Technology Informatics Guiding Education Reform Nine TIGER Collaboratives

1. Technology Informatics Guiding Education Reform Nine TIGER Collaboratives Donna DuLong, BSN, RN Program Director, The TIGER Initiative Denver, Colorado Marion Ball, EdD Professor, Johns Hopkins University School of Nursing Columbia, MD Monday, February 25, 2008 Session 53

2. Technology Informatics Guiding Education Reform The focus of the TIGER Initiative is to better prepare our nursing workforce (all practicing nurses and nursing students) to use technology and informatics to improve the delivery of patient care. We believe that necessary skills for nurses’ portfolio in 2007 includes basic computer competencies, information literacy and informatics skills. The TIGER Initiative is a program; not an organization. TIGER has been a grass-roots effort to engage with all stakeholders that are committed to a common “vision” of ideal EHR-enabled nursing practice. Today, more than 120 diverse organizations have joined this effort.

3. TIGERVision • 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

4. Background Converging forces that are serving as a catalyst for transforming nursing practice Rising cost and disparity of U.S. Healthcare system demands transformation IOM studies and reports Emerging technologies Growing consumerism Impending nursing shortage Disaster recovery preparedness

5. U.S. Health Care Workforce - Nursing Nearly 3 million practicing nurses in the U.S. More than 55% of all health care workers Nurses are knowledge workers Average age of nurse is 47 Estimated severe shortage of nurses by 2014 Nursing’s workforce must be capable of innovating, implementing, and using health communications and information technologies “There is no aspect of our profession that will be untouched by the informatics revolution in progress.” Angela McBride Distinguished Professor and University Dean Emeriti Indiana University School of Nursing

6. IOM Vision While clinicians are trained to use an array of cutting-edge technologies related to care delivery, they often are not provided a basic foundation in informatics (Gorman et al.,2000; Hovenga, 2000). “All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches and informatics.” IOM - Health Professions Education: A Bridge to Quality, 2003.

7. Building the Work Force for HIT A work force capable of innovating, implementing and using health communications and information technologies will be critical to healthcare’s success. For health Information Transformation AHIMA and AMIA http://www.ahima.org/emerging_issues/Workforce_web.pdf Page 7

8. National Efforts In Alignment with the TIGER Initiative Groundbreaking Reports To Err is Human (2000) Crossing the Quality Chasm (2001) Health Literacy: A Prescription to Ending Confusion (2004) Building a Better Delivery System: A New Engineering/HealthCare Partnership (2005) Building the Workforce for Health Information Transformation (2006) Mandates/Executive Orders (President Bush, 4/2004) Electronic Health Records for all Americans in 10 years Appointment of a National Coordinator for Healthcare Informatics Technology (ONC/HHS) Page8

9. The Decade of Health Information Technology The Decade of Health Information Technology: Delivering consumer-centric and information-rich health care http://www.hhs.gov/onchit/framework/ Four Cornerstones: Inform clinical practice Interconnect clinicians Personalize care Improve population health

10. ONC Efforts In Alignment with the TIGER Initiative http://www.hhs.gov/healthit/onc/mission/ Developing a Strategic Framework Inform Clinical Practice Interconnect Clinicians Personalize Care Improve Public Health Defining Elements of Success for HIT Policy Governance Technology Adoption Page10

11. TIGER Summit – Phase I • October 31 -November 1, 2006 • Held at the Uniformed Services University for Health Sciences (USUHS) in Bethesda, MD • 100 participants representing all stakeholders • Created a collective vision for nursing practice and education within 10 years if nurses were fully enabled with IT resources • Developed a 3-year action plan required to achieve this vision • Summary Report published at www.tigersummit.com

12. 10 Year Vision and 3 Year Action Plan Accomplished

13. 3-Year Action Plan Based on a common “vision” of ideal EHR-enabled nursing practice Focused on identifying the “gaps” in nursing preparedness to practice in an EHR-enabled environment Agree to take actions within the next 3 years that can close these gaps Main focus of deliverables is on the creation of educational tools and resources that can be shared with entire healthcare community

14. Report Format Executive Summary Action Plan with Specific Goals Background – Overview of the topic including key projects, publications, and subject experts Recommendations for significant gaps Case Studies/Exemplars Recommendations Resource lists/tools Participants/Affiliates/Sponsors Distribution Page14

15. Organizational Commitment 70 organizations were represented at the Summit Each committed to creating action plans aligned with the TIGER vision within their organization/membership TIGER following organizational progress on these action plans over the next 3-years Examples of organizational actions taken to date: Distribution of TIGER Summary report to all professional members (AONE) Presentations of TIGER at National and International Conferences (AMIA, ANIA/CARING, HIMSS, STTI, HIMSS-AsiaPac, SINI, I-MIA/MedInfo, ONS) Regional presentations of TIGER (BANIC, State-HIMSS e.g., Colorado, Michigan, Wisconsin, N. California) Professional organization presentations of TIGER (ASPAN, AORN, AWHOHN, MONE) State-wide initiatives supporting TIGER vision (Minnesota, Massachusetts, Tennessee) Page15

16. Matrix Approach – Phase II • Enabled by the Alliance for Nursing Informatics (ANI) – a collaboration between AMIA and HIMSS • Continue to support progress of each participating organization’s 3-year action plan • Formalize cross-organizational activities/action steps into collaborative TIGER Teams (9 identified) • Define measurable outcomes of each collaborative team • Provide the infrastructure and support to facilitate the development and dissemination of the activities of the collaborative • Develop educational materials that can be distributed to all practicing nurses and nursing students

17. 9 Collaborative Teams Created from combining all 3-year action steps into common themes/topics • Standards and Interoperability • Healthcare IT National Agenda/HIT Policy • Informatics Competencies • Education and Faculty Development • Staff Development/Continuing Education • Usability/Clinical Application Design • Virtual Demonstration Center • Leadership Development • Consumer Empowerment/Personal Health Record

18. Measurable Outcomes of Each Collaborative • Definition, Scope of Project • An inventory and analysis of existing resources • Publications • Research • Subject matter experts • Ongoing Projects • Identification and access to subject matter experts and constituent targets • Educational web-based audio conferences (target = 2) • Conference presentations • A comprehensive white paper-type document (modeled after TIGER Summary Report) • Define topic-specific evaluation criteria • Submit articles for publication and dissemination amongst broader TIGER audience • Chapter in the 4th Edition of the Nursing Informatics Series Where Caring and Technology Meet

19. Standards and InteroperabilityJoyce Sensmeier, MS, RN-BC, CPHIMS, FHIMSS,VP, Informatics, HIMSSElizabeth C. Halley, RN MBA, The MITRE Corporation Identify the most relevant HIT standard setting efforts that are important to the TIGER mission and ensure that there is adequate representation/input of the TIGER mission/perspective on said efforts. Communicate the existence and importance of HIT standards and initiatives to the broad nursing community. Create tutorials on standardizing data elements, implementing electronic health records, using nursing terminology, and using evidence-based practice tools.

20. TIGER Standards & Interoperabilityhttp://tigerstandards.pbwiki.com WG#1 - Catalogue the most relevant Health IT standard setting efforts and related resources Currently developing a comprehensive framework that consists of data standards, terminologies, standards, standards organizations, transaction standards, and infrastructure standards Expand the framework to contain references, links, and relevant resources and contacts WG#2 - Create tutorials related to standardized data elements, EHR implementation, nursing terminology, and the use of decision support and evidence-based practice tools WG#3 – Create awareness campaigns to disseminate #2 and #3 to broader nursing community WG#4 – Collect examples and case studies of interoperable systems to demonstrate the value of standards in various practice and education settings

21. TIGER Standards & InteroperabilityAccomplishments to Date Educational webinars Leveraging Health Information Exchange to Improve Quality and Efficiency – a review of the importance of HCIT standards in providing a foundation for interoperability, the current landscape for health information exchange, and the potential impact of HITSP specifications on consumers and healthcare systems Introduction to the Standards Lifecycle and HITSP Harmonization Process – a detailed explanation of the lifecycle of standards development within the national HCIT agenda and how nurses can get involved in the interoperability effort Facilitated Review of Specifications and Use Cases Medication Management HITSP Interoperability Specification Consultations and Transfers of Care Use Case

22. 2. Health IT National Agenda/HIT PolicyCDR Alicia Bradford MS, RN-BC, Department of Health and Human Services, Office of the National Coordinator for Health ITDr. Carolyn Padovano PhD, RN, Director, SNOMED-CT Identify the most relevant HIT agendas and policies that are important to the TIGER mission and ensure that there is adequate representation/input of the TIGER mission/perspective on said policy issues. Communicate the existence and importance of the National HIT agenda and policies to the broad nursing community. Create communication strategies that enable nursing participation in strategic HIT policy-setting efforts and disseminate policies back to the nursing community.

23. Engage Nursing participation to facilitate input and help disseminate information regarding national HIT initiatives in the following four areas: WG#1 - Standards and interoperability efforts (ANSI-HITSP) WG#2 - Clinical and policy initiatives generated by the AHIC/ONC workgroups, including use cases, clinical scenarios WG#3 - Participate in the certification process for the electronic health record (such as reviewing/commenting on CCHIT work products) WG#4 - Develop a communication and outreach strategy for which those materials can be widely disseminated to the TIGER and Nursing Community. TIGER National Health IT Agendahttp://tigerhitagenda.pbwiki.com

24. TIGER National HIT AgendaAccomplishments to Date Educational webinars National Health Information Technology Agenda – a review of the Office of the National Coordinator (ONC), strategic framework, timeline of activities, and opportunities for nursing involvement in these activities. Invited presentation to the AHIC/Sec. Leavitt re: National Health Workforce Preparedness Dr. Carole Gassert, RN, PhD Facilitated Discussion of HITSP Medication Management Interoperability Specification and AHIC Use Case on Consultations & Transfers of Care Participate in AHIC meeting on Tuesday, February 26, 2008 from 10:15 a.m. – 4:00 p.m. at HIMSS (Rosen Center Rooms 9 &10) - meet at 9:45 a.m. outside the Rosen Center Room 9

25. 3. Informatics CompetenciesConnie White Delaney, PhD, RN, FAAN, FACMI, Professor and Dean, School of Nursing University of MinnesotaBrian Gugerty DNS, RN, Clinical Informatician, Principal Consultant Harmonize and set informatics competencies for all levels of nursing education: nursing assistants, associate degree, diploma, undergraduate and graduate. Harmonize and set informatics competencies for nursing practice. Advocate for and support adding informatics competencies into nursing specialty certifications. Include informatics competencies in the scope and standard statements (and like documents) of nursing specialties.

26. WG#1 – Define the scope of this collaborative and adopt a framework for competencies within nursing and healthcare Collect select non-informatics competency exemplars used within nursing (both practice and education) healthcare, and other industries WG#2 – Develop a comprehensive inventory of competencies and resources gathered from the literature and ongoing programs WG#3 – Develop a comprehensive inventory of competencies and resources gathered from practice and educational settings TIGER Informatics Competencieshttp://tigercompetencies.pbwiki.com

27. Integration Team (HSG) – Harmonize the competencies collected from WGs 1-3 and synthesize into framework with proposed recommendations for the other TIGER teams to implement (Education, Staff Development, and Leadership) Draft Recommendations – 4 Categories of Competencies: Computer Competencies Information Literacy Competencies Information Management/Informatics Competencies Attitudes & Awareness TIGER Informatics CompetenciesAccomplishments to Date

28. Informatics Competencies Categories

29. Basic Computer Competencies • Recommend adopting the International Computer Driving License (ICDL)*(*Also called the European Computer Driving License) • Used by 7 million users across industries – not specific to health care • Well developed and validated syllabus, tests, and training centers • Also recommended by American Medical Informatics Association (AMIA) and…. • Learning modules mirror basic computer competencies gathered by the TIGER team • Module 1 – Concepts of Information Technology (IT) • Module 2 – Using the Computer and Managing Files • Module 3 – Word Processing • Module 4 – Spreadsheets • Module 5 – Database • Module 6 – Presentation • Module 7 – Information and Communication

30. Information Literacy Competencies Source:  http://www.nsula.edu/watson_library/shreve/curri_enhanct.ppt#270,32,Slide 32

31. Information Management/Informatics Recommend adopting the ANSI HL7 Electronic Health Record – System Functional Model

32. Sample Topics from HL7’s EHR-S Functional Model DC.1 (Care Management) DC.1.1 (Record Management) DC.1.2 (Manage Patient History) DC.1.3 (Preferences, Directives, Consents and Authorizations) DC.1.4 (Summary Lists) i.e. Manage Allergy, Intolerance and Adverse Reaction List DC.1.5 (Manage Assessments) DC.1.6 (Care Plans, Treatment Plans, Guidelines, and Protocols) DC.1.7 (Orders and Referrals Management) DC.1.8 (Documentation of Care, Measurements and Results) DC.1.9 (Generate and Record Patient-Specific Instructions) DC.2 (Clinical Decision Support) DC.2.1 (Manage Health Information to Provide Decision Support) DC.2.2 (Care and Treatment Plans, Guidelines and Protocols) DC.2.3 (Medication and Immunization Management) DC.2.4 (Orders, Referrals, Results and Care Management) DC.2.5 (Support for Health Maintenance: Preventive Care and Wellness) DC.2.6 (Support for Population Health) DC.2.7 (Support for Knowledge Access) DC.3 (Operations Management and Communication) DC.3.1 (Clinical Workflow Tasking) DC.3.2 (Support Clinical Communication) i.e. Support for Inter-Provider Communication

33. Attitudes and Awareness Competencies • A precursor to effective adoption of all competencies • Competency encompasses more than just a psychomotor skill. The team competency in these contexts now describes the attributes of knowledge, abilities, skills and attitudes that underlie competent performance. (Gonczi et al., 1990: 62). • Currently evaluating the European Computer Driving License-Health model for correlation to awareness competencies • Overlapping concepts with the other three categories (basic computer competencies, information literacy, and information management/informatics) • Alspatch, 1984: "a simultaneous integration of knowledge, skill and attitudes that are required for performance in a designated role or setting."

34. Attitudes and AwarenessExample competencies • Understands concepts and processes regarding computer systems and impact on practice (1015, 859, 857, 852, 853, 954, 657, 671, 392, 969, 970, 123, 779, 9, 781, 649, 652, 792) • data integrity • ethics • legalities • economics • professional practice standards/trends/issues • improved quality/safety • societal/technological trends/issues • Scholarly process (632, 840, 668) • publication • evidence-based practice • Benefits/limitations of communication technologies and impact on health care (791, 870, 675) • bulletin/discussion boards • chat rooms • wikis • blogs • newsgroups • email • Understands the advantages of electronic tools for consumer health (849, 858, 862, 798) • telehealth • home monitoring/alert equipment • medication aides/reminders

35. 4. Education and Faculty DevelopmentDiane J. Skiba. PhD, FAAN, FACMI, Professor, UCDHSC & Chair, Task Force Faculty Development related to informatics, National League for Nursing Mary Anne Rizzolo, EdD, RN, FAAN, Senior Director, Professional Development, National League for Nursing Use the informatics competencies, theories, research and practice examples throughout nursing curriculums. Create programs and resources to develop faculty with informatics knowledge, skill and ability and measure the baseline and changes in informatics knowledge among nurse educators and nursing students. Develop a task force to examine the integration of informatics throughout the curriculum.

36. 4. Education and Faculty Development (cont.) Improve and expand existing Nursing/Clinical/Health Informatics education programs. Encourage existing Health Services Resources Administration Division of Nursing to continue and expand their support for informatics specialty programs and faculty development. Encourage foundations to start programs that provide funding for curriculum development, research, and practice in nursing informatics and IT adoption. Develop strategies to recruit, retain, and train current and future nurses in the areas of informatics education, practice, and research. Collaborate with industry and service partners to support faculty creativity in the adoption of informatics technology and offer informatics tools within the curriculum.

37. TIGER Education and Faculty Development Work Groupshttp://tigereducation.pbwiki.com

38. 5. Staff Development/Continuing EducationElizabeth O. Johnson, MSN, BSN, RN, FHIMSS, Vice President of Clinical Informatics, Tenet Health SystemJoan M. Kiel, Ph.D., C.H.P.S., Chairman, University HIPAA Compliance Associate Professor, Duquesne University, Pittsburgh, PA Create educational resources and affordable programs within the practice setting that foster IT innovation and adoption. Create competency-based, cost-effective staff development and continuing education programs and training strategies specifically for informatics knowledge, skill and ability. Improve and expand existing Nursing/Clinical/Health Informatics education programs by collaborating with industry, service and academic partners to support and enhance the use of technology and informatics in practice.

39. TIGER Staff Development/Continuing Education http://tigerstaffdev.pbwiki.com WG#1 - Collect case studies, practice examples, models of staff development programs from nursing, healthcare, other industries and develop a framework to categorize the models (e.g., web-based, face-to-face, etc.) WG#2 - Review, inform and integrate work from the TIGER Competencies Collaborative into Staff Development Collaborative WG#3 – Complete comprehensive literature review of staff development and field-based training models WG#4 - Develop recommendations for Industry/Academic Partnerships – e.g., with technology partners, academic institutions, professional organizations, and others WG#5 – Collaborate with the TIGER Leadership Development team to evaluate the impact of leadership development on staff development programs

40. TIGER Staff Development/Continuing Education Accomplishments to Date Completed a survey to gather general information on the “state of staff development/continuing education” — e.g., who delivers the education, how computer literate are nursing staff as well as to help identify organizations that have innovative models of staff development and continuing education for case studies. Currently collecting case studies from various practice environments Comprehensive literature search – evaluation in progress Currently evaluating recommendations from the informatics competencies for implementation into staff development/continuing education programs

41. 6. Usability/Clinical Application DesignNancy Staggers, PhD, RN, FAAN, Associate Professor, Informatics and Interim Director, Informatics Program, College of Nursing, University of UtahMichelle R. Troseth, RN, MSN, Executive Vice President and Chief Professional Practice Officer, Clinical Practice Model Resource Center (CPMRC) Design requirements and/or goals Support evidence-based practice Enables collaborative and interdisciplinary care Provide seamless access to published literature, knowledge Support the creation of new knowledge (knowledge discovery requirements) Speed the translation of research into practice Usability requirements and/or goals Informed by and/or positively transforms nursing workflows Systems designed using principles of human factors Work with system developers to maximize clinical system effectiveness and efficiency for nurses

42. WG#1 – Develop a comprehensive literature review on topics related to usability and clinical application design. Obtain resources from nursing and other disciplines (e.g., Human Factors, Engineering, etc.) WG#2 - Collect case studies and examples that illustrate usability/clinical application design from your experience/environment Exemplars (good, replicable examples) Lessons to be learned (bad examples that can help to inform others what to avoid) WG#3 - Summarize recommendations for: Highly usable applications Good clinical application design WG#4 - Develop recommendations for vendors for usability and good clinical application design WG#5 - Develop a usability/clinical application “toolkit” for healthcare providers and organizations TIGER Usability & Clinical Application Designhttp://tigerusability.pbwiki.com Page42

43. Completed extensive literature search—in process of synthesizing the results Currently collecting case studies and examples that illustrate usability/clinical application design from various practice experience/environment Will start to synthesize and summarize recommendations in March for: Highly usable applications Good clinical application design TIGER Usability & Clinical Application DesignAccomplishments to Date Page43

44. Virtual Demonstration CenterTeresa McCasky, RN, MBA, Chief Nursing Strategist, McKessonMarion J. Ball, Ed.D., FHIMSS, CHIME, IBM Research, Fellow, Center for Healthcare Management, Professor Emerita, Johns Hopkins University School of NursingJeanine Martin, Microsoft Corporation, US Provider Healthcare Industry Provide visibility to the 10 year vision of IT-enabled nursing practice and education to broader healthcare audience by demonstrating how integrated IT systems impact nurses and the quality and safety of patient care. Demonstrate the breadth and depth of IT resources in use by nurses to enhance their practice and educational environments. Demonstrate collaboration between industry, healthcare organizations academic institutions, and professional organizations to create educational modules for nurses that are based upon informatics competencies. Provide universal accessibility to this demonstration for all nursing stakeholders. Use practice examples from different practice environments that can demonstrate best practices, results of research, case studies and lessons learned by partnering with nursing professional organizations.

45. Work Group 1 – Johns Hopkins/IBM – physical simulation lab Work Group 2 – Future state scenarios based on the context of global trends (e.g., staff shortages, globalization, increases in chronic diseases, consumer empowerment, etc.). These will focus more on the abstract—or “art of the possible”. Work Group 3 – Technology currently available today – A scenario-approach allows us to utilize current technologies (that are available today) and expand their use into the future.  TIGER Virtual Demonstration Centerhttp://tigervirtualdemo.pbwiki.com

46. TIGER Virtual Demonstration CenterActivities to Date • Site visits to IBM’s Hawthorne Demonstration Center • Site visits to Johns Hopkins Center of Excellence Simulation Lab • Selected demonstration platform – working with HIMSS Virtual Conference team – visit http://www.himssvirtual.org/ • Demonstration Platform • Distribution of reports, recommendations, white papers • Educational Center • Social Networking/lounge • Starting to develop clinical scenarios/vignettes

47. 8. Leadership DevelopmentDana Alexander, RN, MSN, MBA, Chief Nurse Officer, GE Healthcare Integrated IT SolutionsJudy Murphy, RN, FACMI, FHIMSS, Vice President, Information Services, Aurora Health Care, Milwaukee, WI A relatively small investment of TIGER effort with nursing leaders will be multiplied many times due to the leaders’ power and influence in their organizations and the profession. Develop programs for nurse executives that stress the value of information technology and empower them to use IT knowledgeably, giving the leaders of the profession a strong and identifiable voice. Facilitate nursing leadership to understand, promote, own, and measure the success of IT projects.

48. WG#1 - Complete a comprehensive review of the literature, ongoing research, publications, subject experts, programs and other materials related to nursing leadership,  leadership qualities, transformation and technology, leadership development programs, etc. WG#2 – Incorporate informatics competencies into leadership development programs WG#3 - Determine strategy for working with the magnet program WG#4 - Complete an assessment of nursing leadership development needs WG#5 – Synthesize the results from WG1-4 and develop the recommendations and summary report TIGER Leadership Developmenthttp://tigerleadership.pbwiki.com

49. TIGER Leadership DevelopmentActivities to Date • Cataloguing leadership development programs by type, e.g., academic, organizational fellowships, industry network programs, vendor-sponsored, self-education, etc. • Developed a survey to assess nursing leadership development needs by role and competency category • Integrating the work of the competencies into leadership programs • Developing a strategy for working with magnet programs and ANCC

50. 9. Patient-Focus/Personal Health RecordCharlotte Weaver, RN, PhD, Vice President and Executive Director for Nursing Research, Cerner Corporation Rita D. Zielstorff, RN MS, PricewaterhouseCoopers LLP Consumers are becoming more empowered healthcare participants. Informatics can mediate consumers drive for improved health and healthcare as well as broker the relationship between nurse and client. Establish efforts to develop health information literacy with the public and healthcare consumers. Work with Personal Health Record (PHR) advocates and developers to optimize PHRs as they relate to nursing.