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Pediatric Ambulatory Nurses at the Intersection of Healthcare Reform and Health Information Technology
Journal of Pediatric Nursing (2013) 28, 611–612
TECHNOLOGY COLUMN Column Editor: Karen Goldschmidt MSN, RNC
Karen Goldschmidt MSN, RNC
Pediatric Ambulatory Nurses at the Intersection of Healthcare Reform and Health Information Technology Maria C. Mihalko MSN, RN ⁎ The Children's Hospital of Philadelphia, Philadelphia, PA NURSES ARE AT the forefront of dramatic changes in healthcare. When reading this statement it brings to mind nurses in acute care settings utilizing technology for the treatment of critically ill patients. Seldom is this concept of technology placed within the context of the nurse at a pediatrician's office or at a community clinic. However, with the passage of the Patient Protection and Affordable Care Act (ACA) the landscape is changing. The next decade will bring about dramatic changes targeted at primary care practices with an emphasis on increasing access to care, improving quality, and controlling costs (Swan & Haas, 2011). Nurses will need to not only be prepared to respond to the paradigm shift, they will need to lead it. It is a well-known fact that individuals who have access to regular primary care are more likely to receive preventative care and to avoid the development of chronic health conditions that are difficult and costly to treat. Having regular access to a primary healthcare provider is associated with a lower rate of preventable emergency room visits and less hospitalizations. Underutilized primary care resources have contributed to an uncoordinated and expensive U.S. healthcare system (Abrams, Nuzum, Mika, & Lawlor, 2011). The Institute of Medicine (2010) report on the future of nursing emphasizes that nurses and advanced practice nurses are uniquely qualified to remodel the current health care system. Nurses are in a strategic position to create innovative models of care, engage in patient-centered outcomes research, and promote collaborative practice improvement efforts geared to strengthening the quality and affordability of care for all Americans. Robert W. Block, MD, FAAP, president of the American Academy of Pediatrics (AAP), endorses the provisions of the ACA because it supports the AAP's mission of child ⁎ Corresponding author: Maria C. Mihalko, MSN, RN. E-mail address: [email protected]. 0882-5963/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pedn.2013.09.002
advocacy and providing all children access to health care services (American Academy of Pediatrics Department of Federal Affairs, 2010). The ACA is investing $8.3 billion to increase Medicaid reimbursement to primary care physicians, including pediatricians. It expands health insurance coverage to nearly thirty-two million more children and The requirement to their parents and establishes grants engage with patients for the development of innovative, and families electrocollaborative, community-based nically will increase inter-professional practices (AAP, 2010; AAP, 2012). the demand to digiWith the goal of exploring a tally interact with primary care model redesign and patients and virtually identifying the workflow and workcoordinate care with force needs to achieve success, the multiple disciplines American Hospital Association and providers. (AHA) convened a roundtable made up of physician and nurse leaders. The AHA made several recommendations that focus primarily on shifting to an accountability-based primary care workforce model that places the patient, family and healthy community at the center. Healthcare professionals, support personnel and health information technology (HIT) will work collaboratively and seamlessly in the proposed accountability-based model to achieve and sustain wellness instead of intervening and treating illnesses. The AHA acknowledges the critical role that a robust and sophisticated HIT infrastructure will play in providing preventative health care. The plan suggests leveraging technology to engage and partner people with their primary care provider for the long haul. Technology will be used in the ambulatory setting for targeted screening, care reminders, after-hours access to care, access to immunization records, and online communication. In addition, providers will have on-demand digital access to
612 diagnostic results, severity adjustment and population management tools, and patient education materials; all with the aim to enhance the patient experience (AHA, 2013). Integral to the strategies outlined by the ACA is the requirement of healthcare providers to report performance measures electronically. The ACA will demand greater transparency and accountability for health outcomes and will incentivize quality care and efficiency (Dubow, 2010). The American Recovery and Reinvestment Act of 2009, commonly known as Meaningful Use, also has several provisions that require the implementation, adoption and integration of HIT. The requirement to engage with patients and families electronically will increase the demand to digitally interact with patients and virtually coordinate care with multiple disciplines and providers (Sochalski & Weiner, 2011). HIT will dramatically change the way nurses document, plan, coordinate, and evaluate care. The resilience of primary care to survive and respond to the reform will depend a great deal on its ability to redesign workflows, reassign responsibilities and maximize its utilization of electronic tools. A well-designed electronic health record (EHR) is instrumental in supporting effective workflows, promoting safety and quality and capturing reportable data. A poorly designed EHR can result in the development of “workarounds” that avoid the use of technology resulting in failure to capture data, bypassing clinical decision support tools, ineffective redundancies, poor care coordination, delays in care and poor outcomes (Friedman et al., 2013). Ambulatory nurses need to be prepared to lead the transformation in healthcare and address several initiatives without delay. Among these initiatives is the development of competencies on care coordination and transitions of care. In addition, standardization of telehealth modalities as well as evaluation of competencies of telehealth assessments and interventions will be needed (Swan & Haas, 2011). Ambulatory nurses must ensure that EHRs include robust documentation tools that support autonomous practice while ensuring adherence to scope of practice limitations while promoting the use of the EHR by each member of the team (American Academy of Ambulatory Care Nursing, 2012). The goal in developing an EHR is to provide consistency in documentation, improve the quality of the clinical data documented, improve compliance with standards of care, and clinical guidelines, and facilitate access to patient information during telehealth episodes (Crist-Grundman, Douglas, Kern, Gregory, & Switzer, 1995). Increasing the involvement of ambulatory nurses and support personnel in the design, configuration, and usability testing of EHR tools and templates is imperative. Practice managers may struggle with removing busy nursing and support personnel from patient care to engage in non-clinical work; however, the return on investment will provide for a well-designed EHR that will prove to be invaluable.
M.C. Mihalko
References Abrams, M., Nuzum, R., Mika, S., & Lawlor, G. (2011, January 4). Realizing Health Reform's Potential: How the Affordable Care Act Will Strengthen Primary Care and benefit Patients, Providers and Payers. Retrieved July 22, 2013, from The Commonwealth Fund: http://www. commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/ 2011/Jan/1466_Abrams_how_ACA_will_strengthen_primary_care_ reform_brief_v3.pdf. American Academy of Ambulatory Care Nursing. (2012). American Academy of Ambulatory Care Nursing Position Paper: The role of the registered nurse in ambulatory care. Pitman, NJ: American Academy of Ambulatory Care Nursing Retrieved August 2013, from. http://www. aaacn.org/sites/default/files/documents/PositionPaper.pdf. American Academy of Pediatrics [AAP]. (2010, September 9). Health Reform and the AAP: What the New Law Means to Children and Pediatricians. Retrieved July 22, 2013, from www.aap.org: http://www. aap.org/en-us/advocacy-and-policy/federal-advocacy/Documents/ ACAImplementationFactSheets.pdf. American Academy of Pediatrics. [AAP]. (2012, June 28). Children's health advocates react to affordable care act ruling. Retrieved August 24, 2013, from AAP.org: http://www.aap.org/en-us/about-theaap/aap-press-room/pages/Childrens-Health-Advocates-React-toAffordable-Care-Act-Ruling.aspx?nfstatus=401&nftoken=000000000000-0000-0000-000000000000&nfstatusdescription=ERROR%3a. American Academy of Pediatrics Department of Federal Affairs. (2010, October). Health Reform and the AAP: What the New Law Means for Children and Pediatricians. Retrieved from American Academy of Pediatrics: http://www.aap.org/en-us/advocacy-and-policy/federaladvocacy/Documents/ACAImplementationFactSheets.pdf. American Hospital Association. [AHA]. (2013, January). Workforce Roles in a Redesigned Primary Care Model. Retrieved August 17, 2013, from www.aha.org: http://www.aha.org/content/13/13-0110-wf-primarycare.pdf. Crist-Grundman, D., Douglas, K., Kern, V., Gregory, J., & Switzer, V. (1995). Evaluating the impact of structured text and templates in ambulatory nursing. In P. Reed, & M. Gardner (Eds.), Towards Cost Effective Clinical Computing (pp. 712–716). New Orleans, LA: Hanley & Belfus, Inc Retrieved July 6, 2013, from. http://www.ncbi.nlm.nih. gov/pmc/articles/PMC2579186/pdf/procascamc00009-0741.pdf. Dubow, J. (2010, July). How health reform will affect health care quality and the delivery of services. Retrieved July 22, 2013, from AARP Policy Institute: http://assets.aarp.org/rgcenter/ppi/health-care/fs197-health.pdf. Friedman, A., Crosson, J., Howard, J., Clark, E., Pellarno, M., Karsh, B. -T., & Cohen, D. J. (2013). A typology of electronic health record workarounds in small-to-medium size primary care practices. Journal American Medical Informatics Association Published Online First, 1–6 Retrieved August 20, 2013, from. http://jamia.bmj.com/content/early/ 2013/07/31/amiajnl-2013-001686. Institute of Medicine. (2010). The future of nursing: Leading change and advancing health. Washington, DC: National Academies Press Retrieved August 19, 2013, from. http://www.thefutureofnursing.org/sites/ default/files/Future%20of%20Nursing%20Report_0.pdf. Sochalski, J., & Weiner, J. (2011). Health care system reform and the nursing workforce: Matching nursing practice and skills to future needs, not past demands. In R. W. Foundation (Ed.), The Future of Nursing: Leading Change, Advancing Health (pp. 375–398). Washington, DC: National Academy Press Retrieved August 3, 2013, from. http://www. nap.edu/openbook.php?record_id=12956&page=375. Swan, B. A., & Haas, S. A. (2011). Health care reform: Current updates and future initiatives for ambulatory care nursing. Nursing Economics, 29, 331–334 Retrieved from http://jdc.jefferson.edu/cgi/viewcontent.cgi? article=1047&context=nursfp.
TECHNOLOGY COLUMN Column Editor: Karen Goldschmidt MSN, RNC
Karen Goldschmidt MSN, RNC
Pediatric Ambulatory Nurses at the Intersection of Healthcare Reform and Health Information Technology Maria C. Mihalko MSN, RN ⁎ The Children's Hospital of Philadelphia, Philadelphia, PA NURSES ARE AT the forefront of dramatic changes in healthcare. When reading this statement it brings to mind nurses in acute care settings utilizing technology for the treatment of critically ill patients. Seldom is this concept of technology placed within the context of the nurse at a pediatrician's office or at a community clinic. However, with the passage of the Patient Protection and Affordable Care Act (ACA) the landscape is changing. The next decade will bring about dramatic changes targeted at primary care practices with an emphasis on increasing access to care, improving quality, and controlling costs (Swan & Haas, 2011). Nurses will need to not only be prepared to respond to the paradigm shift, they will need to lead it. It is a well-known fact that individuals who have access to regular primary care are more likely to receive preventative care and to avoid the development of chronic health conditions that are difficult and costly to treat. Having regular access to a primary healthcare provider is associated with a lower rate of preventable emergency room visits and less hospitalizations. Underutilized primary care resources have contributed to an uncoordinated and expensive U.S. healthcare system (Abrams, Nuzum, Mika, & Lawlor, 2011). The Institute of Medicine (2010) report on the future of nursing emphasizes that nurses and advanced practice nurses are uniquely qualified to remodel the current health care system. Nurses are in a strategic position to create innovative models of care, engage in patient-centered outcomes research, and promote collaborative practice improvement efforts geared to strengthening the quality and affordability of care for all Americans. Robert W. Block, MD, FAAP, president of the American Academy of Pediatrics (AAP), endorses the provisions of the ACA because it supports the AAP's mission of child ⁎ Corresponding author: Maria C. Mihalko, MSN, RN. E-mail address: [email protected]. 0882-5963/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pedn.2013.09.002
advocacy and providing all children access to health care services (American Academy of Pediatrics Department of Federal Affairs, 2010). The ACA is investing $8.3 billion to increase Medicaid reimbursement to primary care physicians, including pediatricians. It expands health insurance coverage to nearly thirty-two million more children and The requirement to their parents and establishes grants engage with patients for the development of innovative, and families electrocollaborative, community-based nically will increase inter-professional practices (AAP, 2010; AAP, 2012). the demand to digiWith the goal of exploring a tally interact with primary care model redesign and patients and virtually identifying the workflow and workcoordinate care with force needs to achieve success, the multiple disciplines American Hospital Association and providers. (AHA) convened a roundtable made up of physician and nurse leaders. The AHA made several recommendations that focus primarily on shifting to an accountability-based primary care workforce model that places the patient, family and healthy community at the center. Healthcare professionals, support personnel and health information technology (HIT) will work collaboratively and seamlessly in the proposed accountability-based model to achieve and sustain wellness instead of intervening and treating illnesses. The AHA acknowledges the critical role that a robust and sophisticated HIT infrastructure will play in providing preventative health care. The plan suggests leveraging technology to engage and partner people with their primary care provider for the long haul. Technology will be used in the ambulatory setting for targeted screening, care reminders, after-hours access to care, access to immunization records, and online communication. In addition, providers will have on-demand digital access to
612 diagnostic results, severity adjustment and population management tools, and patient education materials; all with the aim to enhance the patient experience (AHA, 2013). Integral to the strategies outlined by the ACA is the requirement of healthcare providers to report performance measures electronically. The ACA will demand greater transparency and accountability for health outcomes and will incentivize quality care and efficiency (Dubow, 2010). The American Recovery and Reinvestment Act of 2009, commonly known as Meaningful Use, also has several provisions that require the implementation, adoption and integration of HIT. The requirement to engage with patients and families electronically will increase the demand to digitally interact with patients and virtually coordinate care with multiple disciplines and providers (Sochalski & Weiner, 2011). HIT will dramatically change the way nurses document, plan, coordinate, and evaluate care. The resilience of primary care to survive and respond to the reform will depend a great deal on its ability to redesign workflows, reassign responsibilities and maximize its utilization of electronic tools. A well-designed electronic health record (EHR) is instrumental in supporting effective workflows, promoting safety and quality and capturing reportable data. A poorly designed EHR can result in the development of “workarounds” that avoid the use of technology resulting in failure to capture data, bypassing clinical decision support tools, ineffective redundancies, poor care coordination, delays in care and poor outcomes (Friedman et al., 2013). Ambulatory nurses need to be prepared to lead the transformation in healthcare and address several initiatives without delay. Among these initiatives is the development of competencies on care coordination and transitions of care. In addition, standardization of telehealth modalities as well as evaluation of competencies of telehealth assessments and interventions will be needed (Swan & Haas, 2011). Ambulatory nurses must ensure that EHRs include robust documentation tools that support autonomous practice while ensuring adherence to scope of practice limitations while promoting the use of the EHR by each member of the team (American Academy of Ambulatory Care Nursing, 2012). The goal in developing an EHR is to provide consistency in documentation, improve the quality of the clinical data documented, improve compliance with standards of care, and clinical guidelines, and facilitate access to patient information during telehealth episodes (Crist-Grundman, Douglas, Kern, Gregory, & Switzer, 1995). Increasing the involvement of ambulatory nurses and support personnel in the design, configuration, and usability testing of EHR tools and templates is imperative. Practice managers may struggle with removing busy nursing and support personnel from patient care to engage in non-clinical work; however, the return on investment will provide for a well-designed EHR that will prove to be invaluable.
M.C. Mihalko
References Abrams, M., Nuzum, R., Mika, S., & Lawlor, G. (2011, January 4). Realizing Health Reform's Potential: How the Affordable Care Act Will Strengthen Primary Care and benefit Patients, Providers and Payers. Retrieved July 22, 2013, from The Commonwealth Fund: http://www. commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/ 2011/Jan/1466_Abrams_how_ACA_will_strengthen_primary_care_ reform_brief_v3.pdf. American Academy of Ambulatory Care Nursing. (2012). American Academy of Ambulatory Care Nursing Position Paper: The role of the registered nurse in ambulatory care. Pitman, NJ: American Academy of Ambulatory Care Nursing Retrieved August 2013, from. http://www. aaacn.org/sites/default/files/documents/PositionPaper.pdf. American Academy of Pediatrics [AAP]. (2010, September 9). Health Reform and the AAP: What the New Law Means to Children and Pediatricians. Retrieved July 22, 2013, from www.aap.org: http://www. aap.org/en-us/advocacy-and-policy/federal-advocacy/Documents/ ACAImplementationFactSheets.pdf. American Academy of Pediatrics. [AAP]. (2012, June 28). Children's health advocates react to affordable care act ruling. Retrieved August 24, 2013, from AAP.org: http://www.aap.org/en-us/about-theaap/aap-press-room/pages/Childrens-Health-Advocates-React-toAffordable-Care-Act-Ruling.aspx?nfstatus=401&nftoken=000000000000-0000-0000-000000000000&nfstatusdescription=ERROR%3a. American Academy of Pediatrics Department of Federal Affairs. (2010, October). Health Reform and the AAP: What the New Law Means for Children and Pediatricians. Retrieved from American Academy of Pediatrics: http://www.aap.org/en-us/advocacy-and-policy/federaladvocacy/Documents/ACAImplementationFactSheets.pdf. American Hospital Association. [AHA]. (2013, January). Workforce Roles in a Redesigned Primary Care Model. Retrieved August 17, 2013, from www.aha.org: http://www.aha.org/content/13/13-0110-wf-primarycare.pdf. Crist-Grundman, D., Douglas, K., Kern, V., Gregory, J., & Switzer, V. (1995). Evaluating the impact of structured text and templates in ambulatory nursing. In P. Reed, & M. Gardner (Eds.), Towards Cost Effective Clinical Computing (pp. 712–716). New Orleans, LA: Hanley & Belfus, Inc Retrieved July 6, 2013, from. http://www.ncbi.nlm.nih. gov/pmc/articles/PMC2579186/pdf/procascamc00009-0741.pdf. Dubow, J. (2010, July). How health reform will affect health care quality and the delivery of services. Retrieved July 22, 2013, from AARP Policy Institute: http://assets.aarp.org/rgcenter/ppi/health-care/fs197-health.pdf. Friedman, A., Crosson, J., Howard, J., Clark, E., Pellarno, M., Karsh, B. -T., & Cohen, D. J. (2013). A typology of electronic health record workarounds in small-to-medium size primary care practices. Journal American Medical Informatics Association Published Online First, 1–6 Retrieved August 20, 2013, from. http://jamia.bmj.com/content/early/ 2013/07/31/amiajnl-2013-001686. Institute of Medicine. (2010). The future of nursing: Leading change and advancing health. Washington, DC: National Academies Press Retrieved August 19, 2013, from. http://www.thefutureofnursing.org/sites/ default/files/Future%20of%20Nursing%20Report_0.pdf. Sochalski, J., & Weiner, J. (2011). Health care system reform and the nursing workforce: Matching nursing practice and skills to future needs, not past demands. In R. W. Foundation (Ed.), The Future of Nursing: Leading Change, Advancing Health (pp. 375–398). Washington, DC: National Academy Press Retrieved August 3, 2013, from. http://www. nap.edu/openbook.php?record_id=12956&page=375. Swan, B. A., & Haas, S. A. (2011). Health care reform: Current updates and future initiatives for ambulatory care nursing. Nursing Economics, 29, 331–334 Retrieved from http://jdc.jefferson.edu/cgi/viewcontent.cgi? article=1047&context=nursfp.