Informatics Strategies & Tools to Link Nursing Care with Patient Outcomes in

the Learning Health Care System

Patricia C. Dykes PhD, RN, FAAN, FACMI

Judy Murphy RN, FHIMSS, FAAN, FACMI

Dana Womack MS, RN

March 31, 2014

Nursing Informatics Working Group

1

Overview

• Best Care at Lower Cost: The Learning Health Care System (LHCS)

– Meaningful Use

– Informatics strategies to support the LHCS

• Credentialing in nursing education and practice

• Data harmonization

– Advantages

• Demonstration: NDNQI Dashboards

• Discussion/Conclusions

2

Best Care at Lower CostThe Path to Continuously Learning

Health Care in America

September 2012

iom.edu/bestcare

3

• Patient harm – One-fifth to one-third of hospital patients are

harmed during their stay, largely preventable.

• Recommended care – Only about half of the recommended

preventive, acute, and chronic care is actually received.

• Outcome shortfalls – If all states matched care quality in the

highest-performing states, 75,000 fewer deaths would have

occurred in 2005.

Why now?

Quality – persistent shortfalls

4

From Best Care at Lower Cost: The Path to Continuously Learning Health Care in America, IOM, 2012

The Result?The U.S. health care system today

5

From Best Care at Lower Cost: The Path to Continuously Learning Health Care in America, IOM, 2012

The VisionContinuous Learning, Best

Care, Lower Cost

6

Transition to the

Learning Health System

From Best Care at Lower Cost: The Path to Continuously Learning Health Care in America, IOM, 2012

Meaningful Use

HITECH ACT

The 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act:

• Provides $30 billion in Medicare and Medicaid incentive payments

• For the meaningful use of health information technology by clinicians and hospitals

• Estimated to yield savings of $93 billion between 2011 and 2019

7

A Remarkable Journey

Stage 2 MUACO’s

“Stage 3 MU”PCMH

3-Part Aim

Registries to manage patient populations

Team based care, case management

Enhanced access and continuity

Privacy & security protections

Care coordination

Privacy & security protections

Patient centered care coordination

Improved population health

Registries for disease

management

Evidenced based medicine

Patient self management

Privacy & security protections

Care coordination

Structured data utilized

Data utilized to improve delivery

and outcomes

Data utilized to improve delivery

and outcomes

Patient informed

Patient engaged, community resources

Stage 1 MU

Privacy & security protections

Basic EHR functionality,

structured data

Utilize technology

Access to information

Transform health care

Meaningful Use as a Building Block

8

EHR Adoption Has Reached a Tipping Point

Meaningful Use – Professionals and Hospitals Registered and Paid by Medicare or Medicaid

Source: CMS EHR Incentive Program Data as of 12/31/2013

0

100,000

200,000

300,000

400,000

500,000

Total Professionals Paid: 335,646

(64%)

Total Professionals Registered: 436,295

(83%)

527,000Total Eligible Professionals

0

1,000

2,000

3,000

4,000

5,000

Total Hospitals Paid: 4,400(88%)

Total Hospitals Registered: 4,693

(94%)

5,011 Total Eligible Hospitals

9

Total EHR Incentive Payments to All Eligible Providers and Hospitals by Month

$22 $16 $26 $31

$108 $81

$116

$276 $237

$387

$605

$831

$564

$629 $660

$623 $587

$445 $409

$536 $576

$715

$907

$1,400

$1,109

$823

$1,021

$906

$354

$723

$360 $344 $342

$419

$797

$1,451

Cumulative Total$19,438

$0

$5,000

$10,000

$15,000

$20,000

$25,000

$0

$200

$400

$600

$800

$1,000

$1,200

$1,400

$1,600

Jan

-11

Feb

-11

Mar

-11

Ap

r-1

1

May

-11

Jun

-11

Jul-

11

Au

g-1

1

Sep

-11

Oct

-11

No

v-1

1

De

c-1

1

Jan

-12

Feb

-12

Mar

-12

Ap

r-1

2

May

-12

Jun

-12

Jul-

12

Au

g-1

2

Sep

-12

Oct

-12

No

v-1

2

De

c-1

2

Jan

-13

Feb

-13

Mar

-13

Ap

r-1

3

May

-13

Jun

-13

Jul-

13

Au

g-1

3

Sep

-13

Oct

-13

No

v-1

3

De

c-1

3

Cu

mu

lati

ve A

mo

un

t P

aid

(M

illio

ns)

Am

ou

nt

Pai

d p

er

Mo

nth

(M

illio

ns)

Source: CMS EHR Incentive Program Data as of 12/31/2013 10

Stage Cumulative Capabilities 2011Q1

2013Q4

Stage 7Complete EMR; CCD transactions to share data; Data warehousing; Data continuity with ED, ambulatory, OP

1.0% 2.9%

Stage 6Physician documentation (structured templates), full CDSS (variance & compliance), full R-PACS

3.5% 12.5%

Stage 5 Closed loop medication administration 5.9% 22.0%

Stage 4 CPOE, Clinical Decision Support (clinical protocols) 10.7% 15.5%

Stage 3Nursing/clinical documentation (flow sheets), CDSS (error checking), PACS available outside Radiology

48.4% 30.3%

Stage 2CDR, Controlled Medical Vocabulary, CDS, may have Document Imaging; HIE capable

14.1% 7.6%

Stage 1 Ancillaries - Lab, Rad, Pharmacy - All Installed 6.7% 3.3%

Stage 0 All Three Ancillaries Not Installed 9.6% 5.8%

Data from HIMSS Analytics® Database ©2012, 2014 N = 5,275 N = 5,458

U.S. EMR Adoption ModelTM - Progress in 3 YearsFrom HIMSS Analytics

53%

17%31%

21%

11

Health Information Technology Informatics Competency

Critical for nursing:

• Largest number of health care providers in the US.

• 19.6% of all healthcare workers or over 3 million nurses.

Courtesy of Clancy, T. (2013). Nursing Organization Alliance Fall Summit 12

Quality and Safety Education for Nurses (QSEN) Project*

Based on IOM competenciesProposes knowledge, skill, and

attitude targets to be developed in nursing programs

Defines quality, safety, informatics competencies for

nursing

Available as guides to curricular development , certification, and

continuing education

Goal: To prepare student nurses with knowledge, skills and attitudes needed

to continuously improve the quality and safety of healthcare systems

*http://qsen.org/competencies 13

Quality• Describe strategies for

improving outcomes of care in the setting in which one is engaged in clinical practice.

• Explain common causes of variation in outcomes of care in the practice specialty.

• Describe common quality measures in the practice specialty.

Safety• Describe best practices

that promote patient and provider safety in the practice specialty.

• Describe processes used to analyze causes of error and allocation of responsibility and accountability.

Informatics• Formulate essential

information that must be available in a common database to support patient care in the practice specialty.

• Describe and critique taxonomic and terminology systems used in national efforts to enhance interoperability of information systems and knowledge management systems.

Quality and Safety Education for Nurses (QSEN) Competencies

14

Using Electronic Documentation to Measure Clinical Competence

• Are nurses documenting accurately?

• Is documentation in a structured, coded format?

• Does the data have integrity?

• Can nurses pull out data needed to engage in clinical decision-making?

• What are the right things that nurses need to do? Did they do them?

• Does a nurses’ documentation and their patients’ corresponding outcomes suggest that he/she is practicing at height of their license?

• Does the documentation of each individual nurse support building linkages between nursing care and patient outcomes?

Quality

Safety

Informatics

Clinical Competencies

15

‘Continuing Competence’ and the Learning Health Care System

• Current state of clinical documentation is a barrier to nurses demonstrating meaningful use.

• Strategies are needed to link nursing documentation to patient safety and quality measures, to nurse competency, and to organizational competency.

Institute of Medicine Report Brief (2009). Redesigning Continuing Education in the Health Professions. http://www.acrm.org/pdf/IOM_Report_Brief.pdfCommittee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine (2011). The Future of Nursing: Leading Change, Advancing Health. http://www.iom.edu/Reports/2010/The-future-of-nursing-leading-change-advancing-health.aspx

16

‘Continuing Competence’ and the Learning Health Care System

• Integration of QSEN competencies into practice settings:

– Ensures that “all health professionals engage effectively in a process of lifelong learning aimed squarely at improving patient care and population health” (IOM, 2009).

– Supports data integrity so that data entered for clinical documentation is available for secondary use and for building evidence from practice.

Institute of Medicine Report Brief (2009). Redesigning Continuing Education in the Health Professions. http://www.acrm.org/pdf/IOM_Report_Brief.pdfCommittee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine (2011). The Future of Nursing: Leading Change, Advancing Health. http://www.iom.edu/Reports/2010/The-future-of-nursing-leading-change-advancing-health.aspx

17

Advantages: Data Integrity• Improved data quality for building evidence from practice and

secondary use:– Clinical decision support– Populate quality/safety dashboards– Populate quality measures– Research

• Nurses are responsible for defining their practice through what is documented for their patients and by analyzing the impact of their practice on patient outcomes.

• Provides a means to visualize the linkage between nursing care provided, how that care is documented and patient outcomes.

• Structured coded data will be available across organizations benchmarking.

18

Demo

NDNQI Quality Dashboards

19

Summary• Adoption and meaningful use of health IT are foundational to

the learning healthcare system.• Competencies to ensure data integrity and harmonization are

also needed. • The QSEN quality, safety, and informatics competencies can

address the skills needed by practicing nurses to build a digital infrastructure, but they are not used yet in practice settings.

• Use of quality, safety, and informatics competencies across healthcare settings will ensure that data entered once can be reused for decision support, performance improvement, benchmarking, and research.

Meaningful use of health IT and integration of quality, safety, and informatics competencies into educational AND practice settings would support evidence based

practice and build the foundation for a learning health care system.20

www.amia.org

AMIA

www.amia.org

Membership

Education

Meetings

Networking

Mentorship

And more…

www.amia.org

AMIA NIWG

AMIA Nursing Informatics Working Group (NIWG)

Patricia Dykes,

PhD, RN, FAAN,

FACMI

Chair

Laura Heerman

Langford, RN, PhD

Chair-Elect

www.amia.org/NIWG

AMIA’s 450 nurse informaticians work as developers of communication and information technologies, educators, researchers, chief nursing officers, chief information officers, software engineers, implementation consultants, policy developers, and business owners, to advance healthcare.