AJN REPORTS
Health Information Technology: Bane or Boon?
Photo by Frank Muller / Hollandse Hoogte / Redux.
As some nurses campaign against HIT, others promote ‘high touch–high tech’ care.
“A
computer can never do what I do. I FEEL.” This anonymous comment, left on a blog post about older nurses alienated by technologically savvy younger nurses, speaks to a seemingly irreconcilable rift in nursing: the hands-on comfort that a nurse provides opposite the information that technology makes available in most clinical settings. Earlier this year National Nurses United (NNU), the largest U.S. union representing RNs, launched a campaign opposed to what it called the “unchecked proliferation of unproven medical technology.” The campaign has focused, in part, on the automated clinical decision support (CDS) systems that are built into the electronic health record (EHR) at many institutions. (CDS provides best-practice protocols for care given to individual patients.) Decrying the use of “computers that diagnose and dictate treatment,” as an NNU press release puts it, the union acknowledges
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AJN ▼ December 2014
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Vol. 114, No. 12
that such technologies may cut costs but can also “supplant” clinical judgment, leading to costly, and sometimes deadly, medical error. As a part of the campaign, in July the NNU responded to a request for comment on a draft proposal for regulating health information technology (HIT) by the U.S. Food and Drug Administration, the Office of the National Coordinator for Health Information Technology (ONC), and the Federal Communications Commission. In its comments, the union criticized the billions of dollars the federal government has spent in support of EHRs in hospitals, in spite, it says, of the insufficient evidence that the technology saves lives and the inadequate safeguards against billing fraud. The union proposes that HIT be regulated at the same level as medical devices— “the highest level of oversight.” The copresident of the NNU and the California Nurses Association, Deborah Burger, told AJN that although the campaign has received ample attention online, nurses have organized for tighter regulation of technology for quite some time. She knows of many nurses who have been disciplined—from a written warning to several days’ suspension—for overriding protocols put forth by CDS. By not allowing clinicians to follow their own clinical judgment when they know a “best practice” protocol is inappropriate, Burger said, “you set yourself up to be liable.” And she pointed out that the billions of dollars in federal incentives hospitals have received to implement EHR technology gives them plenty of reason to keep moving forward. (The incentives were instituted as part of the American Recovery and Reinvestment Act, the federal economic-stimulus package enacted in 2009. Facilities receiving the incentives must show that EHRs demonstrate “meaningful use” in specific areas such as drug-allergy checks in order to continue to receive these funds.) “The hospital industry can’t get rid of the technology because they’ve got the [diagnosis] codes and progress notes attached to it for billing,” Burger said. “As far as billing goes, it’s extremely successful. But ajnonline.com
they’re not in it just for the patient’s interests, as we are. They’re in it for the billing.” As a part of EHRs, CDS systems are in widespread use in hospitals—especially when it comes to medication safety—according to a recent Robert Wood Johnson Foundation (RWJF) report, Health Information Technology in the United States: Progress and Challenges Ahead, 2014. The RWJF cites data from an American Hospital Association survey showing that 81% of hospitals use CDS on all units to alert clinicians to possible drug allergies and drug– drug interactions. But just 55% of hospitals surveyed make clinical practice guidelines a part of CDS on all units, suggesting that there’s much room for improvement when it comes to using the technology to promote evidence-based practice.
More and more nurses are engaging with technology in ways that seek to keep patients as the focus of care. Also, the RWJF cites important limitations of CDS: the database must be updated as evidence changes, and in some cases the “decision support” provided won’t apply at all. In fact, the authors write, a CDS system can be “inflexible,” exasperating clinicians to the point where they don’t even use it. The report urges facilities to make every effort to find tools that guide users in how to standardize procedures and also “leave room to customize care for the individual patient.”
CDS AND EHRs: ARE THEY SAFE AND EFFECTIVE?
For nurse informaticist Patricia Sengstack, that goal represents a natural fit. Nursing informatics has evolved as a specialty since the 1980s; in recent years it has grown to include the analysis of clinical and financial data and the redesign of clinical procedures to incorporate technology. Sengstack, the president of the American Nursing Informatics Association and the chief nursing informatics officer at Bon Secours Health System, headquartered in Marriottsville, Maryland, has worked to design HIT systems for the people who use them. “One of the things I’ve learned is you cannot configure the [technology] nurses use without nurses at the table,” Sengstack said. “It won’t work, and you’ll [email protected]
have angry nurses.” She characterizes the ideal nursing care in this era of increasing technology as being “high touch–high tech”—that is, hands-on attention that also makes good use of HIT tools. Sengstack gave the example of a nurse bringing a computer to a patient’s bedside, pulling up records to discuss test results, and linking to MedlinePlus to show an illustration of a procedure. While studying for her doctorate at Vanderbilt University, Sengstack conducted a literature review on the safety of computerized physician order entry and EHRs and found plenty of evidence to support the safe incorporation of EHRs into clinical practice. “There are possibilities and benefits we haven’t even realized yet,” she said. Research is ongoing. In September, the ONC released a new “Health IT Safety Plan” (available at http://bit.ly/1yI4dMH). The plan cites a systematic review by Jones and colleagues, published in the January 7, 2014, issue of Annals of Internal Medicine, that evaluated meaningful-use data and found strong evidence to support CDS systems, with most studies showing positive or mixed-positive findings. “CDS generally results in improvements in the processes targeted by the decision support,” they wrote. And more and more nurses are engaging with technology in ways that seek to keep patients as the focus of care. Patricia Flatley Brennan served as the director of Project HealthDesign, an RWJF program that helped patients design their own personal health records as a way of enhancing care decisions. Brennan, a professor of nursing and engineering at the University of Wisconsin–Madison, said, “In my research since the 1980s we have moved the needle away from nursing and technology toward how technology will help in the more informal spaces and lives of people.” In the final report of Project HealthDesign, published in April (http://bit.ly/1vK4l8r), Brennan wrote that patients’ own observations of their health should be viewed as data that can “strengthen the patient-clinician partnership by allowing clinicians to see a more robust picture of a patient’s daily health experience.” Despite the inexorable advances of HIT, NNU is not a lone voice in criticizing it. In mid-September the American Medical Association issued a report on the “usability” of EHRs, highlighting eight challenges physicians face, including the interference of technology in patient interactions and the insufficient support it provides for team-based care. Sengstack hopes the questions being raised now about HIT will give everyone involved, patients included, an opportunity to come to consensus on the answers. “EHRs are not perfect,” she said, “but we’re all in this together.”—Joy Jacobson ▼ AJN ▼ December 2014
▼
Vol. 114, No. 12
19
Health Information Technology: Bane or Boon?
Photo by Frank Muller / Hollandse Hoogte / Redux.
As some nurses campaign against HIT, others promote ‘high touch–high tech’ care.
“A
computer can never do what I do. I FEEL.” This anonymous comment, left on a blog post about older nurses alienated by technologically savvy younger nurses, speaks to a seemingly irreconcilable rift in nursing: the hands-on comfort that a nurse provides opposite the information that technology makes available in most clinical settings. Earlier this year National Nurses United (NNU), the largest U.S. union representing RNs, launched a campaign opposed to what it called the “unchecked proliferation of unproven medical technology.” The campaign has focused, in part, on the automated clinical decision support (CDS) systems that are built into the electronic health record (EHR) at many institutions. (CDS provides best-practice protocols for care given to individual patients.) Decrying the use of “computers that diagnose and dictate treatment,” as an NNU press release puts it, the union acknowledges
18
AJN ▼ December 2014
▼
Vol. 114, No. 12
that such technologies may cut costs but can also “supplant” clinical judgment, leading to costly, and sometimes deadly, medical error. As a part of the campaign, in July the NNU responded to a request for comment on a draft proposal for regulating health information technology (HIT) by the U.S. Food and Drug Administration, the Office of the National Coordinator for Health Information Technology (ONC), and the Federal Communications Commission. In its comments, the union criticized the billions of dollars the federal government has spent in support of EHRs in hospitals, in spite, it says, of the insufficient evidence that the technology saves lives and the inadequate safeguards against billing fraud. The union proposes that HIT be regulated at the same level as medical devices— “the highest level of oversight.” The copresident of the NNU and the California Nurses Association, Deborah Burger, told AJN that although the campaign has received ample attention online, nurses have organized for tighter regulation of technology for quite some time. She knows of many nurses who have been disciplined—from a written warning to several days’ suspension—for overriding protocols put forth by CDS. By not allowing clinicians to follow their own clinical judgment when they know a “best practice” protocol is inappropriate, Burger said, “you set yourself up to be liable.” And she pointed out that the billions of dollars in federal incentives hospitals have received to implement EHR technology gives them plenty of reason to keep moving forward. (The incentives were instituted as part of the American Recovery and Reinvestment Act, the federal economic-stimulus package enacted in 2009. Facilities receiving the incentives must show that EHRs demonstrate “meaningful use” in specific areas such as drug-allergy checks in order to continue to receive these funds.) “The hospital industry can’t get rid of the technology because they’ve got the [diagnosis] codes and progress notes attached to it for billing,” Burger said. “As far as billing goes, it’s extremely successful. But ajnonline.com
they’re not in it just for the patient’s interests, as we are. They’re in it for the billing.” As a part of EHRs, CDS systems are in widespread use in hospitals—especially when it comes to medication safety—according to a recent Robert Wood Johnson Foundation (RWJF) report, Health Information Technology in the United States: Progress and Challenges Ahead, 2014. The RWJF cites data from an American Hospital Association survey showing that 81% of hospitals use CDS on all units to alert clinicians to possible drug allergies and drug– drug interactions. But just 55% of hospitals surveyed make clinical practice guidelines a part of CDS on all units, suggesting that there’s much room for improvement when it comes to using the technology to promote evidence-based practice.
More and more nurses are engaging with technology in ways that seek to keep patients as the focus of care. Also, the RWJF cites important limitations of CDS: the database must be updated as evidence changes, and in some cases the “decision support” provided won’t apply at all. In fact, the authors write, a CDS system can be “inflexible,” exasperating clinicians to the point where they don’t even use it. The report urges facilities to make every effort to find tools that guide users in how to standardize procedures and also “leave room to customize care for the individual patient.”
CDS AND EHRs: ARE THEY SAFE AND EFFECTIVE?
For nurse informaticist Patricia Sengstack, that goal represents a natural fit. Nursing informatics has evolved as a specialty since the 1980s; in recent years it has grown to include the analysis of clinical and financial data and the redesign of clinical procedures to incorporate technology. Sengstack, the president of the American Nursing Informatics Association and the chief nursing informatics officer at Bon Secours Health System, headquartered in Marriottsville, Maryland, has worked to design HIT systems for the people who use them. “One of the things I’ve learned is you cannot configure the [technology] nurses use without nurses at the table,” Sengstack said. “It won’t work, and you’ll [email protected]
have angry nurses.” She characterizes the ideal nursing care in this era of increasing technology as being “high touch–high tech”—that is, hands-on attention that also makes good use of HIT tools. Sengstack gave the example of a nurse bringing a computer to a patient’s bedside, pulling up records to discuss test results, and linking to MedlinePlus to show an illustration of a procedure. While studying for her doctorate at Vanderbilt University, Sengstack conducted a literature review on the safety of computerized physician order entry and EHRs and found plenty of evidence to support the safe incorporation of EHRs into clinical practice. “There are possibilities and benefits we haven’t even realized yet,” she said. Research is ongoing. In September, the ONC released a new “Health IT Safety Plan” (available at http://bit.ly/1yI4dMH). The plan cites a systematic review by Jones and colleagues, published in the January 7, 2014, issue of Annals of Internal Medicine, that evaluated meaningful-use data and found strong evidence to support CDS systems, with most studies showing positive or mixed-positive findings. “CDS generally results in improvements in the processes targeted by the decision support,” they wrote. And more and more nurses are engaging with technology in ways that seek to keep patients as the focus of care. Patricia Flatley Brennan served as the director of Project HealthDesign, an RWJF program that helped patients design their own personal health records as a way of enhancing care decisions. Brennan, a professor of nursing and engineering at the University of Wisconsin–Madison, said, “In my research since the 1980s we have moved the needle away from nursing and technology toward how technology will help in the more informal spaces and lives of people.” In the final report of Project HealthDesign, published in April (http://bit.ly/1vK4l8r), Brennan wrote that patients’ own observations of their health should be viewed as data that can “strengthen the patient-clinician partnership by allowing clinicians to see a more robust picture of a patient’s daily health experience.” Despite the inexorable advances of HIT, NNU is not a lone voice in criticizing it. In mid-September the American Medical Association issued a report on the “usability” of EHRs, highlighting eight challenges physicians face, including the interference of technology in patient interactions and the insufficient support it provides for team-based care. Sengstack hopes the questions being raised now about HIT will give everyone involved, patients included, an opportunity to come to consensus on the answers. “EHRs are not perfect,” she said, “but we’re all in this together.”—Joy Jacobson ▼ AJN ▼ December 2014
▼
Vol. 114, No. 12
19
