The nursing informatics workforce: who are they and what do they do?

Nursing informatics has evolved into an integral part of health care delivery and a differentiating factor in the selection, implementation, and evaluation of health IT that supports safe, high-quality, patient-centric care. New nursing informatics workforce data reveal changing dynamics in clinical experience, job responsibilities, applications, barriers to success, information, and compensation and benefits. In addition to the more traditional informatics nurse role, a new position has begun to emerge in the health care C-suite with the introduction of the chief nursing informatics officer (CNIO). The CNIO is the senior informatics nurse guiding the implementation and optimization of HIT systems for an organization. With their fused clinical and informatics background, informatics nurses and CNIOs are uniquely positioned to help with "meaningful use" initiatives which are so important to changing the face of health care in the United States.     

'Customerizing' in the new millennium

Many might challenge the concept of customerizing in the health care systems in the face of financial losses caused by the Balanced Budget Act. But, now more than ever, we should be obsessed with the customer and work relentlessly to understand that the procedure is not the end goal. The experience around that procedure will bond the patient to us, or create a consumer who is left with anger. The secret to success, according to Seybold (1998), is "It's the customer, stupid!" (pp. xvi). She also notes that all we have to do is to focus on making it easier for the customer to work with us. We should pick our customers' brains, visit them, learn what they care about, and make it easier for them to work with us. We can't afford not to.$     

Research Forecasting for Health Information Technology (HIT), using technology intelligence

Due to the rapid pace of change in technology and its impact on society, there is an increasing demand for use of Technology Forecasting methods to improve policy planning and implementation. One such area is the field of Health Care and the impact of Health Information Technology (HIT) on this field. Using HIT has shown to be associated with reduced cost, improved quality, and better patient experience; yet HIT adoption has been slow. Therefore, there is a need to better understand the HIT adoption processes in order to meet the evolving requirements for health care delivery.We propose collecting Technology Intelligence for use in Research Forecasting as part of the larger HIT Technology Forecasting efforts. In this study, we systematically probed for HIT-related technology intelligence in the fields of Information Systems, Engineering Management, and Medical Informatics. Results of our analysis show that all three fields are active in Health IT research, but could benefit from further collaboration. We were also able to identify instances of emerging journals and emerging topics in Health IT research. We conclude that it is indeed plausible and meaningful to collect technology intelligence on HIT adoption, to support the overall goal of improving healthcare delivery.     

Is HIT a hit? The impact of health information technology on inpatient hospital outcomes

In an effort to eliminate inefficiencies in the US health care sector, policymakers have made a concerted effort to encourage hospitals and physicians to adopt health information technology (HIT) systems. Using a unique data set on HIT adoption and health outcomes in New York State, we conduct a hospital-level analysis identifying the impact of adopting HIT on inpatient outcomes (rates of adverse drug events and severity-adjusted mortality). Unlike previous studies, the patient population is not restricted to Medicare patients, but covers all ages and insurance types. After controlling for unobserved hospital quality and endogenous HIT adoption, our results suggest that a hospital’s severity-adjusted mortality decreases by 0.3 percentage points. When restricted to the Medicare patients, we find HIT adoption lowers a hospital’s severity-adjusted mortality rate by 0.5 percentage points. We find HIT to have no significant effect on the rate of ADEs.     

A fragmented patient safety concept: the structure and culture of safety management in health care

The uniform and visible commitment to safety management is a cultural and structural change that health care organizations have not typically attempted. Committee structures are just one example of how culture drives structure in managing health care safety. The question is: "Are we interested in making nonpatient safety programs as well understood and as culturally significant as patient safety programs?" Models exist to institutionalize safety management in health care. We need only look to the JCAHO or OSHA and other high-hazard industry models for examples of safety management. Change requires a focus on safety, not occupational safety or patient safety, but just safety. In health care, safety would be a key characteristic of organizational culture. The organizational expectation is then that all employees will work safely and practice safety. Employees will apply safe practices when handling chemicals, in lifting, and when giving medications. Only when safety imbues the work and decisions of each employee in this way will the highest level of safety be attained.     

How can nurses help patients work more effectively with nurses to improve the safety of patient care?

The literature seems quite clear that patients still regard the nurse as the principal link between the technical and interpersonal aspects of their care. The often-discussed medical error crisis tends to create in the patient mistrust of all care providers. The health care industry is driving towards a system that requires patients to be self-reliant in managing their care, without allowing for factual limitations in patient capability, ability, and interest in such an enterprise. Unfortunately for the overworked, understaffed nurse, patients still look to them to provide quality compassionate care without the patient having to police them. Health care providers have been mandated to provide assessment and intervention for pain management. It was mandated because we as health care professionals failed to perform this vital function in a consistent, quality manner. It did add to the workload of the nurse. However, if done properly, it is a valuable communication tool for the nurse and the patient to comfortably discuss pain and its management--the interpersonal part of care.     

Reliability between nurse managers: the key to the high-reliability organization

Flawless execution rests in the hands of nurse managers. No one can work alone in health care any more. We are interdependent and know that the best outcomes happen when practices are organized around collegial supportive structures rather than autonomous competitive units. We are only as strong as our weakest link. If all managers see the big picture and look beyond their units for what is right for the common good, we will achieve high-reliability organizations in health care. In turn health care organizations will become very safe places to operate. Shared governance structures for nurse managers are the perfect vehicle to develop collaborative organizations and flawless execution, and to adopt high-reliability organization principles.     

Redesigning nursing work in long-term care environments

The authors present a highly statistically oriented argument for examining work attitudes and activities among three groups of caregivers [RNs, RPNs, and HCAs] working in long-term care. The investigators used both work sampling, written surveys, and interviews with a sample of 46 caregivers in a large university-affiliated LTC facility in Toronto, Canada. While RNs stated their strong affinity for direct patient care activities, they perform the lowest percentage of direct care, chiefly due to their accountability for planning and coordinating the care provided by others. The HCAs who provided the bulk of direct patient care "valued it the least," apparently finding little gratification with this aspect of their role. This study suggests that there is a need to examine and clarify work roles and perceptions for all caregivers as part of any work redesign process. A higher level of RN involvement in direct patient care activities, along with "attention to enhancing the importance" of these activities for staff employed in the HCA role, could be beneficial.     

The journey to meaningful use of electronic health records

The American Recovery and Reinvestment Act and its important Health Information Technology Act provision became law on February 17, 2009. Commonly referred to as "The Stimulus Bill" or "The Recovery Act," the landmark legislation allocated $787 billion to stimulate the economy, including $147 billion to rescue and reform the nation's seriously ailing health care industry. Of these funds, $19 billion in financial incentives were earmarked for the relatively short period of 5 years to drive reform through the use of advanced health information technology (HIT) and the adoption of electronic health records (EHRs). he incentives were intended to help health care providers purchase and implement HIT and EHR systems, and the HITECH Act also stipulated clear penalties would be imposed beyond 2015 for both hospitals and physician providers who failed to adopt use of EHRs in a meaningful way. Nurses will be integral to achieving a vision that will require a nationwide effort to adopt and implement EHR systems in a meaningful way.     

Marketing service guarantees for health care

The author introduces the concept of service guarantees for application in health care and differentiates between explicit, implicit, and conditional vs. unconditional types of guarantees. An example of an unconditional guarantee of satisfaction is provided by the hospitality industry. Firms conveying an implicit guarantee are those with outstanding reputations for products such as luxury automobiles, or ultimate customer service, like Nordstrom. Federal Express and Domino's Pizza offer explicit guarantees of on-time delivery. Taking this concept into efforts to improve health care delivery involves a number of caveats. Customers invited to use exceptional service cards may use these to record either satisfaction or dissatisfaction. The cards need to provide enough specific information about issues so that "immediate action could be taken to improve processes." Front-line employees should be empowered to respond to complaints in a meaningful way to resolve the problem before the client leaves the premises.     

Deconstructing health care reform

As health reform is deconstructed, we need to stop and do some deconstructing of our thinking about it, looking at the context of our assumptions or frames. If we think of health as taking the supreme welfare of the people seriously, we will not allow it to be framed only in terms of for-profit interests and the status quo. Nurses have expertise and knowledge regarding what is needed for a quality health care system. We have to join the conversation with as many good questions as ideas. Working from a different frame, one that reflects more of your values, may give you new insights into holding the conversation.     

Health IT adoption,productivity and quality in primary care

Within the last decade, there has been a growing push towards the use of electronic medical records and health information technology (IT) within primary care physician practices. Despite financial subsidies, smaller practices remain reluctant to adopt these information systems. Using a nationally representative survey of physicians, this study explores the relationship between physician, practice and area attributes and the adoption of health IT systems. Controlling for these attributes, the analysis subsequently studies the relationship between health IT, physician productivity and perceived quality of care. It finds that smaller practices and physicians with lower incomes are less likely to adopt health IT systems and that adoption varies with the type of medical conditions the practice typically treats. With regards to productivity, health IT adopters are more likely to see fewer patients and spend a larger amount of time on each visit with marginal increases in time on administrative tasks and no differences in perceived ability to deliver quality health care.     

Cost of health care and quality outcomes of patients at nurse-managed clinics

Lack of health insurance is a critical factor in access to appropriate health services and is directly associated with poor functioning, increased morbidity and mortality, lack of continuity of care, and rising health care costs. Nurse-managed clinics (NMCs) can serve as an important safety net in the health care delivery system by offering needed health services to the poor and underinsured populations. Indicators of quality of care at NMCs include removing barriers to care, improving health care access, and developing therapeutic relationships with nurse practitioners. Much evidence also exists that nurse-managed clinics improve the use of preventative services, aid in the promotion of health, compliance of treatment and patient satisfaction, and reduce emergency room visits and rehospitalizations. One of the consistent themes in this review is the need for patient volume enhancement and the importance of reimbursement through Medicaid and third-party payers if nurse-managed clinics are to remain viable.     

Engaging patients and families in ehealth

National Health IT Week, which ran from September 11-16, 2011, served as a time to highlight the importance of efficient information systems that protect the privacy and security of personal health information while improving the delivery of health care in the United States. During the week, the health IT community came together to raise national awareness regarding the consistent breakthroughs and hard work industry professionals, providers, and consumers have put forward to ensure they are moving toward the common goal of advancing the future of health care through private and secure health IT. Two events during the week (the Consumer Health IT Summit and the launch of the HealthlT.gov web site) brought home a theme increasingly seen as important to improving our health care system--patients participation in their care. Nurses will need to work with patients so they understand the importance of their participation as a partner in their care, instead of playing a passive role. One way we can do that is to encourage our patients to actively use technology to manage their own health care and to share information with their health care providers.     

Technicity in nursing and the dispensation of thinking

While technology and health care delivery are inextricably and increasingly intertwined and technology has driven major advances in quality and efficiency in health care, technology does not replace the need for a thinking human being in care delivery. The term "technicity" refers to the tension created by the ability of humans to think versus their risk of being exploited as objects subservient to technologies. Drawing upon the philosophical works of Thoreau, Heidegger, and others, the authors pause on the conundrum created by expanding technology with the assumption that technological "improvements" should be evaluated with caution. Health care information systems are an example of tools that have improved our ability to collect and store information, but when systems "go down," staff can be rendered helpless. Similarly, technology can impose personal distance between the patient and provider in instances where staff are positioned as a mechanism for collecting data rather than a person interacting with another person. In some cases, health care providers function as navigators helping patients reach the correct pharmaceutical, rather than as teachers helping patients seek better health. Lastly, the tendency toward systems analysis in the context of the complex hospital environment leads solely toward uniform solutions rather than instances where a customized solution is warranted.     

Patient satisfaction and high-reliability organizations: what's the connection?

So how do we get there? Wagner and Harter (2006) report that it is apparent that managers who can make all of this happen view their work beyond profitability. Their motivation is created from deeply held beliefs about the solemn responsibility of management for those around them. When we view the patient satisfaction scores on the public ally reported Web sites, we will have a clear view into how the organization has eliminated negative variability and has also managed to engage the hearts and minds of their employees and their patients.     

Unmet need for health care during pregnancy: A French – Romanian comparison

ABSTRACT

Health inequalities emerge from birth, the early neonatal mortality and infant mortality rates being different between countries. These differences may be related to inequalities in use of health care during pregnancy. The aim of this research is to identify and compare the profiles of women who do not follow pregnancy health care recommendations in two European countries with different health systems and indicators: namely France and Romania. However, health care recommendations for pregnant women are free in the two countries. Firstly, unmet need for health care during pregnancy is observed. Secondly, our results reveal that there is a relationship between perinatal health care abandonment and several forms of inequalities (social, informational and psychological). Thirdly, the much higher probability of forgoing perinatal health care for Romanian women could be associated with financial or informational problems which seems counterintuitive because perinatal health care recommendations are free. Free coverage is too insufficient to ensure the efficiency of the perinatal health care system.     

The cost of imperfect agency in health care: Evidence from rural Cameroun

Health is a pressing problem facing Africans today, yet health care systems in Africa are inadequate and under-funded. We show that pervasive imperfect agency means that they are also inefficient. Imperfect agency (due to unobservable medical effort) is a recognized market failure in health care, but its impact is difficult to measure. We take an indirect approach to estimation and infer the cost of unobservable effort from the behavior of utility-maximizing patients, specifically their willingness to incur measurable costs to avoid practitioners who shirk. We use a unique data set from rural Cameroun where patients choose between the government health system, church-operated (mission) health facilities and, importantly, traditional healers. Traditional healers provide health services on an outcome–contingent basis where patients pay only if they are cured. Both government and mission facilities, in contrast, are paid on a fee-for-service basis. Patients' choices of practitioners, combined with quantitative information about patients' illnesses, permit a structural estimation of the value of unobservable medical effort. The results allow investigation into the nature of agency, its costs, and the manner in which contracts reduce and patient behavior mitigates those costs. We estimate that in the absence of imperfect agency, utility from health care would increase by at least 160%. Even in the face of imperfect agency, the sophistication of patients in choosing between existing contracts for different illnesses increases utility by up to 20%.     

Health care reform: current updates and future initiatives for ambulatory care nursing

While the signing of the Patient Protection and Affordable Care Act was a historical event marking the beginning of health care reform in the United States, it signaled the start of a golden age for ambulatory care nursing. Ambulatory care RNs are well-positioned to fully participate in health care reform initiatives. RNs are well-positioned to lead, facilitate, and/or participate in all patient care medical homes' and accountable care organizations' quality and safety initiatives through enhanced use of major ambulatory care RN role dimensions such as advocacy, telehealth, patient education, care coordination and transitional care, and community outreach. RNs are also well-positioned to provide patient-centered care, coordinate care, and manage transitions across ambulatory care settings. For the golden age of ambulatory care nursing to become a reality, initiatives surrounding competencies, education modules, and leadership must be addressed immediately.     

End-of-life care in nursing homes: the high cost of staff turnover

Nursing home staff turnover results in high cost--both economic and personal--and has a negative impact on the quality of care provided to residents at the end of life. Reducing staff turnover in nursing homes would benefit both the cost to the U.S. health care system, and, most importantly, the care residents receive in the vulnerable period leading to death. There is rising pressure on nursing homes to improve their palliative and end-of-life care practices and reduce transfers to hospital for situations and conditions that can be safely managed on site. Nursing care staff deserve an investment in the specific training necessary for them to give the highest quality care to dying residents. This training should be multifaceted and include the physiological, psychological, spiritual, interpersonal, and cultural (including ethnic) aspects of dying. Empowerment with these necessary knowledge, skills, and attitudes will not only result in better care for residents but likely also will reduce the burnout and frustration staff experience in caring for residents near death.