CHIMSS NIC Roundtable May 9, 2006

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CHIMSS NIC RoundtableMay 9, 2006

• Industry Conference Update

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Technology Informatics Guiding Educational
Reform The TIGER Initiative
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TIGER Executive Council

• Marion Ball, Ed.D
• Connie Delaney, PhD, RN, FAAN, FACMI (Co-Chair.
  ANI)
• Donna DuLong, RN
• Brian Gugerty, DNS, RN (Chair, Fund-Raising
  Committee)
• Angela Barron McBride
• Joyce Sensmeier MS, RN, BC, CPHIMS, FHIMSS
  (Co-Chair, ANI)
• Diane J. Skiba, Ph.D., FAAN, FACMI
• Michelle Troseth, RN, MSN (Chair, Program
  Committee)
• Charlotte Weaver, Ph.D.

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History

• July 2005 National Coordinator Announcement
• January 2005 Johns Hopkins Meeting
• Summer 2005 IOM Submission
• November 2005 IOM Approval
• January 2006 Release from IOM
• October 30-November 1, 2006 TIGER Summit

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TIGER Vision

• Allow informatics tools, principles, theories and
  practices to be used by nurses to make healthcare
  safer, effective, efficient, patient-centered,
  timely and equitable
• Interweave enabling technologies transparently
  into nursing practice and education, making
  information technology the stethoscope for the
  21st century

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TIGER Stakeholders

• Alliance for Nursing Informatics
• Nursing Organizations
• ANA, AONE, AACN, AORN, etc
• Government Agencies
• Military-Chief Nurses
• Vendor Community
• Academic Institutions

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Tiger Summit

• Invitational Conferences
• 120 Participants
• Uniformed Services University of Health Sciences
• Bethesda, MD
• Keynote Panel Presentations
• Exemplars Clinical and Academic
• Gallery Walk

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SUMMIT Outcomes

• Publish a report, including Summit findings and
  exemplars of excellence
• Establish guidelines for organizations to follow
  as they integrate informatics into academic and
  practice settings and
• Set an agenda whereby the nursing organizations
  specify what they plan to do to bridge the
  quality chasm via IT strategies.

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Actionable Plans

• Individual nursing organization will develop
  collaborative action plans to increase the
  knowledge and skills of nurses to practice in an
  informatics rich and consumer centric health care
  environment
• Identify organizations or partnerships that can
  help them accomplish their action plans
• Agree to commit a point person who will respond
  to evaluation surveys and reporting mechanisms

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Actionable Plans

• Agree to accomplish at least 85 of their
  established short-term (first year) goals, and
• Agree to accomplish 100 of long term goals
  within the three year time span.
• Evaluation
• Goal Attainment
• Diffusion Index

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TIGER Summit

• Evidence and Informatics Transforming Nursing
• October 30-November 1, 2006
• Uniformed Services University of the Health
  Sciences
• Bethesda, Maryland

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HIMSS Annual Conference and Nursing Informatics
Symposium

• Michele Norton MS RN
• Terri Barylak-Roge BSN RN

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HIMSS NI Symposium

• Dr. Carol Romano CNO US Public Health Service
• The role of informatics in improving the health
  of all people in our country
• Caring for public health begins with caring for
  individuals and linking information so that it
  can be used to improve the care and outcomes
• Federal initiatives- ONC, CMS, VA health e vet
• Technology- systems to assist Public Health,
  biosurveillance and health promotion
• HIMSS NI Taskforce and Partners Survey- Impact of
  HIT on interdisciplinary communication
• Respondents agree that HIT support the role of
  nurses and communication
• Key areas where we need to focus our work
  interoperability, promoting care efficiency and
  usability- global deployments
• Barriers to Effective Comm dual processes,
  information silos, HIT tools not optimized
• .

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HIMSS NI Symposium

• UKs National Health Service Connecting for
  Health-Barbara Stuttle
• Nurses function as information repositories
• A key challenge-nurses and informaticists to take
  a transformational approach to design and
  implementation of IS
• Develop competencies to support transformation
  from a paper to electronic world
• design technology so it is viewed as an enabler,
  not a barrier to transformation

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HIMSS NI Symposium

• The evolving role of informatics nurses- Leslie
  Nicol
• link of past and future roles- nursing-nursing
  informatics
• Nursing Informatics education and roles
• HIMSS NI Survey
• MA Regional Data Exchange initiatives- Cindy Spur
• RHIOs for information sharing through the MA
  Share project.
• Steps to share information, link care in MA
• Nursing/Interdisciplinary communication missing
  from RHIOs

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HIMSS NI Symposium

• David Cornwall described the benefits of
  informatics, technology and telehealth in an
  integrated HC delivery system including care
  coordination, clinical outcomes, decreased costs
  and improved satisfaction.
• Rosemary Kennedy and Susan Matney talked about
  strategies for success and the value associated
  with integrating structured terminology within
  the electronic health record to improve the
  processes and outcomes of care.

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HIMSS NI Symposium

• Using Benchmarking to Quantify Benefits in HIT
  Implementation- Judy Murphy
• Diagnostics- use benchmarks to determine area of
  focus and goals
• Assess baseline measures
• Design and Implement IT
• Remeasure
• Disseminat improvements or action plan

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HIMSS NI Symposium

• Nancy Lorenzi presented the Success Factor
  Profile
• A practice guideline for selecting an
  implementation site to improve the probability of
  system acceptance and success.
• Reasons for project failure
• Communication
• Culture
• Underestimation of complexity
• Scope creep
• Organizational issues
• Technology
• Training
• Leadership
• Strategies for Success
• Understand IT and users
• Demonstrate value
• Engage clinicians early and continuously
• Reach and teach
• Leverage knowledge and experience

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HIMSS NI Symposium

• Leah Curtin- The Future Moving from
  Impossibility to Probability
• When the unthinkable becomes thinkable, it
  moves from the realm of impossibility to
  probability
• Genomics
• Designer drugs
• Teleportation
• Biometrics
• Implanted electrodes in brain- run smart room

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HIMSS Conference Themes

• Interoperability
• Focus on HIE, vendor showcase, EHR Standards
• RHIO Research Launched-federal gov will begin
  research effort to support the evolution and
  maturation of regional health information
  organizations
• HIMSS RHIO Federation
• Evolution toward consumer centered care
• State initiatives funding/organization/support of
  RHIO initiatives- Tennessee

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HIMSS Conference Themes

• Reducing Error/Improving Care
• Reduce Variances by
• CPOE order sets, vocabularies, knowledge
  management
• Programming tools
• Alerts dynamically fed by the database
• Paging, faxing, clip boards
• Decrease medication turn around time
• Accurate and timely data
• Evidence based clinical decision support
• Clinical systems with embedded clinical decision
  support

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HIMSS Conference Themes

• Integration of EBP into HIT improving quality of
  care
• Pay for performance- Quality incentives
• Successful implementations- CPOE
• Transforming Healthcare
• The Katrina Story-

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AONE April 2006

• Teresa McCasky, MBA, RN,BC
• Chief Nursing Strategist

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AONE

• Introduction to AONE
• The American Organization of Nurse Executives
• AONE is designed for Nursing Executives and Nurse
  Leaders
• CNO and Nursing Managers
• Annual Meeting
• 6000 attendees in 2006
• Next year in Washington DC

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AONE

• 2006 KEYNOTE Presentation with Dr. Mae
  JemisonHealth Care Technology Powering
  Nursings Future

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AONERescue Me  The Value of Empowering Nurses
to Initiate Rapid Response Teams

• RRT is part of the IHI 100,000 lives campaign
• UPMC presented
• RRT usually mean no physician on the team
• MET (medical emergency team) typically has a
  physician on the team
• Finding great results, improved outcomes,
  empowered nurses
• How to start?
• For small hospitals, hard to justify budget
• Start with what you have, current code blue team
• New term new miss code blues
• Many pt saves being documented ( 30 decrease in
  code blue)
• Good web link www.metconference.com
• Family RRT teams ( helps with pt satisfaction)

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AONE

• PLENARY SESSION with Dr. John IzzoReawakening
  the Soul--Renewing Joy Wonder at Work
• REMEMBER why you got into nursing
• Remember why you do this work, write it down
• What nurses do, does matter, patients do care
• Books
• Radical Loving Care
• Enlighten Leaders
• Video on patients perspective of care

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AONE

• Wharton Lecture with Dr. Roch Parayre How Blue
  is Your Ocean? 
• What does your organization want to be known as?
• Patient experience of care ( is it personalized?)
• How do you make nursing indispensable?
• Role changes, shortage?
• What will nursing be like in the future?
• If your value straddles competition, its a red
  ocean
• Reinvent your core value curve
• How do you change the game to make competition
  irrelevant?
• Cirque du Soleil

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AONE

• Multi-Site Study of How Medical-Surgical Nurses
  Spend Their Time
• Ann Hendrich, MS, RN, FAAN, Robert Wood Johnson
  Fellow Vice President of Clinical Excellence,
  Ascension Health, St. Louis, MO and Marilyn
  Chow, RN, DNSc, FAAN, Vice President, Patient
  Care Services, Kaiser Permanente, Oakland, CA.
• 4 methods of workflow analysis used, try to
  understand what nurses spend their time on
• Results
• Spend 10 seconds in one spot
• Walk on average 6 miles per shift
• Understand the physical impact on nursing
  workload and stress
• Need to understand work environment before you
  can change it
• Impact direct patient care

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AONE

• Common Themes of Conference
• Leveraging Energy and Dreams The Power for
  Nursings Future
• Unionization
• What will happen to the workforce
• AONE would like to enhance the workforce
• 9 elements of care, defined by NOA
• Patient Safety, key focus
• Requires collaborative communication
• Empowering nursing and nursing
• CNOs big worry, lack of recognition and
  acknowledgement of the work nurses do ( C suite
  and pts)
• TCAB ( transforming care at the bedside)

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AONE

• AONE Institute Annual Lecture with Dr. Mary
  BlegenPatient Safety Process and Outcomes Nurse
  Staffing and Work Environment
• Key finding research does not support the
  premise that bar coding medications decreases
  errors.
• Hard to do pre and post studies when technology
  in place ( error reporting poor in manual world)

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AONE

• Nursing intensity billing for hospitals
• John Welton, PhD, RN, Professor of Nursing and
  Mary Fischer, RN, MSN Medical University of
  South Carolina, Charleston, SC.
• CMS bill 1488P
• Debasing DRG model
• More focus on med/surg and not surgical
• Control cost
• Payment based on cost of care, not charges
• ?? Move nurse charges to charges based on
  service, not room/bed charge

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AONE

• Dr. Phyllis KritekCelebrating the Legacy of
  Nursing Leadership Writing the Story of the
  Future
• First time 4 generations are in the workforce at
  same time
• Classics
• Boomers
• Gen X
• Gen Y

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AONE

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ANIAAutomated Patient Care Innovations in
Nursing Informatics April 2006

• Michele Norton MS, RN, INS

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ANIA

• Writing for Publication in Nursing Workshop-
  McKesson
• A workshop walking attendees through the writing
  process, resources, tips, targeting journals,
  letters to the editors etc

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ANIA

• Keynote- Carol Romano CNO US Dept PH
• Nursing as translators of information,
  information literacy- Public Health
• Priorities for Health- prevention, preparedness,
  health literacy
• Public Health globalization- telenursing,
  connectedness
• PHR
• IT- Culture/technology and innovations

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ANIA

• Innovations Beyond the Lab
• Emerging Practice/academic partners
• IOM Workforce challenge-preparing nurses for the
  future
• Johns Hopkins/Eclipsys
• Nursing education/next generation

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ANIA

• Establishing a Foundation for Innovation Dont
  Fall to pieces over pt. safety
• Importance of dialogue techniques
• Have meaningful conversations about patient
  safety
• Healthy culture

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ANIA

• Going from good to great- A sustainable approach
  to meeting regulatory compliance
• Key Clinical Initiatives-core measures, falls,
  med rec, hand offs etc
• ? focus on clinical pathways/processes
• Develop technology and systems that support
  quality outcomes
• Role of nursing with quality measures
• EBP
• Compliance tools-continuous evaluation

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ANIA

• Pay for Performance
• Quality initiatives
• Under treatment of pt
• Financial incentives
• Variability leads to safety issues
• Clinical Focus
• Both patient and aggregate clinical data
  collection
• Efficacious care optimizing quality and cost
  --not under treating or over treating
• Outcomes (associated with cost merging clinical
  and financial data)
• Achieving practice standards that are evidence
  and research based

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ANIA

• High Touch/High Tech Nursing
• Importance of Emotional Intelligence skills in
  nursing leadership and change management
• Adoption of technology

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The NANDA, NIC, NOC AllianceMarch 2006

• Kathleen Kimmel RN, MHA, CHE

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NANDA NIC/NOC Alliance

• Background
• The North American Nursing Diagnosis Association
  (NANDA) began in 1973 and was officially founded
  in 1982. In cooperation with the University of
  Iowa, NANDA has developed a nursing practice
  taxonomy and structure. NANDA accommodates
  interventions and outcomes from the Nursing
  Interventions Classification (NIC) and Nursing
  Outcomes Classification (NOC).

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NANDA NIC/NOC Alliance

• EHRs Optimizing e-Nursing Data - Nancy Staggers,
  Intermountain Healthcare
• The 1st EMR was at El Camino hospital in
  California in 1968, (Technicon, TDS). Technology
  has been around for 38 years, but the incentives
  have not been there to move the adoption and the
  technology forward
• US economic incentives have not helped stimulate
  EHRs.
• Stressed the importance of user-centered product
  development.
• Called for predictive modeling for EHR
  implementations
• RHIOs will have interoperability challenges that
  stem from not having standards

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NANDA NIC/NOC Alliance

• Nursing Intervention Classification (NIC) Update
  Gloria Bulechek, Univ of Iowa
• NIC is a standard language that names and
  describes the treatments that nurses perform.
• NIC interventions are both physiological and
  psychological
• The NIC book is in its 4th edition. It includes
  linkages with NANDA
• There are 514 interventions
• Licensed for inclusion into SNOMED in 2002
• Translated into nine foreign languages

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NANDA NIC/NOC Alliance

• Nursing Outcomes Classification (NOC) Update Sue
  Moorehead, Univ of Iowa
• NOC is beneficial for evaluating care over time
  and across settings of care.
• Believes older nurses have a more difficult time
  thinking about outcomes and goals
• The rating score has changed. It now includes 1)
  positive (rating increased) 2) negative (rating
  decreased) 3) rating stayed the same
• Includes time frames frequent and non-frequent
  outcomes. For example, quality of life is
  unlikely to change frequently. However, pain
  status might change frequently
• Also in nine languages
• Linked with NANDA and Gordons Functional Health
  Patterns
• Moving away from using the terms, terminology
  and languages to calling it effectiveness
  research.

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NANDA NIC/NOC Alliance

• Using the Omaha System to Describe what is inside
  the Black Box
• Kathryn Bowles, Univ of Pennsylvania Background
  
• The Omaha System is a research-based,
  comprehensive and standardized taxonomy designed
  to enhance practice, documentation, and
  information management.
• Consists of three components the Problem
  Classification Scheme, the Intervention Scheme,
  and the Problem Rating Scale for Outcomes.
• Work on the Omaha system began in 1970 through
  the efforts of the Omaha Visiting Nurses
  Association.
• Presentation discussed the Advanced Practice
  Nurse (APN) program at the Univ of Pennsylvania.
  
• Focus on an interdisciplinary program to improve
  outcomes and reduce costs for high risk elderly
  using APNs.
• Most of the data on this research project has
  been collected manually
• They are partnering with two Aetna plans and one
  Kaiser plan to determine if their model of
  translating research to practice is feasible in
  the real world.
• The patients they treat have an average of 8
  active problems at one time.
• High interest in determining the relationship
  between patient knowledge and behavior change.

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NANDA NIC/NOC Alliance

• Computerized Cross-Mapping with Linguistic
  Optimal Mapping Technique Implications for the
  Standardization of International Nursing Practice
  Marge Simon Colier, Univ of Connecticut
• Presentation focused on the ability to cross map
  Axis 1 nursing concepts/diagnoses of NANDA
  taxonomy II with those of the International
  Classification of Nursing Practice (ICNP)
• In order to adapt their optimality theory, they
  created an optimal mapping technique (OMT). How
  it works for each NANDA input there is a set of
  possible ICNP outputs that are generated
• Universal constraints and violable constraints
  are used in the mapping process

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NANDA/NIC/NOCUsing Nursing Outcomes to Define
the Role of the Clinical Nurse Leader Sally
Decker RN PhD

• The role of the clinical nurse leader (CNL) was
  defined as overseeing the care coordination of
  group of patients.
• A CNL evaluates patient outcomes, assesses
  cohort risk and has decision making authority to
  change care plans when necessary. The CLN serves
  in the role of an Outcomes Manager
• Five common outcomes were identified
• Patient satisfaction
• Symptom reduction
• Compliance/adherence
• Knowledge of patient/family
• Quality of Life
• The CNL is also interested in care delivery
  processes and collaboration between healthcare
  providers (i.e., how accurately did the provider
  meet the needs of the patient
• Recently new psychosocial outcomes were added,
  such as perception of being well cared for and
  trust in your provider

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Meeting Magnets Research Criteria with Studies
of NANDA, NIC and NOC Christa Minthorn,
Hackettstown Regional Medical Center

• The use of NANDA, NIC and NOC (NNN) to meet the
  research criteria for Magnet status.
• There are 14 Forces of Magnetism, which form the
  framework for accreditation. Force number 6,
  Quality of Care, includes a component that
  refers to research and evidence-based practice.
• Research tips for non-academic organizations are
• Educate nurse leaders and obtain executive
  buy-in. The education should include an
  introduction to research methods
• Use and operate through existing structures, such
  as shared governance councils, practice and
  quality councils
• Mentor and coach staff nurses
• Hire a nurse researcher consultant if needed
• Pay attention to privacy and research protection
  issues
• Establish budget
• Collaborate with NNN and local colleges
• Select the patient population(s)

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Organization Nursing Diagnosis for a Taxonomy of
Nursing Practice Administrative Domain Jane
Kelley, Southeast Missouri State University

• The purpose of this session was to develop
  nursing languages to meet administrative/
  organizational management requirements. Some of
  the organizational nursing problem terms are
• Nursing recruitment inadequate
• Nurse-patient ratio unbalanced
• Patient morbidity increased, related to
  unbalanced nurse-patient ratio and staff mix
• Budget variance related to increased use of
  disposable supplies
• Capital budget misaligned with strategic terms

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NANDA NIC/NOC Alliance

• Use of Standardized Nursing Language for Outcomes
  Effectiveness Research Marita Titler, University
  of Iowa Hospitals and Clinics
• This session address the topic of outcomes
  effectiveness research.
• There are three key areas 1) effectiveness 2)
  efficacy and 3) appropriateness.
• The importance of using the standardized nursing
  language in electronic documentation systems was
  emphasized with respect to articulating nursing
  contributions to patient outcomes across care
  settings.

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NANDA/NIC/NOC Alliance

• The Nursing Appointment as a Component of the
  Patients Electronic Records Miram de Abreu
  almeida, Elenara Franzen, Szana Zachia, Vera
  Lucia Dias
• This session addressed
• The usefulness of electronic appointments
• Recording of nursing actions in an outpatient
  health clinic in Brazil.
• Espoused the value of demographic information to
  track the patient longitudinally, and recording
  of nursing teaching and treatments in a primary
  care setting.

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NANDA/NIC/NOC Alliance

• Care Planning with Electronic Problem List and
  Care Set Functions Jane Brokel, Cindy Nicholson,
  Trinity Health, Novi, Michigan
• The purpose of this session was to identify the
  attributing factors from admission interview and
  assessments that guide nurses to select core
  patient problems/nursing diagnoses for adults
  select nursing outcomes and interventions from a
  care set to plan the care of patients in an
  electronic health record and, to evaluate
  nurses care planning using NNN
• Most common problems in literature coincided with
  findings across 6 facilities
• Knowledge Deficit
• Self-care Deficit
• Confusion, acute
• Impaired mobility
• Acute Pain
• Nutrition, less than requirements
• Risk of Injury
• Impaired Skin Integrity
• Impaired Tissue Integrity
• Impaired Gas Exchange
• Ineffective Breathing Pattern
• Fluid Volume Deficit
• Fluid Volume Excess
• Conclusions 1) approach patient situations in
  terms of outcomes and eliminate the list of
  problems 2) integrate clinical decision making
  into the workflow 3) use standardized language

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NANDA/NIC/NOC Alliance

• Nursing outcomes Classification (NOC) in SNOMED
  CT A Cross-mapping Validation Debra Konicek
  Connie Delaney
• Purpose of the study was to validate a
  back-mapping of NOC into SNOMED-CT, with NOC as
  the source system and SNOMED-CT as the target
  system.
• Researchers used a knowledge representation
  comparison between source and target systems.
• Findings Only 4.8 of cross-mapped NOC concepts
  were mis-assigned in SNOMED-CT. SNOMED-CT is a
  good reference terminology model

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NANDA NIC/NOC Alliance

• Economic Evaluations and Usefulness of
  Standardized Nursing Terminologies Patricia Stone
• Objectives of this session were to demonstrate
  why we should care about the money review
  different types of economic analyses commonly
  found in healthcare literature discuss the
  potential roles of standardized terminologies in
  providing cost and outcome data useful in
  economic evaluations. Presenter described types
  of economic evaluations
• Cost Minimization used when health outcomes are
  equivalent. Goal is to find the least costly
  alternative
• Cost Consequences no attempt to aggregate costs
  and effects into one outcome measure. An array
  of consequences is usually presented.
• Cost Effectiveness (cost utility) effects
  expressed in their natural units. Cost
  effectiveness important not to look at average
  cost effectiveness. Cost Utility analysis look
  at per quality of life year gained. Use the
  QUALY summation of TU. T time in health
  state, U utility of health state
• Cost Benefit both cost and consequences valued
  in monetary terms requires placing a dollar
  value on health outcomes
• Presenter challenged the NNN group to utilize
  standard terminologies to conduct economic
  analyses

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NANDA NIC/NOC Alliance

• The Importance of Perspective and Primary Focus
  in Choosing and Measuring Outcomes Sue Moorehead,
  University of Iowa
• Focus of this session was to consider whose
  perspective should be considered when selecting
  NOC outcomes for measurement, i.e. patient,
  family, caregiver, nurse, members of the
  community, etc.
• Key Points
• More work needed in NOC to better represent
  perspective
• Education of staff nurses needs to include a
  discussion on the importance of perspective on
  outcome selection
• Definitions are a useful tool to determining the
  focus of an outcome
• Measurement of pain level in NOC is not the same
  thing as using a ten point pain scale
• When measuring outcomes of care nurses must
  carefully select sources of information to
  measure an outcome to not violate the focus of
  the outcomes being measured
• Most NOC outcomes are evaluated from the
  perspective of the nurse as expert
• Adding outcomes that include the patient
  perspective is an important criteria for
  evaluating care provided by nurses
• Without the patient perspective it is difficult
  to evaluate the human responses to illness

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NANDA NIC/NOC Alliance

• A Secondary Analysis of Selected Patient Factors
  Associated with the Status of Nursing-Sensitive
  Patient Outcomes Peg Kerr, University of Iowa
• Research sought to assess the ability of specific
  patient characteristics (age, gender, primary
  medical diagnosis, comorbid medical diagnoses,
  and socioeconomic status) to explain variation in
  change in each of four selected NOC outcomes
• Implications for practice
• Awareness of those at risk for poor outcomes
• Development of profiles of risk to incorporate
  into electronic health records risk alerts
• Development of risk adjustment methods to
  meaningfully interpret institutional-level
  reporting of outcomes

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Upcoming Events

• May 20-24 Toward Electronic Patient Records
  TEPR-Baltimore
• June 11-14 NI 2006- 9th Annual International
  Nursing Informatics Conference- Seoul
• July 19-22 SINI- Summer Institute of NI-
  Baltimore
• October TIGER Summit
• November 11th AMIA NI Symposium RHIOs Nursing
  at the Center of Care
• http//nursing.umaryland.edu/snewbold/sknconf.htm