CHIMSS NIC Roundtable May 9, 2006

1. CHIMSS NIC RoundtableMay 9, 2006 Industry Conference Update

2. Technology Informatics Guiding Educational Reform: The TIGER Initiative

3. 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.

4. 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

5. 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

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

7. Tiger Summit Invitational Conferences 120 Participants Uniformed Services University of Health Sciences Bethesda, MD Keynote & Panel Presentations Exemplars: Clinical and Academic Gallery Walk

8. 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.

9. 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

10. 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

11. TIGER Summit: Evidence and Informatics Transforming Nursing October 30-November 1, 2006 Uniformed Services University of the Health Sciences Bethesda, Maryland

12. HIMSS Annual Conference and Nursing Informatics Symposium Michele Norton MS RN Terri Barylak-Roge BSN RN

13. 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 .

14. HIMSS NI Symposium UK’s 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

15. 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 RHIO’s

16. 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.

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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-

23. AONE April 2006 Teresa McCasky, MBA, RN,BC Chief Nursing Strategist

24. 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

25. AONE 2006 KEYNOTE Presentation with Dr. Mae JemisonHealth Care Technology – Powering Nursing’s Future

26. 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) Sissy Carter, RN, MSN, CNAA, BC, Nursing Director, Med/Surg Services, Baptist Hospital of Miami, Miami, FL. Carol C. Scholle, RN, MSN, Director of Critical Care and Transplant Services, University of Pittsburgh Medical Center- Presbyterian, Pittsburgh, PA. Sissy Carter, RN, MSN, CNAA, BC, Nursing Director, Med/Surg Services, Baptist Hospital of Miami, Miami, FL. Carol C. Scholle, RN, MSN, Director of Critical Care and Transplant Services, University of Pittsburgh Medical Center- Presbyterian, Pittsburgh, PA.

27. 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 patient’s perspective of care

28. 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, it’s a red ocean Reinvent your core value curve How do you change the game to make competition irrelevant? Cirque du Soleil

29. 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

30. AONE Common Themes of Conference Leveraging Energy and Dreams The Power for Nursing’s 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 CNO’s big worry, lack of recognition and acknowledgement of the work nurses do ( C suite and pts) TCAB ( transforming care at the bedside)

31. 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)

32. 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

33. 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

34. AONE

35. ANIAAutomated Patient Care: Innovations in Nursing Informatics April 2006 Michele Norton MS, RN, INS

36. 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

37. 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

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

39. ANIA Establishing a Foundation for Innovation: Don’t Fall to pieces over pt. safety Importance of dialogue techniques Have meaningful conversations about patient safety Healthy culture

40. 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

41. 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

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

43. The NANDA, NIC, NOC AllianceMarch 2006 Kathleen Kimmel RN, MHA, CHE

44. 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).

45. 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

46. 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

47. 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 Gordon’s Functional Health Patterns Moving away from using the terms, “terminology and languages” to calling it “effectiveness research.”

48. 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.

49. 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

50. 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 The CNL is different from an advanced practice nurse (APN). The CNL is a generalist while the APN has a specialized practice focus. The CNL is different from an advanced practice nurse (APN). The CNL is a generalist while the APN has a specialized practice focus.

51.  Meeting Magnet’s 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)

52. 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

53. 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.

54. NANDA/NIC/NOC Alliance The Nursing Appointment as a Component of the Patient’s 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.

55. 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

56. 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

57. 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 T*U. 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

58. 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”

59. 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

60. 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 –RHIO’s Nursing at the Center of Care http://nursing.umaryland.edu/~snewbold/sknconf.htm