Connection Alliance for Nursing Informatics
Lessons Learned and Barriers Discussed By Beacon Communities as They Aim to Improve Health Outcomes Through Health Information Technology An Interview by the Informatics and Technology Expert Panel Kathryn H. Bowles, PhD, RN, FAAN, FACMI Gail Latimer, MSN, RN, FACHE, FAAN Bonnie Wesorick, MSN, RN, FAAN Lillee Gelinas, MSN, RN, FAAN Darina Molkina, RN, MN
a convenience sample of Beacon project leaders to gain insights into the barriers encountered and lessons learned during the Beacon project implementations. The cochairs of the expert panel (G.L., K.B., L.G.) developed the interview guide and provided it to the interviewers with instructions about the goals of the project, review of the questions, and how to document the responses. The expert panel cochairs requested interested volunteers from the membership, who then chose which Beacon sites they wanted to interview. The telephone interviews followed a structured format and the interviewers documented the responses in written notes they eventually typed for thematic analysis. Several key themes emerged from the grant coordinators as Beacon communities hope to improve patient outcomes through HIT. While making progress in the aims of the program, site leaders also identified barriers that hinder successful implementation of HIT. The following interview findings illustrate themes related to lessons learned and barriers to implementation.
DOI: 10.1097/CIN.0000000000000065
Lessons Learned The American Recovery and Reinvestment Act funded 18 communities to apply HIT to improve quality, provider coordination, and population health and reduce overall costs. The goals of the projects included reducing in-hospital readmissions, non–life threatening emergency department visits, and medical complications in chronically ill patients and increasing use of preventative services. Of 17 communities, 15 focused on diabetes management. Additional conditions include asthma, cardiovascular disorders, chronic obstructive pulmonary disease, obesity, and behavioral health. Nine nurse fellows in the American Academy of Nursing Informatics and Technology Expert Panel interviewed
When describing a telemonitoring program, one site coordinator expressed: The practice can set parameters for when they want to be notified—for example, a practice may request an alert sent when a patient with congestive heart failure gains more than 7 pounds in 2 days. With the alert, they can contact the patient, adjust their medications, and avoid a trip to the emergency room. The system is constantly vigilant and can automatically “detect and notify,” saving a great deal of work for practices, yet providing them with tools to intervene early and prevent the unnecessary pain, suffering, and expense that accompanies an ED visit
CIN: Computers, Informatics, Nursing • April 2014 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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and hospitalization. Statewide integration of the home monitoring unit will drive the overall costs down and facilitate more effective communication between providers and patients.
Some of the sites are using social media for the patients to share stories and develop a sense of community. As one site leader revealed, some of their activities included development of monthly e-newsletters, which are available on their Web site. A key focus has been on hearing from patients themselves about the benefits received through the Beacon community. Care managers emerged as a key connection between providers and patients: They individualize their approach with each patient, making it possible for the patient to connect and engage with healthcare system. With patients in mind, care managers develop close relationships with the individuals. From the contact and interaction, they develop close relationships with their care manager. The relationships are comfortable; there was a man who lost his wife and stated that he felt like she was back since he had someone checking on him and asking things like, “what did you have to eat last night?” Such close relationships contribute greatly to patient engagement, and follow-up care is important for self-care and preventative services.
Increased clinical engagement came as a surprise to the Beacon communities. Providers were quick to adopt electronic health records (EHRs) and engage with the communities to streamline healthcare efforts. A site leader remarked,The project providers have 100% EHR adoption. They are committed to using technology in a “meaningful manner” and are helping define with national visibility how to best provide “high value” primary care. The Beacon experience also revealed lessons for improvement: Getting the individual proprietary systems to merge effectively with the system supported by Beacon has been an ongoing issue. Much time has been devoted by the Beacon staffers to working through the quagmire of resistance and developing ways of enhancing the interconnectivity of these multiple systems. Not having one consistent system across providers and settings inhibits effective transmission of healthcare information. Spending time fixing the system is necessary but takes away from time spent to improve health outcomes for patients.
One of the aims of Beacon communities includes sustainability of HIT beyond the timeline of the project. These achievements [policy development] have enabled us to establish a long-term funding model involving contributions of $1 per member per month from the fully insured employers via all major health insurers, the state, self-funded employers, and state Medicaid, the latter generating federal matching funds. Having this funding in place enables us operate what we’ve built and continue to develop new functionalities and services.
154
Existing health information exchange (HIE) initiatives were extended and expanded to new areas allowing for greater communication between care managers and patients. The overall goal is to connect all health providers through a statewide HIE. The investigators are focusing on use of HIT to support care coordination and improve the management and outcomes of chronic health conditions.
Barriers Encountered One of the biggest challenges faced by the Beacon communities was lagging payment models. We have realized that our interventions and technologic capabilities are out ahead of payment system reforms. In our state, providers are still under payment systems that reward volume rather than value. When the payment system doesn’t reward quality, it’s very difficult to engage providers who are overwhelmed with the challenges of practicing in a primarily fee-for-service environment. Transforming practice and adopting new innovations takes significant time and effort. Some of our most important outcomes from our Beacon program are the increased awareness and collaborative action on what it takes to promote health and healing, the scaling of our Patient Centered Medical Home initiatives, and moving to payment systems aligned with quality, population health, and cost reduction goals.
Time and money were some of the biggest challenges that Beacon site leaders faced. Time and money; …it takes time to create the networks and trust across all of the communities and sites. The grant is considerably short for all this work to occur and have outcomes and sustainability.
In addition, collaborative efforts between networks and providers took significant time to build and sustain. It was a common theme among the sites to discuss a lack of coordination of care between facilities due to competition and legal capacity. Lack of knowledge of health promotion emerged as another central theme among Beacon site leaders. A barrier that is likely to emerge when the payment systems do finally align with promoting health rather than just treating illness is healthcare’s lack of experience in just that—promoting health. We know how to do procedures, tests, and prescribe medications…we are not as good at promoting health, teaching the person to manage and adapt. This calls for partnering in ways we have not done before.
Discussion Beacon communities were asked to build upon their already established HIT with innovative approaches and strategies. Now that these programs are completed, we look forward to their formal analysis as they share evidence of their effectiveness. As reported here, some of the lessons learned were of a positive nature, and the barriers
CIN: Computers, Informatics, Nursing • April 2014 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
faced contribute greatly to our understanding of successful HIT implementation. Soon we will see how the Beacon projects meet their largest challenge, the continuation of the work outside grant funding. Sustained interest in the efforts of the Beacon sites will provide continued financial and public efforts to maintain the programs. However, payment models need to keep pace with clinical innovation. New models such as Patient Centered Medical Homes, bundled payments, and Accountable Care Organizations are moving in the right direction. Those involved with the Beacon communities reported great satisfaction of making a difference in the lives of patients. As one site leader remarked,Because this work is groundbreaking, complex, and challenging to the status quo, we need to constantly remind people that they’re not just “laying bricks,” but instead building a cathedral. It’s critical to keep referencing the raison d’eˆtre of this work—saving lives, reducing suffering, reducing the cost burden on our society, and helping people live the lives they’ve hoped for through robust health and well-being.
Conclusion Eighteen communities around the US were designated by the American government as leaders in designing, implementing, and expanding the use of HIT to improve health outcomes. Interviews with the site leaders helped identify lessons learned and barriers faced. Several key themes from the interviews are helpful for building future HIT programs and add to the discussion of how HIT advances patients’ outcomes. The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article. Acknowledgments The Academy Informatics and Technology Expert Panel cochairs thank the following fellows for their time and expertise in completing the Beacon interviews: Charlene Clark, Karen Martin, Dee McGonigle, Anna McDaniel, Karen Monsen, Joanne Pohl, Pam Shiao, Bonnie Wesorick, and Bonnie Westra.
CIN: Computers, Informatics, Nursing • April 2014 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
155
Lessons Learned and Barriers Discussed By Beacon Communities as They Aim to Improve Health Outcomes Through Health Information Technology An Interview by the Informatics and Technology Expert Panel Kathryn H. Bowles, PhD, RN, FAAN, FACMI Gail Latimer, MSN, RN, FACHE, FAAN Bonnie Wesorick, MSN, RN, FAAN Lillee Gelinas, MSN, RN, FAAN Darina Molkina, RN, MN
a convenience sample of Beacon project leaders to gain insights into the barriers encountered and lessons learned during the Beacon project implementations. The cochairs of the expert panel (G.L., K.B., L.G.) developed the interview guide and provided it to the interviewers with instructions about the goals of the project, review of the questions, and how to document the responses. The expert panel cochairs requested interested volunteers from the membership, who then chose which Beacon sites they wanted to interview. The telephone interviews followed a structured format and the interviewers documented the responses in written notes they eventually typed for thematic analysis. Several key themes emerged from the grant coordinators as Beacon communities hope to improve patient outcomes through HIT. While making progress in the aims of the program, site leaders also identified barriers that hinder successful implementation of HIT. The following interview findings illustrate themes related to lessons learned and barriers to implementation.
DOI: 10.1097/CIN.0000000000000065
Lessons Learned The American Recovery and Reinvestment Act funded 18 communities to apply HIT to improve quality, provider coordination, and population health and reduce overall costs. The goals of the projects included reducing in-hospital readmissions, non–life threatening emergency department visits, and medical complications in chronically ill patients and increasing use of preventative services. Of 17 communities, 15 focused on diabetes management. Additional conditions include asthma, cardiovascular disorders, chronic obstructive pulmonary disease, obesity, and behavioral health. Nine nurse fellows in the American Academy of Nursing Informatics and Technology Expert Panel interviewed
When describing a telemonitoring program, one site coordinator expressed: The practice can set parameters for when they want to be notified—for example, a practice may request an alert sent when a patient with congestive heart failure gains more than 7 pounds in 2 days. With the alert, they can contact the patient, adjust their medications, and avoid a trip to the emergency room. The system is constantly vigilant and can automatically “detect and notify,” saving a great deal of work for practices, yet providing them with tools to intervene early and prevent the unnecessary pain, suffering, and expense that accompanies an ED visit
CIN: Computers, Informatics, Nursing • April 2014 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
153
and hospitalization. Statewide integration of the home monitoring unit will drive the overall costs down and facilitate more effective communication between providers and patients.
Some of the sites are using social media for the patients to share stories and develop a sense of community. As one site leader revealed, some of their activities included development of monthly e-newsletters, which are available on their Web site. A key focus has been on hearing from patients themselves about the benefits received through the Beacon community. Care managers emerged as a key connection between providers and patients: They individualize their approach with each patient, making it possible for the patient to connect and engage with healthcare system. With patients in mind, care managers develop close relationships with the individuals. From the contact and interaction, they develop close relationships with their care manager. The relationships are comfortable; there was a man who lost his wife and stated that he felt like she was back since he had someone checking on him and asking things like, “what did you have to eat last night?” Such close relationships contribute greatly to patient engagement, and follow-up care is important for self-care and preventative services.
Increased clinical engagement came as a surprise to the Beacon communities. Providers were quick to adopt electronic health records (EHRs) and engage with the communities to streamline healthcare efforts. A site leader remarked,The project providers have 100% EHR adoption. They are committed to using technology in a “meaningful manner” and are helping define with national visibility how to best provide “high value” primary care. The Beacon experience also revealed lessons for improvement: Getting the individual proprietary systems to merge effectively with the system supported by Beacon has been an ongoing issue. Much time has been devoted by the Beacon staffers to working through the quagmire of resistance and developing ways of enhancing the interconnectivity of these multiple systems. Not having one consistent system across providers and settings inhibits effective transmission of healthcare information. Spending time fixing the system is necessary but takes away from time spent to improve health outcomes for patients.
One of the aims of Beacon communities includes sustainability of HIT beyond the timeline of the project. These achievements [policy development] have enabled us to establish a long-term funding model involving contributions of $1 per member per month from the fully insured employers via all major health insurers, the state, self-funded employers, and state Medicaid, the latter generating federal matching funds. Having this funding in place enables us operate what we’ve built and continue to develop new functionalities and services.
154
Existing health information exchange (HIE) initiatives were extended and expanded to new areas allowing for greater communication between care managers and patients. The overall goal is to connect all health providers through a statewide HIE. The investigators are focusing on use of HIT to support care coordination and improve the management and outcomes of chronic health conditions.
Barriers Encountered One of the biggest challenges faced by the Beacon communities was lagging payment models. We have realized that our interventions and technologic capabilities are out ahead of payment system reforms. In our state, providers are still under payment systems that reward volume rather than value. When the payment system doesn’t reward quality, it’s very difficult to engage providers who are overwhelmed with the challenges of practicing in a primarily fee-for-service environment. Transforming practice and adopting new innovations takes significant time and effort. Some of our most important outcomes from our Beacon program are the increased awareness and collaborative action on what it takes to promote health and healing, the scaling of our Patient Centered Medical Home initiatives, and moving to payment systems aligned with quality, population health, and cost reduction goals.
Time and money were some of the biggest challenges that Beacon site leaders faced. Time and money; …it takes time to create the networks and trust across all of the communities and sites. The grant is considerably short for all this work to occur and have outcomes and sustainability.
In addition, collaborative efforts between networks and providers took significant time to build and sustain. It was a common theme among the sites to discuss a lack of coordination of care between facilities due to competition and legal capacity. Lack of knowledge of health promotion emerged as another central theme among Beacon site leaders. A barrier that is likely to emerge when the payment systems do finally align with promoting health rather than just treating illness is healthcare’s lack of experience in just that—promoting health. We know how to do procedures, tests, and prescribe medications…we are not as good at promoting health, teaching the person to manage and adapt. This calls for partnering in ways we have not done before.
Discussion Beacon communities were asked to build upon their already established HIT with innovative approaches and strategies. Now that these programs are completed, we look forward to their formal analysis as they share evidence of their effectiveness. As reported here, some of the lessons learned were of a positive nature, and the barriers
CIN: Computers, Informatics, Nursing • April 2014 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
faced contribute greatly to our understanding of successful HIT implementation. Soon we will see how the Beacon projects meet their largest challenge, the continuation of the work outside grant funding. Sustained interest in the efforts of the Beacon sites will provide continued financial and public efforts to maintain the programs. However, payment models need to keep pace with clinical innovation. New models such as Patient Centered Medical Homes, bundled payments, and Accountable Care Organizations are moving in the right direction. Those involved with the Beacon communities reported great satisfaction of making a difference in the lives of patients. As one site leader remarked,Because this work is groundbreaking, complex, and challenging to the status quo, we need to constantly remind people that they’re not just “laying bricks,” but instead building a cathedral. It’s critical to keep referencing the raison d’eˆtre of this work—saving lives, reducing suffering, reducing the cost burden on our society, and helping people live the lives they’ve hoped for through robust health and well-being.
Conclusion Eighteen communities around the US were designated by the American government as leaders in designing, implementing, and expanding the use of HIT to improve health outcomes. Interviews with the site leaders helped identify lessons learned and barriers faced. Several key themes from the interviews are helpful for building future HIT programs and add to the discussion of how HIT advances patients’ outcomes. The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article. Acknowledgments The Academy Informatics and Technology Expert Panel cochairs thank the following fellows for their time and expertise in completing the Beacon interviews: Charlene Clark, Karen Martin, Dee McGonigle, Anna McDaniel, Karen Monsen, Joanne Pohl, Pam Shiao, Bonnie Wesorick, and Bonnie Westra.
CIN: Computers, Informatics, Nursing • April 2014 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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