REPORT ON THE SUMMER INSTITUTE OF NURSING INFORMATICS 2006
The Summer Institute of Nursing Informatics (SINI) 2006, "Advancing Clinical Practice Through Nursing Informatics," opened on Wednesday, July 19, with introductions and a welcome from Janet Allan, Dean of the School of Nursing at the University of Maryland. She reminded all of us that information and technology have changed the way that we relate and are going to relate to healthcare and that informatics is relevant to every nurse, not just those in the specialty. The need for a clinical transformation informed the themes of many speakers at the conference, who collectively stated that "because we have always done it this way" is an outmoded concept.
Dr Don Detmer, President and CEO of AMIA and Professor of Medical Education at the University of Virginia, was the first keynote speaker. He stated that informatics is essential but not sufficient for greater value in healthcare, a statement echoed by many speakers. There is a separation between information technology (IT), which is hardware and software, and informatics, which involves items related to how and when the technology is used, including change management, usability, organizational culture, workflow, and an increase in productivity. He stated that the information infrastructure must operate so that information can be shared and that it must deliver not only patient care data but also knowledge. To provide top quality healthcare, which means delivering knowledge, it is necessary that the information infrastructure integrates personal health records, patient care records, and public health population information. These should all be available through an interlocking computer-based health record. The informatics infrastructure must network all care sites, link all health workers and patients, and include formal interdisciplinary informatics education and research. Barriers to these transformations are misaligned financial incentives, low capital availability, and lack of interoperability. He stated emphatically that the US is behind the rest of the world because we cannot even "get our act together" for unique provider and patient identifiers. He pointed out that while we are worrying about who controls the data, the rest of the world are conducting research on their data. Showing his knowledge of the different need of medicine and nursing, he stated that buying IT systems is often more dependent on the needs of physicians than those of nurses. To solve this, he suggests an integrated system with the patient as the center of focus. Dr Detmer strongly supports integrated informatics and stated that only 25% needs to be specialized in domains such as nursing and medicine. Many of these comments were in response to questions from the audience. The federal government pays for 75% of healthcare, but if we are to achieve an information infrastructure and integrated computerized patient record, it will require pressure from the middle class; thus, we need to educate them.
Thursday morning opened with a talk by Michael S. Zamore, a policy advisor to The Honorable Patrick J. Kennedy and cochair of the 21st Century Health Care Caucus. Mr Zamore pointed out that the increase in healthcare expenditures is an unstainable trend and that our outcomes are out of line with our spending. There are no villains in this; the problem is that the system is not designed to get the best possible outcomes for patients at the lowest possible cost. We have some of the best hospitals, doctors, and nurses, but the system does not work well. The need for a healthcare system, not a sick care system, is needed. One difficulty in changing healthcare is the culture. A study of pilots and physicians in which each was asked if it were appropriate for junior members of a team to question the senior members revealed that 90% of the pilots said it was, while only 50% of physicians had this opinion. He reported on a statewide initiative in Rhode Island for ICU improvements that emphasized teamwork and empowering the nurse. Some of the outcomes show a great improvement in patient care, and the rate of nursing retention skyrocketed. He stated that we are not using the knowledge we already have and that too much money is spent on care that does not result in improved outcomes. Tinkering around the edges will not solve a problem with the system. Mr Zamore echoed Dr Detmer in stating the need for interoperability standards. Information technology systems should be built so that they can use standardized performance measures to report quality. Although he was not optimistic about the chance for any bills this year to address these problems, he stated that this transformation is a bipartisan goal, noting that Washington is built for gridlock in more places than the Beltway. The reality is that there are limited federal resources, and we must consider ways to use any money for real change. Mr Zamore pointed out that the money for the creation of information systems is supposed to come from hospitals and physicians, but that it is the payers who benefit. He believes that there can be collaboration in this area to equitably divide costs. A large barrier to IT could be consumer rebellion against a lack of privacy in an integrated system. He proposed that individuals have absolute control over who sees what in their records, that they be able to opt out of the system, that breaches be disclosed, and that all who control another's information be bound by privacy rules. He closed by stating that every day that we waste in tackling these problems produces more unnecessary deaths.
The distinguished lecturer was Dr Victoria Bradley, Director of Patient Information at the University of Kentucky Hospital, and the topic of her address was "Transformation of the Work Environment through Information Technology." Dr Bradley detailed the sorry state of healthcare: fragmentation and lack of information produce poorly designed care processes that result in errors, unnecessary duplication of services, long waiting times, and delays, with poor outcomes. Healthcare today has many problems, among them are increased costs, lack of equity in available healthcare, the nursing shortage, and information explosion. Lack of robust information systems and care standardization contribute to medical errors. It is estimated that Health Information Technology (HIT) could save $10.6 billion in outpatient expenditures and $31.2 billion in inpatient spending. Most of the literature on multifaceted HIT systems comes from homegrown systems such as the Department of Veterans Affairs, Intermountain Health Care (formerly LDS), and Women's Hospital/Partners Healthcare, with little study on the effects of multifunctional vendor systems. One of the major efficiency benefits of HIT is the decreased use of care, which provided an example of Mr Zamore's point about the lack of equitability in costs of IT; expecting care providers to spend money to decrease their income is unrealistic. Dr Bradley emphasized the importance of evaluating the outcomes of HIT implementations, in terms of both user acceptance and patient outcomes. "Did we improve outcomes?" is a question that must be asked of every implementation.
Dr Kathryn Hannah, President of HECS, Inc, and Professor in the Department of Community Health Sciences, Faculty of Medicine at the University of Calgary, presented the Cerner Distinguished Lecture, "Lighting the Way for Modern Nurses With Nursing Informatics." Starting with some history, she stated that Florence Nightingale was our first statistician. Ms Nightingale also loved technology and could also be regarded as our first informatics nurse. The fact that data, especially when recorded after the fact, can be inaccurate was illustrated with the traditional picture of Florence Nightingale with the lamp that we associate with her and a picture of the actual lamp that Ms Nightingale used-a huge difference. Dr Hannah reiterated earlier talks about the increasing costs of healthcare and the "super abundance" of data from many sources, including reporting requirements, litigation protection, and the many research findings. Although good data are needed for good decisions, the human mind cannot keep track of all the data. To add to this, there is a shifting paradigm from institutional to home care and a maldistribution of RNs and MDs, leaving rural areas underserved. On top of these problems, we want healthcare to be efficient and have good outcomes. Dr Hannah presented a broad interpretation of health informatics, stating that it is a unique combination of "knowledge of health services delivery, technology, applications, information, methodologies, and data management processes" that meet the needs of the health system for integrated information. Currently, there are gaps in the information available for many areas, such as policy making, evaluation and reprogramming, self-care, primary care, ambulatory care, knowledge bases, and expert systems. To transform health data into actions, we need to define the information requirements for patient care, populations, and administration. Dr Hannah stated unequivocally that "nursing care impacts patient outcomes." Nursing is a learning profession, and the nature of nursing has changed because patients have more complex health problems resulting in increased responsibility and accountability, all of which need information. Some of the changes are a move from relying on historical precedents to evidence-based care, from a micro perspective to a macro perspective, from authority based on position and results based on process and performance to an outcome focus, and from judgmental to learning. Clinical nursing has information needs related to patient care and the management of nursing resources. The goal of nursing informatics is to improve the health of individuals, families, and communities by using information and technology in many areas: direct care, administration, education, research, and lifelong learning. Information needs in patient care include demographics, client problems and outcomes, plan of care and its recording, and decision support tools. To manage nursing resources, nurses must have information about physical and fiscal resources as well as patient classification and workload management. The need for standards in nursing terminology was discussed. Dr Hannah stated that Canada has accepted SNOMED-CT as a national standard. They plan to integrate the International Classification of Nursing Practice with SNOMED to augment the nursing standards. She stated that she does not believe in nursing information systems but instead in patient-centered information systems in which unique nursing-sensitive data, such as nursing phenomena (problems/diagnoses), outcomes, and interventions, are identified and retrievable. An interesting point about documentation was made: that in the US, home care assessment is documented to justify funding, while in Canada, they document to find the needs, then funding follows.
Dr Jeffrey Goldsmith, President of Health Futures, gave the closing presentation, a discussion of the influence of informatics on the future of healthcare. Showing a slide of paper medical records with papers falling out of them, stacked on shelves, and piled in a corner, Dr Goldsmith stated that despite all the dollars spent in healthcare, we still use information systems from the Dickensian era. He then discussed some of the emerging trends, starting with genomics, which he believes will create a new business model in pharmaceuticals using this science for many purposes, such as understanding genetic contributions to individualized drug reactions and personalized therapies. Remote patient monitoring and intelligent clinical care systems are other emerging technologies. He presented the possibility of a Global Positional System for patients in which the patient's location and status would be immediately available. He believes that the electronic health record (EHR) will evolve from passive documentation to a control panel that will provide easy navigation and knowledge resources. Some of the constraints to an all-encompassing EHR are practice autonomy, the many locations of patient information, and patient and family access to records. Usability is still a big issue: "Does a system make work easier or harder?" He stated that the US will be lucky to have 50% of its physicians use EHRs within the next 10 years. On the horizon are technologies such as "eNose" that will smell an infection before it would otherwise be detected, as well as noninvasive internal organ viewing. He stated that IT is about people and asked how we can use it to reduce stress and turnover while maximizing scarce professional time. The need is to find more effective ways of providing care rather than increasing the number of healthcare workers. Dr Goldsmith closed by presenting some implications of IT for nursing. He stated that there should never be an IT installation without work redesign, a task that cannot be bought from a vendor. The objectives of an IT systems should be to reduce turnover, increase morale, decrease overtime, and increase nursing time with patients. Information needs to follow the patient and family inside and outside the hospital instead of just presenting a small slice of the patient. To achieve these ends, it is necessary to "play" with no preconceived ideas, just as children learn to use computers by experimenting with all the options.
Besides the many excellent keynote speakers, there were breakout sessions, with invited speakers covering many topics based on six overall themes: leadership, evidencebased practice, patient care technology, systems design, systems analysis and evaluation, and consumer informatics. The conference was rounded out with referred papers and poster sessions. There was also a lively panel session hosted by Dr Goldsmith that featured Dr Peter Murray (UK), Dr Kathryn Hannah (Canada), and Ms Joyce Sensmeier (US), who discussed the coming innovations.
Like in the past years, those who could not attend physically were able to see and hear the keynote speakers in a webcast. In addition, Drs Peter Murray and Scott Erdley provided an immediate Weblog of the event. For a different perspective on the speakers, information about some of the concurrent session, or reports on the social events, visit the blog at http://www.differanceengine.net/SINI2006blog/.
Contributed by
Linda Q. Thede, PhD, RN
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ROBERT WOOD JOHNSON FOUNDATION FUNDS PROJECT HEALTHDESIGN
For people to be engaged in their health and healthcare, they are required to interpret complex health data and use these data effectively. Few tools exist in the information age to help consumers manage their healthcare or aid them in pursuing good health.
Consequently, a $3.5-million Robert Wood Johnson Foundation (RWJF) project has been funded, with the objective of a national program to stimulate innovation in the development of personal health record (PHR) systems. The project aims to move the field beyond simply providing consumers with access to electronic medical records to designing a suite of PHRs that work together to help people achieve their health goals in an integrated fashion.
Project HealthDesign was established by RWJF to promote the development of interoperable PHR systems that will provide a range of flexible tools that support individuals' needs and preferences. The program will support up to 10 teams of technology designers working closely with consumers-to design and test prototypes of innovative PHR applications that can be built on a common record platform. By enlisting the expertise and creativity of designers, patients, healthcare professionals, and informaticists to design PHR systems, Project HealthDesign aims to greatly expand the ways that PHRs can support patients' specific needs and medical providers' ability to provide optimal care.
"Today's PHRs are not scalable," says Patricia F. Brennan, RN, PhD, program director for Project HealthDesign and professor of nursing and industrial engineering at the University of Wisconsin. "We need to think instead about a set of interoperative tools working on a common platform. We want to stimulate the designers and users of personal health tools to brainstorm and design a system of personal health information management, not simply create discrete records or repositories of personal health data. Project HealthDesign is less about PHRs than it is about taking a new approach to designing a range of personal health information tools."
Research shows that individuals who actively engage in their own care can achieve improved quality of life and health outcomes. Recent progress to integrate information technology into the healthcare arena has given rise to PHRs, information tools that help individuals and providers collect, track, and manage health data.
Today's PHRs, which are electronic repositories of a person's medical history and health status, generally provide people with access to institutional healthcare records or allow them to compile freestanding collections of personal health observations. Although most patients find first-generation PHRs useful, several challenges prevent these PHRs from meeting their potential. For example, many PHRs today are proprietary in nature, foiling customization efforts that would allow PHR products to meet the specific health needs of each individual or family-from the patient trying to prevent a flare-up of diabetes to the family coordinating care and multiple medications for a chronically ill child, or the baby boomer managing a parent's early dementia from afar.
Other barriers come into play as well. Institutional PHRs based on doctor or hospital records generally become inaccessible to patients when they change providers. Also, too often, PHR products developed for consumers' use at home fail to integrate effectively with institutional records.
Despite the challenges, there is widespread agreement that the potential held by PHRs is impressive and within reach. Many experts envision PHRs as the centerpiece of a national health information infrastructure, intended to improve healthcare quality and patient safety while reducing costs. A PHR in the near future could provide individual patients with easy access to their own medical records from multiple providers and help them track vital signs or condition specific data gathered by sensors in their home or workplace or help asthma patients factor weather and air quality updates into their daily health decisions, for example. The PHR then could be coupled with alerts when a person's glucose level or heart beat falls outside a reference range, remind a person to take his or her medicine, or even identify the pharmacy offering the best price on the person's prescription drugs.
The grants will be awarded in autumn 2006, with a start date targeted for December 1, 2006. Visit the Web site at http://www.projecthealthdesign.org for more details.
The RWJF, based in Princeton, NJ, is the nation's largest philanthropy devoted exclusively to health and healthcare.
PEW INTERNET PROJECT REPORT ON BLOGGERS
The ease and appeal of blogging are inspiring a new group of writers and creators to share their voices with the world.
A new national telephone survey of bloggers conducted by the Pew Internet & American Life Project finds that most people are focused on describing their personal experiences to a relatively small audience of readers and that only a small proportion focus their coverage on politics, media, government, or technology.
Related surveys found that the blog population has grown to approximately 12 million American adults, or approximately 8% of adult Internet users. The number of blog readers has jumped to 57 million American adults, or 39% of the online population.
The following are some of the key findings in a new report issued by the Pew Internet Project, entitled "Bloggers:"
* Fifty-four percent of bloggers say that they have never published their writing or media creations anywhere else; 44% say they have published elsewhere.
* Fifty-four percent of bloggers are younger than 30 years.
* Women and men have statistical parity in the blogosphere, with women representing 46% of bloggers and men representing 54%.
* Seventy-six percent of bloggers say that the reason they blog is to document their personal experiences and share them with others.
* Sixty-four percent of bloggers say that the reason they blog is to share practical knowledge or skills with others.
* When asked to choose one main subject, 37% of bloggers say that the primary topic of their blogs is "my life and experiences."
* Other topics ran distantly behind: 11% of bloggers focus on politics and government; 7% focus on entertainment; 6% focus on sports; 5% focus on general news and current events; 5% focus on business; 4% focus on technology; 2% focus on religion, spirituality, or faith; and additional smaller groups who focus on a specific hobby, a health problem or illness, or other topics.
Bloggers are avid consumers and creators of online content. They are also heavy users of the Internet in general. Forty-four percent of bloggers have taken material they find online-like songs, text, or images-and remixed it into their own artistic creation. By comparison, only 18% of all Internet users have done this. A whopping 77% of bloggers have shared something online that they created themselves, like their own artwork, phtographs, stories, or videos. By comparison, 26% of Internet users have done this.
The following are some additional data points from the bloggers' report:
* Eighty-seven percent of bloggers allow comments on their blogs.
* Seventy-two percent of bloggers post photographs to their blogs.
* Fifty-five percent of bloggers blog under a pseudonym.
* Forty-one percent of bloggers say they have a blogroll or friends list on their blogs.
* Eight percent of bloggers earn money on their blogs.
The Pew Internet & American Life Project has created an online version of the Blogger Callback telephone survey and invites participation from the general public. The resulting answers will not be a representative sample, but the online survey will give observers a chance to see the questions in context and to comment on some specific aspects of blogging. The survey is available online at the following Web site: http://www.psra.com/PewBloggerSurvey.html.
About the Pew Internet & American Life Project: The Pew Internet Project produces reports that explore the social impact of the Internet. Support for the nonprofit Pew Internet Project is provided by The Pew Charitable Trusts. The project is an initiative of the Pew Research Center. The project's Web site is http://www.pewInternet.org.
ENVIRONMENTAL PROTECTION AGENCY-FUNDED EFFORT RECOGNIZES COMPUTERS AND MONITORS FROM CTL, DELL, HP, AND OTHERS AS ENVIRONMENTALLY FRIENDLY
More than 60 desktop computers, laptops, and monitors from three manufacturers were recognized today as part of a US Environmental Protection Agency (EPA)-funded effort to identify high-performance, environmentally friendly computer equipment. All of the products meet the new Electronic Products Environmental Assessment Tool (EPEAT) "green" computer standard, and they are listed online in the EPEAT database at http://www.epeat.net.
Compared with traditional computer equipment, all EPEAT-registered computers have reduced levels of cadmium, lead, and mercury to better protect human health and the environment. They are more energy efficient, which reduces emissions of climate-changing greenhouse gases. They are also easier to upgrade and recycle. In fact, manufacturers must offer safe recycling options for the products when they are no longer useable.
The products of EPEAT are identified as EPEAT Bronze, EPEAT Silver, or EPEAT Gold, depending on the number of optional environmental criteria incorporated into the product.
"This initial list of EPEAT-registered computers is just the tip of the iceberg," according to Jeff Omelchuck, Executive Director of the Green Electronics Council (GEC), which manages the EPEAT program. "Other manufacturers are currently registering products. We're thrilled to see the race to the top as manufacturers compete to develop the greenest possible computers."
Additional details on the EPEAT standard and the searchable database listing all EPEAT-registered computer products are available online at http://www.epeat.net.
An easy-to-use tool that helps purchasers rank computer desktops, laptops, and monitors based on their environmental attributes, the three-tiered EPEAT rating system includes 23 required criteria and 28 optional criteria. The optional criteria are used to determine if the equipment receives EPEAT Bronze, Silver, or Gold recognition.
The tool EPEAT was developed over a 3-year period in an extensive consensus-based, EPA-funded process that included more than 100 representatives from environmental groups, government officials, large-volume computer purchasers, subject matter experts, electronics recyclers, and manufacturers. In developing the standard, the group integrated a wide variety of existing environmental standards and requirements into the EPEAT "umbrella" standard, including the most recent US Energy Star energy efficiency requirements, EPA's Plug-In Guidelines for Materials Management, Rechargeable Battery Recycling Coalition recommendations, Coalition of North Eastern Governors Model Toxics in Packaging Legislation, European Union (EU) restriction on hazardous substances, EU Waste Electrical and Electronic Equipment requirements, EU battery directives, and various global environmental labeling standards.
The US EPA, using very conservative assumptions, estimates that over the next 5 years, purchases of EPEAT-registered computers will result in reductions of more than 13 million pounds of hazardous waste, more than 3 million pounds of nonhazardous waste, and more than 600 000 MWh of energy-enough to power 6 million homes.
The GEC partners with environmental organizations, government agencies, manufacturers, and other interested stakeholders to improve the environmental and social performance of electronic products.
In January 2006, the council received a grant from the USEPA to promote and implement the EPEAT green computer standard. Additional information on GEC is available at http://www.greenelectronicscouncil.org