Transforming the continuum of care with technology

Nurse Leader Insider, July 14, 2016

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Judy Murphy, RN, FACMI, FHIMSS, FAAN, has been a leader in health information technology (IT) for more than 25 years. She is currently chief nursing officer (CNO) for IBM Global Healthcare. Prior to joining IBM, Murphy served as CNO and deputy national coordinator for programs and policy at the Office of the National Coordinator (ONC) for Health IT in Washington, D.C. There, she led federal efforts to help healthcare providers use IT to improve care and to promote consumers’ understanding and use of IT for their own health. Murphy went to ONC in 2011 with more than 25 years of health informatics experience at Aurora Health Care in Wisconsin, an integrated delivery network with 15 hospitals, 120 ambulatory centers, and more than 30,000 employees. She led Aurora’s electronic health record program starting in 1995, when Aurora was an early adopter of health IT. Murphy has a long-standing reputation as a patient advocate, as well as a champion for nurses and nurse informaticists. She recently talked with Sally Graver, a healthcare writer based in Chicago, about leadership and health IT.

Graver: What is nurses’ role in the healthcare transformation that’s being enabled by technology?

Murphy: The first thing to remember is that healthcare is all about managing information and turning that into knowledge about the patient—knowing what’s going on with the patient, the labs and radiology results, care plan, best practices, and more. Information technology (IT) is an important enabler of the knowledge management that nurses need to do every day.

Second, we organize and drive workflow through the use of technology. With mobile devices, we can have anytime, anywhere access to all the data, create tailor-made to-do lists, and better respond to patients’ needs. A nurse can walk into one patient’s room and get an alarm from a different patient in a different room without even logging in.

Third, nurses are the most trusted health professionals. We understand the patients the best, and they trust us. So our ability to have an impact on care, on how it’s delivered, and on how patients participate in their own care is unparalleled. Because of this, I think nurses are uniquely positioned to make a difference in the health and wellness of our country as we go forward with changing payment models.

Graver: How do we keep technology centered on the patient?

Murphy: If you want technology focused in a patient-centric way, you want the nurse to participate in its design and development. In the acute care setting, the last line of defense for the patient is the nurse. Physicians, dietitians, or physical therapists only know certain pieces; nurses know almost everything about the patient—that’s our role. To understand technology’s impact on the patient, it’s extremely important that nurses are involved in its review and evaluation. Nurses do a lot of documentation and data review, 24/7, so nurses need to be at the table. At many organizations, the chief nursing officer or chief nursing informatics officer is involved in the selection and acquisition of new technology.

Another important function is configuring the system to meet the hospital’s specific needs. That’s done by going through worksheets designed by the vendor to help define how the system should be configured. Nurses are engaged in that 100%. They’re also involved in testing new systems and training hospital staff members—not only other nurses, but also physicians, respiratory therapists, pharmacists, and others. Far beyond being “support” staff, nurses are engaged at every level, at every stage, and in many different ways in the selection and implementation of electronic health records and other clinical technologies.

The use of technology is an evolution, not a revolution. Today’s systems have evolved over time, and no system is ideal. Product changes take time to implement, especially in a highly regulated environment. Evolving the product is another point where it’s really helpful to have nurses engaged. Again, they use the system 24/7, so they’re best able to provide the kind of input that will help improve the system. When an organization is able to make changes, it wants to pick the right things to change and determine whether these are local configuration changes they can make or changes that need to be made by the vendor.

Graver: What is the nurse informaticist’s role?

Murphy: Nurse informaticists are focused on collecting information from practicing nurses and being the champions, taking it back to the vendor and doing the local configuration. Non-nurses can certainly be trained to do some of this work, but my preference will always be the nurse informaticists, who typically have continuing education or a master’s degree in informatics. They don’t just observe a shift and get a feel for what nurses go through; they actually know the work and can craft the appropriate solutions to meet the need. If I had to choose, I’d always pick the informatics specialists.

That being said, I think you can make many different models work. The nurse informaticist could certainly be a consultant. But again, consulting is generally sporadic or episodic, compared to having somebody who is there all the time and understands the workings of that particular organization.

Graver: Where are we now with regard to technology?

Murphy: In the last couple of years, I think we’ve reached a tipping point where people believe that the same technology we use in the rest of our lives should also apply to healthcare. We’ve accepted online scheduling, online bill pay, and online results of all kinds. At a conference I recently attended, someone asked participants, “How many of you have patient portals?” Eighty percent of the people in the room raised their hand. Two years ago, that number would have been less than 50%.

The key is to keep the patient in the center of all we do in healthcare. The only way to make sure that clinicians are coordinated around the patient is to talk to each other. Often we’re not even in the same care venues, so we can’t physically talk to each other. The way we talk is through the electronic health record. It’s important to enter information and pull information out of that record in reliable ways, so we’re not asking people for their insurance, allergies, and medication lists multiple times. We want to understand what patients have already been taught about diabetes and can add to it, instead of starting from scratch.

I think the idea of using automation to maintain patient-centricity is now universally accepted. We’re at the point of taking these technologies and making them better. I don’t think anybody thinks that the tools we have today are the best, but I think everybody would agree that the tools we have are better than paper.

Most nurse executives and nurse leaders would agree that we need technology, but they aren’t sure how to take it to the next level. They have so many things to worry about. That’s why they hire the nursing informatics specialist who can wake up every day and worry about how to make things better for the nurses throughout the organization by using technology.

Graver: How is nursing’s role evolving?

Murphy: The coordination role that nurses play in acute care is very well known and accepted. When we start talking about the roles nurses play in patient-centered medical homes and nurses coordinating care in the ambulatory and home setting, there’s probably less acceptance there, even on the part of patients.

Traditionally healthcare has revolved around the doctor. But the way to get to the healthcare we need is to have care coordinated and delivered through a team. The doctor is certainly a member of the team, but the appropriate team member needs to contact the patient, based on what the patient needs as an individual.

Patients are members of that team, too. If you’re hypertensive, for example, maintaining your health isn’t just having your blood pressure taken every six months by your doctor or your nurse. Your responsibility is to check your own blood pressure every day, with nurses acting as coaches, as needed. I think these types of mindsets are evolving in the ambulatory and home space, even if nurses may not yet have the same visibility that they have in acute care.

Graver: What do you see coming up?

Murphy: When I left Aurora Health Care in 2011, I had been focusing on some aspect of electronic health records for about 20 years. Then at the Office of the National Coordinator for Health Information Technology (ONC), I started to realize that a lot of health IT was evolving outside of the traditional electronic health records—things like mobile apps, analytics, population health management, big data, etc. I became very interested in getting outside of the acute care facilities to really think about health and healthcare, and how we do disease management and preventive care in the home. That’s what took me to IBM; I wanted to stay in health IT, but not work on electronic health records (EHR), per se. The EHR is certainly important; I would call it the foundation of what we do. But I wanted to work on the next big thing in health IT.

In thinking about the future of healthcare technology, the first thing I’d look at is mobility. What can we put on a mobile device that will empower our caregivers and our patients and make a big difference as to how we think about health and healthcare?

The second thing is population health management. I think that’s becoming the new organizing framework—getting out of the acute care focus and really thinking about these four different population segments:

  • The healthy well
  • The people who are predisposed to disease
  • The management of chronic disease
  • The very small sliver of the acute care episodes

 It’s important to think about how we use health IT in different venues with those different population segments. We need to really think and act on value-based care and maintaining health and wellness, as compared to just managing episodes and diseases. We also need the ability to find patterns and opportunities for improvement by collecting data and analyzing it.

One of the biggest changes will be the government mandates around value-based care. Reimbursement is going to be value-based, not volume-based. You’re going to get reimbursed for maintaining the health of a population and managing chronic disease well, not for itemized episodes of care and services. The government has gone on record saying that by the end of 2018, 50% of payments from Medicare will be bundled payments and value-based.

If you’re not getting paid for every chest x-ray and every lab test that you do, and instead start getting reimbursed for value metrics, such as an 85% mammogram screening rate in primary care, you get a different mindset for how you think about these things.

The industry has consistently maintained that with information comes empowerment, and with empowerment comes better participation of patients in their own care and better outcomes. Getting patients engaged in their own care is being encouraged at all levels—including participation in health and wellness activities, as well as disease management processes. Even in acute care, patient engagement is encouraged, as patients are being given iPads so they can see their own care plan and access their test results. Or they might be presented with a daily itinerary to see what’s going to happen to them during the day. That’s just one more example of how technology is already transforming the whole continuum of care.

Graver: What’s most important as we move ahead?

Murphy: As we continue to strive for the development and adoption of health IT, we have to remember it is the means to an end and not an end unto itself. Health IT should be used wisely and judiciously to support health and healthcare, and to help us move to the transformation we all know we need in our healthcare system. If we are going to improve the industry, all members of the healthcare team need to work together—including the patient—and with nurses helping to lead the way.

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