The VHA Chief Nursing Officer Research Study: The Benefits and the Bane of Technology

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The VHA Chief Nursing Officer Research Study
The Benefits and the Bane of Technology

• Kathleen Covert Kimmel RN, MHA, CHE
• Kathleenkimmel_at_catholichealth.net
• October 23, 2003

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Agenda

• Introduction
• Trends
• IT market trends
• The Nursing Shortage
• Impact of new IT solutions
• IT use in nursing today - the IBM and VHA Survey
  findings
• The barriers to implementing IT in nursing
• The Y generations technology expectations
• Return on investment for IT
• Moving Forward

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Trends that will drive healthcare transformation
Staffing Shortages
Patient Safety Expectations
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Major technology forces are changing how we care
for patients
Patients Clinicians
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Nursing practice has changed
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There is a nursing shortage

• Current number 2.7 Million Peak will be reached
  in 2007
• From 1983-1998, average age increased by more
  than 4 years RNs under 30 declined from 30 to
  12
• Number of new nursing students is starting to
  increase in 2001 - 3.9 overall
• Turnover rates range from 5 - 27

By 2020, the of RNs will be 20 below
projected need. And it is not only a supply
problem
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The problem includes dissatisfaction with the
work -- duplicative work inefficiencies
associated with manual paper-based process
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Part of the problem is that inefficiencies in the
manual-paper based system consume a tremendous
amount of resources
Source HealthMedx.com
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These inefficiencies are expensive. For every
dollar spent on healthcare

• 75 is spent on the non-patient care activities
  of communication, scheduling, coordinating,
  supervising, and documenting care.
• 15 of resources are spent just waiting to
  provide care.

Source HealthMedx.com
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With 75 of resources consumed by non-patient
activities then it's here where the greatest
opportunities exist to improve productivity.
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Can technology help by automating processes?
Automated process tools represent electronic
software products that replace paper-based
processes and are integrated into practice
through change management and business
transformation methods
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What types of automated process and care tools
are available today?

• Document Processing and Ordering
• Computer-Based Medical Record
• Computerized Data Repositories (CDR)
• Electronic charting/documentation
• Electronic patient care plans
• Physician/Clinician Order Entry (CPOE) and order
  management
• Personal Health Record patients own their
  records VA My Health e-Vet on-line access to
  medical records

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There are automated patient care tools

• Patient care tools
• Hemodynamic monitoring interfaces
• Interfaces from smart IVs, beds, etc. Auto
  weights, escape alarms, extra large obesity beds
  with transition to standing
• Data views of lab, radiology, and other test
  results
• Remote ICU monitoring (Visicu)

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There are medication support tools available

• Medication support tools
• Electronic medication administration
  documentation
• Medication dispensing systems (Pyxis, Omnicell)
• Bar Code readers
• Drug Distribution Robots automate storage,
  dispensing, returning, restocking unit dose meds

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There are tools that help administration

• Administrative Support tools
• Staff scheduling
• Acuity Systems
• Nursing shift report.
• Shift bidding software
• Patient and equipment tracking Radio Frequency
  Identification
• PASSIVE RFID low cost, only activated when
  barcodes passes by a reader
• ACTIVE RFID higher cost, active all the time,
  can be used to find the location of products
  within the hospital
• Enterprise Master Patient Identification
• Enterprise Scheduling Systems

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There are decision support tools

• Decision support tools
• CPOE alerts and reminders
• Care paths and clinical protocols
• Formulary guidelines
• Automated cash register functions
• Outcomes assessment tools
• Intelligent interpretation of results

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Some common decision support systems expert rules
that are part of CPOE to prevent (ADEs)

• Perform checks in background
• Drug-allergy Dose ceiling Drug-lab
• Drug-drug Drug-patient Drug-food
• Drug-diagnosis Drug-weight (pediatric dosages)

Examples of rules for clinical decision support
using expert systems Anticoagualtion Aminoglycosid
e monitoring Digitalis and low
K Metformin-IV dye interaction K renal
failure Potassium-Digoxin interaction
NPO-hypoglycemic meds Gentamicin renal status
IV dye-prehydration Metformin-age-renal function
interaction
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Supporting technology is also a factor

• Wireless 802.11a 802.11b
• 802.11g increases volume 4 to 5 more users
• Standardized Medical Vocabulary
• SNOMED available without charge
• HL7 integration, interoperability standards
• Data Warehouse and Data Marts
• Clinical Dashboards
• Bioterrorism Syndromal Surveillance
• Predictive modeling

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Introducing the VHA CNO on-line research study
The VHA wanted to know???
2,200 member organizations

• How prevalent are the use of automated process
  tools in their hospitals and what are their
  plans?
• Are there improvements in nurses satisfaction
  related with the use of automated process tools?
• Can automated process tools help attract and
  retain nurses?
• Would using tools improve patient safety and
  clinical quality?

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Who we asked and who completed the survey

• On-line e-survey
• 1,100 VHA Chief Nursing Officers
• 236 completed the survey

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Would automated tools reduce medical errors?

• 79 of CNOs agreed

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What is the current state of technology?

• Over 80 have
• Data views of results reports
• Medication dispensing systems such as Pyxis or
  Omnicell
• Electronic clerk order entry of MD written orders
• Approximately 50 have
• Admission assessments
• Electronic nurse charting
• Electronic care plans
• Fewer than 33 have
• Computerized Physician Order Entry
• Electronic Medical Records
• Electronic medication administration
  documentation
• Barcoding for medication administration

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What are their priorities for adding automation?

• Computerized Physician Order Entry
• Electronic medication administration
  documentation
• Barcoding for medication administration
• Nurse charting
• Admission assessments

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Thinking of automated process tools

• Paperless information technology is about having
• the right information
• at the right time
• for the right patient
• in the right place, such as the bedside!

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How do you think CNOs felt?

• Would tools improve efficiency?
• Would tools decrease paperwork?
• Would tools increase nursing satisfaction and
  recruitment?
• Would tools facilitate providing a higher level
  of care?
• Would tools give nurses more time for patient
  care?

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The CNOs told us

• 40 did not agree that IT would improve
  efficiency and decrease paperwork
• 50 did not agree that it would increase
  satisfaction or recruitment, allow more time for
  direct care, or improve clinical quality

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At this point, there is a conundrum

• If the IOM report tells us about the magnitude of
  medical errors
• And if 80 of chief nursing officers believe that
  in healthcare (as in almost every industry)
  information technology improves quality and
  decrease costs
• Then, why is it that half of nursing executives
  question the value of automated process tools?

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What did the CNOs tell us were the barriers?

• The number one perceived barrier was COST
• But, the healthcare literature results from
  other industries demonstrate a positive ROI
  (David Bates and The Big Payback Hospitals
  Health Networks, July 2001)

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The real barriers are

• Push back from physicians and administration
• Lack of willingness to set clinical
  transformation as a top priority and stay the
  course -- going for a quick fix versus an
  integrated solution
• Lack of tried and true products and
  implementation processes that are integrated,
  easy to install and easy to use

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The real barriers said differently

• Patient safety, clinical quality, and process
  simplification using IT would be helpful but
• Transformation, implementation, and training are
  a tremendous drain of both time and money
• It represents a hard road, -- requiring
  persistence, leadership, perseverance, and
  fortitude to overcome resistance to change
• Non integrated systems double or triple the
  workload and can introduce errors
• And, we just dont have the skills or resources
  to do it

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A successful CPOE system is also integrated
Nurse
Physician

• Views new orders and alerts
• Verifies medications
• Verifies clinical information (allergies)
• Records med admin (MAR)
• Develops monitors use of drug protocols
• Monitors use of formulary
• Conducts documents medication surveillance

• Accesses CPR views clinical status
• Places orders, uses order sets clinical
  protocols
• Tracks status of orders
• Responds to messages (co-signatures, passive
  alerts)
• Documents response to treatment
• Develops clinical CPOE content

Pharmacist

• Views new orders and any previous alerts with
  alert response
• Verifies medications
• Verifies clinical information (allergies)
• Develops and monitors use of drug protocols and
  medication surveillance
• Monitors use of formulary
• Conducts ADE research

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There are some basic building blocks

• Enterprise Master Patient Index
• Workflow process and data integration
• Architecture to support secure, fast, and
  reliable system
• Organizational effectiveness user acceptance
• Computer-based patient record

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CPOE is complex and workflow-based, involving
clinical applications, infrastructure, and
organizational effectiveness. It is not a
standalone application.
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Moving forward is a patient safety and efficiency
imperative. You need to lead!

• Prioritize the automated process tools that fit
  with your hospitals IT strategic clinical
  technology plans
• Take charge Lead dont let IT run the show
• Implement an integrated clinical package, versus
  building a custom solution
• Factor in business transformation of work
  processes - this is often under budgeted and is a
  critical success factor
• Understand that Inefficiencies in nursing
  processes contribute to dissatisfaction and
  turnover
• Know that automated process tools need to
  demonstrate improvements in efficiency
  effectiveness

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To Summarize, the main points for you to take
away are

• Clinical IT is one of the biggest priorities for
  HC IT in 2003 - source HIMSS 2002
• Inefficiencies in nursing processes contribute to
  dissatisfaction and turnover
• Automated process tools need to demonstrate
  improvements in efficiency effectiveness
• The next generation of nurses must address
  nursing issues and be drivers of setting IT
  expectations

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The Y generation will force a change in how we
use technology

• Children and teens are the highest users of the
  Internet
• 90 of children between 5 and 17 use computers at
  home or in school
• Nursing students are using mobile computing
  devices

source US Deot of Commerce Study, A Nation on
line http//www.esa.doc.gov/58/esa/USEconomy.htm
Columbia Nursing Students given handheld
devices- source Health Data Management, Feb. 20,
02
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Conclusion There are no short cuts. Short cuts
lead to set backs. Do it right the first time.

1. Automate and Support the Workflow How do
we do the work electronically?
? Clinical Data Repository ? Results
Viewing/Notification ?
Clinician/Physician Order Entry ?
Clinical Decision Support ? Nurse MAR
? Pharmacy Integration ?
Intelligent Medical Devices ? Integrated
Structured Documentation ? Charge
Capture/Billing/Coding
3. Improve Outcomes How can we do it
better? Rules On-line References Protocols Man
datory/Optional
2.Measure Outcomes How well did we do
it? Health Status Patient Satisfaction Cost
Utilization Analysis Clinical Results Analysis
Level of resource commitment
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Your leadership determines the future
Thank you!
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Appendix

• Definitions
• Automated Medical Record (AMR) Medical record
  created by scanning paper documents (document
  imaging).
• Electronic Medical Record (EMR) Electronic
  record of a single episode, encounter or visit or
  patient stay.
• Computer-Based Patient Record (CPR) - Electronic
  record created for multiple encounters, episodes
  or visits or patient stays.
• Electronic Health Record (EHR) Electronic
  Patient Record that is extended to cover wellness
  and preventative care (lifetime health record
• Personal Health Record (PHR) A private,
  comprehensive, longitudinal, portable health
  record managed by the patient. The patient grants
  access to care givers