursing therapies?
It could, if we continue to act and raise this as a priority within nursing practice and nursing education.