Editorial
Technology: A Gift for Our Patients
Technology has changed everything, and there is no going back, personally or professionally. For many, it has been a bittersweet goodbye to paper and perhaps a less complicated way of life and work pattern. However, few among us will relinquish our gadgets, now electronic extensions of ourselves. Technology will continue to enrich our lives and the lives of our patients in ways we are just beginning to imagine. The electronic medical record (EMR), electronic patient portals, mobile healthcare, and teleheath are imbedded in our world as firmly as our iPhones, Facebook pages, Twitter feeds, laptops, tablets, YouTube, and an endless array of apps. These technologies have improved our lives, and new tools will allow us to improve our connections to patients. Access to patients will be different, perhaps better, certainly innovative. Patients will connect with their healthcare team using many forms of technology to activate their own learning and become engaged in maintaining their health. There are also economic incentives. It is widely recognized that the increasing adoption of electronic technologies is a key strategy for making health care more cost-effective, a goal for Accountable Health Care. The primary provisions of The Health Information Technology for Economic and Clinical Health, as part of the American Recovery Reinvestment Act of 2009, supports the use of an EMR and establishes meaningful use criteria and fiscal penalties for organizations that fail to meet these standards. ‘‘Meaningful use’’ includes using technology implementation to improve quality, safety, and efficiency; reduce health disparities; engage patients and family; improve care coordination and population and public health; and maintain privacy and security of patient health information.1 The main objectives are to collect information, share information, and use information to improve patient outcomes. With these incentives and the explosion of new technology, nurses will experience changes in the way they manage their own work and mentor others! In this issue of Dimensions of Critical Care Nursing, Schleifer, Carroll, and Moseley remind us that new nursing DOI: 10.1097/DCC.0000000000000048
roles emerge with the advent of telemedicine. The telemedicine registered nurse works in a teleYintensive care unit and is trained as a traditional critical care nurse; but many skills, communication methods, and expectations are different. The development, education, and advancement of this role require a thoughtful approach to education and revised competency tools for this new role. Henneman and her research team at the University of Massachusetts at Amherst introduce eye tracking technology used to evaluate participants during patient simulation educational sessions. Eye tracking technology is an innovative method for providing objective evaluative feedback after a simulation experience. The purpose of this study was to compare 3 forms of simulation-based student feedback (verbal debrief only, eye tracking only, and combined verbal debrief and eye tracking) to determine the most effective method for improving student knowledge and performance. Clearly, using technology to manage technology adds efficiency to our education and training. These are important contributions to nursing as we approach a future where wireless medicine will change how we deliver critical care. We will become more connected to our patients as we direct and manage care remotely during the acute phase of care, recovery, and continued health management. We will continue to develop new ways of educating our workforce, perhaps developing simulated experiences that are very different from traditional functions within the hospital environment. Telehealth is becoming a routine practice in many of our critical care units. Adler-Milstein and coauthors found that 42% of US hospitals had adopted telehealth by late 2012, with significant variation across the country: Alaska was the highest, with 75%, and Rhode Island had minimal adoption.2 Medical practice culture is changing as this mode of care delivery becomes the norm. The work of Adler-Milstein et al2 in the February Health Affairs 2014 issue describes the current evidence and future potential of connected health-encompassing telemedicine, telehealth, and eHealth. The issue was discussed on February 7, 2014, at a Washington, DC, conference. This conference May/June 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
105
Editorial
and 2014 publication examine the concept of connected health as an overarching structure for telemedicine and telehealth, and it provides examples of its value to professionals as well as patients.3
postcardiac surgery assessment. Current telehealth programs using VITAL continue to report improvements in patient and caregiver outcomes in 2013.6
MOBILE DEVICES FOR EVIDENCE-BASED PRACTICE AND TIMELY CARE
Patients have been using the Internet to search for medical information for more than 10 years. Recently, we have noticed that patients are using other forms of media to access information. Recently, a patient at the hospital where I work reported that he had watched a YouTube video on wound care and asked if he would have a vacuum assisted closure (VAC) drainage system that was featured in the video. Founded in February 2005, YouTube allows billions of people to discover, watch, and share originally created videos. YouTube provides a forum for people to connect, inform, and inspire others across the globe and acts as a distribution platform for original content creators and advertisers large and small. Currently, many manufactures of medical equipment, universities, and individuals post video messages to instructions to share information using YouTube. Wearable monitors are moving from medicine to personal use as patients monitor exercise and sleep patterns as well as physiological measurements. Data are wirelessly collected and added to information patient report, adding detail and accuracy to the medical profile. Other technologies connect patients to healthcare centers, clinical trials, and support groups for chronic illness or lifestyle adjustments. Facebook is less than 10 years old, and now there are users who cannot recall a time when it did not exist. Linked-In is keeping us connected professionally. Many of our patients read our profiles and check our credentials. Twitter is changing the world 140 characters at a time. Brevity keeps Twitter fast paced and relevant by encouraging people to tweet in the moment and to focus on the essential idea they are trying to communicate. It is predicted that Twitter may be a useful tool to report and manage possible epidemics or disasters. It was an essential communication tool during the Boston Marathon bombing in 2013, as medical personal were alerted to the events at the scene in real time. The full implications for its application in epidemiology are unknown but quite possibly life changing.
MEDIA, APPS, PATIENT CONNECTIONS Our newest staff members have been educated using electronic resources to emulate the early work of Dr David Sackett, to screen for evidence during rounds using critical appraisal techniques applicable to the bedside.4 We have found that technology is critical to evidence-based practice as we assess and interpret scientific evidence in a timely manner. Technology may not dictate your workflow but may be used to enhance it. Some technology increases flexibility, such as using a tablet when you do not need the entire EMR but want to look at only a slice of information. Tablet technology may help us focus on high-risk patients, new practices, and procedures. The Cleveland Clinic is testing the use of tablets in specific groups, such as its rapid response teams. Clinicians can look up patient information on their way to a patient who is crashing and better know how to treat the patient when they arrive at their room. This offers real time coordination of care using very portable technology.5 Providers in hospitals are increasingly turning to mobile devices as a cost-effective extension of their EMRs, making them more usable and friendly. However, Dr Will Morris from the Cleveland Clinic reminds us, ‘‘It’s not going to be the tablet that transforms practice,’’ he said. ‘‘It’s going to be ‘How do you use the data coming out of your EMR, applied with clinical rules, to empower the clinical practice?’’’5
TELEHEALTH IMPROVING PATIENT ACCESS TO CARE Secure Web-based portals extend the boundaries of care. With this technology, we can collect and share data with our patient and other caregivers. Secure portals also allow us to process data through technology based in the patient’s home. Telehealth services connecting the patient from home are widely used. The use of this method continues to expand as patients become more comfortable with technology and more assessable through wireless technology. As early as 1998, the Virtual Interactive Telehealth Assistance Links (VITAL) was developed to improve continued care for cardiac surgical patients and their caregivers and reduce readmission rates. The success of VITAL continues. This remote site hospital to home monitoring system has involved to include hospital-to-hospital triage, remote site outpatient cardiac catheterization assessment, and remote 106
Dimensions of Critical Care Nursing
FEARS AND CHALLENGES WITH TECHNOLOGY Often, my colleagues and I admit we have never been so fearful and excited, although we can take some comfort in the words of Werlin, a technology educator who reviews Britney Wilson’s work, The Nerdy Nurse’s Guide to Technology, in this issue. Werlin reminds us that the key to becoming comfortable with technology is finding personal relevance; consider how you use technology every day
Vol. 33 / No. 3
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Editorial
to communicate with friends and family, find information, and share professional ideas. She warns that competence with technology takes time, yet time spent learning the basics will overcome fear and establish confidence. The new workforce will not have the same fears and will be more prepared to jump into innovations using technology. Education for student K-12 will focus more on the STEM subjects (science, technology, engineering, and mathematics.).7 This is vital not only to US innovation capacity but also as a foundation for successful employment within the healthcare industry. Technology support may be a gift from the novice practitioner. The new nurse is not just a clean slate waiting to learn about critical care, they have much to teach us! Usually, they infuse a wealth of information about technology as they assimilate quickly to the high-technology world of critical care. They are not afraid of the EMR but are quite suspicious of those big notebooks that contain the traditional patient data. Nursing is blessed with a multigenerational workforce, unique in many ways, but essential as we are propelled into technology. Often, it is a new nurse, student, or our own kids who introduce us to a technique on the keyboard, shortcut, blog, tweet, or app that changes how we do things. Learning how to use technology is a gift we are bringing to patient care!
References 1. US Gov. What is meaningful use? http://www.healthit.gov/ providers-professionals/meaningful-use-definition-objectives. Accessed February 12, 2014.
2. Adler-Milstein J, Kvedar J, Bates D. Telehealth among US hospitals: several factors, including state reimbursement and licensure policies, influence adoption. Heath Aff. 2014;33(2): 2017-215. doi:10.1377/hlthaff.2013.1054 3. Health Affairs Conference Proceeding. Early evidence, future promise of connected health; February 5, 2014; Washington, DC. http://www.healthaffairs.org/events/2014 _02_05_early_ evidence_future_promise_of_connected_health/. Accessed February 12, 2014. 4. Sackett DL, Rosenberg WM, Gray M, Haynes BR, Richardson SW. 1996 Evidence based medicine: what it is and what it isn’t. Br Med J. 1996;312:71-72. http://www.bmj.com/cgi/content/ full/312/7023/71 5. Pittman D. Hospitals use tablets as extension of EHRs. The Gupta Guide. February 10, 2014. http://www.medpagetoday.com/ PracticeManagement/InformationTechnology/44239. Accessed February 12, 2014. 6. Keeping-Burke L, Purden N, Frasure-Smith N, Cossette S, McCarthy F, Amsel R. Bridging the Transition from hospital to home: effects of the VITAL telehealth program on recovery for CABG patients and their caregivers. Res Nurs Health. 2013; 36:540-553. 7. Honey M, Schweingruber H, eds. National Academy of Engineering and National Research Council, STEM Integration in K-12 Education: Status, Prospects, and an Agenda for Research. Washington, DC: The National Academies Press; 2014.
Kathleen Ahern Gould, PhD, RN Editor in Chief Dimensions of Critical Care Nursing Adjunct Faculty William F. Connell School of Nursing Boston College Chestnut Hill, Massachusetts The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article.
May/June 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
107
Technology: A Gift for Our Patients
Technology has changed everything, and there is no going back, personally or professionally. For many, it has been a bittersweet goodbye to paper and perhaps a less complicated way of life and work pattern. However, few among us will relinquish our gadgets, now electronic extensions of ourselves. Technology will continue to enrich our lives and the lives of our patients in ways we are just beginning to imagine. The electronic medical record (EMR), electronic patient portals, mobile healthcare, and teleheath are imbedded in our world as firmly as our iPhones, Facebook pages, Twitter feeds, laptops, tablets, YouTube, and an endless array of apps. These technologies have improved our lives, and new tools will allow us to improve our connections to patients. Access to patients will be different, perhaps better, certainly innovative. Patients will connect with their healthcare team using many forms of technology to activate their own learning and become engaged in maintaining their health. There are also economic incentives. It is widely recognized that the increasing adoption of electronic technologies is a key strategy for making health care more cost-effective, a goal for Accountable Health Care. The primary provisions of The Health Information Technology for Economic and Clinical Health, as part of the American Recovery Reinvestment Act of 2009, supports the use of an EMR and establishes meaningful use criteria and fiscal penalties for organizations that fail to meet these standards. ‘‘Meaningful use’’ includes using technology implementation to improve quality, safety, and efficiency; reduce health disparities; engage patients and family; improve care coordination and population and public health; and maintain privacy and security of patient health information.1 The main objectives are to collect information, share information, and use information to improve patient outcomes. With these incentives and the explosion of new technology, nurses will experience changes in the way they manage their own work and mentor others! In this issue of Dimensions of Critical Care Nursing, Schleifer, Carroll, and Moseley remind us that new nursing DOI: 10.1097/DCC.0000000000000048
roles emerge with the advent of telemedicine. The telemedicine registered nurse works in a teleYintensive care unit and is trained as a traditional critical care nurse; but many skills, communication methods, and expectations are different. The development, education, and advancement of this role require a thoughtful approach to education and revised competency tools for this new role. Henneman and her research team at the University of Massachusetts at Amherst introduce eye tracking technology used to evaluate participants during patient simulation educational sessions. Eye tracking technology is an innovative method for providing objective evaluative feedback after a simulation experience. The purpose of this study was to compare 3 forms of simulation-based student feedback (verbal debrief only, eye tracking only, and combined verbal debrief and eye tracking) to determine the most effective method for improving student knowledge and performance. Clearly, using technology to manage technology adds efficiency to our education and training. These are important contributions to nursing as we approach a future where wireless medicine will change how we deliver critical care. We will become more connected to our patients as we direct and manage care remotely during the acute phase of care, recovery, and continued health management. We will continue to develop new ways of educating our workforce, perhaps developing simulated experiences that are very different from traditional functions within the hospital environment. Telehealth is becoming a routine practice in many of our critical care units. Adler-Milstein and coauthors found that 42% of US hospitals had adopted telehealth by late 2012, with significant variation across the country: Alaska was the highest, with 75%, and Rhode Island had minimal adoption.2 Medical practice culture is changing as this mode of care delivery becomes the norm. The work of Adler-Milstein et al2 in the February Health Affairs 2014 issue describes the current evidence and future potential of connected health-encompassing telemedicine, telehealth, and eHealth. The issue was discussed on February 7, 2014, at a Washington, DC, conference. This conference May/June 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
105
Editorial
and 2014 publication examine the concept of connected health as an overarching structure for telemedicine and telehealth, and it provides examples of its value to professionals as well as patients.3
postcardiac surgery assessment. Current telehealth programs using VITAL continue to report improvements in patient and caregiver outcomes in 2013.6
MOBILE DEVICES FOR EVIDENCE-BASED PRACTICE AND TIMELY CARE
Patients have been using the Internet to search for medical information for more than 10 years. Recently, we have noticed that patients are using other forms of media to access information. Recently, a patient at the hospital where I work reported that he had watched a YouTube video on wound care and asked if he would have a vacuum assisted closure (VAC) drainage system that was featured in the video. Founded in February 2005, YouTube allows billions of people to discover, watch, and share originally created videos. YouTube provides a forum for people to connect, inform, and inspire others across the globe and acts as a distribution platform for original content creators and advertisers large and small. Currently, many manufactures of medical equipment, universities, and individuals post video messages to instructions to share information using YouTube. Wearable monitors are moving from medicine to personal use as patients monitor exercise and sleep patterns as well as physiological measurements. Data are wirelessly collected and added to information patient report, adding detail and accuracy to the medical profile. Other technologies connect patients to healthcare centers, clinical trials, and support groups for chronic illness or lifestyle adjustments. Facebook is less than 10 years old, and now there are users who cannot recall a time when it did not exist. Linked-In is keeping us connected professionally. Many of our patients read our profiles and check our credentials. Twitter is changing the world 140 characters at a time. Brevity keeps Twitter fast paced and relevant by encouraging people to tweet in the moment and to focus on the essential idea they are trying to communicate. It is predicted that Twitter may be a useful tool to report and manage possible epidemics or disasters. It was an essential communication tool during the Boston Marathon bombing in 2013, as medical personal were alerted to the events at the scene in real time. The full implications for its application in epidemiology are unknown but quite possibly life changing.
MEDIA, APPS, PATIENT CONNECTIONS Our newest staff members have been educated using electronic resources to emulate the early work of Dr David Sackett, to screen for evidence during rounds using critical appraisal techniques applicable to the bedside.4 We have found that technology is critical to evidence-based practice as we assess and interpret scientific evidence in a timely manner. Technology may not dictate your workflow but may be used to enhance it. Some technology increases flexibility, such as using a tablet when you do not need the entire EMR but want to look at only a slice of information. Tablet technology may help us focus on high-risk patients, new practices, and procedures. The Cleveland Clinic is testing the use of tablets in specific groups, such as its rapid response teams. Clinicians can look up patient information on their way to a patient who is crashing and better know how to treat the patient when they arrive at their room. This offers real time coordination of care using very portable technology.5 Providers in hospitals are increasingly turning to mobile devices as a cost-effective extension of their EMRs, making them more usable and friendly. However, Dr Will Morris from the Cleveland Clinic reminds us, ‘‘It’s not going to be the tablet that transforms practice,’’ he said. ‘‘It’s going to be ‘How do you use the data coming out of your EMR, applied with clinical rules, to empower the clinical practice?’’’5
TELEHEALTH IMPROVING PATIENT ACCESS TO CARE Secure Web-based portals extend the boundaries of care. With this technology, we can collect and share data with our patient and other caregivers. Secure portals also allow us to process data through technology based in the patient’s home. Telehealth services connecting the patient from home are widely used. The use of this method continues to expand as patients become more comfortable with technology and more assessable through wireless technology. As early as 1998, the Virtual Interactive Telehealth Assistance Links (VITAL) was developed to improve continued care for cardiac surgical patients and their caregivers and reduce readmission rates. The success of VITAL continues. This remote site hospital to home monitoring system has involved to include hospital-to-hospital triage, remote site outpatient cardiac catheterization assessment, and remote 106
Dimensions of Critical Care Nursing
FEARS AND CHALLENGES WITH TECHNOLOGY Often, my colleagues and I admit we have never been so fearful and excited, although we can take some comfort in the words of Werlin, a technology educator who reviews Britney Wilson’s work, The Nerdy Nurse’s Guide to Technology, in this issue. Werlin reminds us that the key to becoming comfortable with technology is finding personal relevance; consider how you use technology every day
Vol. 33 / No. 3
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Editorial
to communicate with friends and family, find information, and share professional ideas. She warns that competence with technology takes time, yet time spent learning the basics will overcome fear and establish confidence. The new workforce will not have the same fears and will be more prepared to jump into innovations using technology. Education for student K-12 will focus more on the STEM subjects (science, technology, engineering, and mathematics.).7 This is vital not only to US innovation capacity but also as a foundation for successful employment within the healthcare industry. Technology support may be a gift from the novice practitioner. The new nurse is not just a clean slate waiting to learn about critical care, they have much to teach us! Usually, they infuse a wealth of information about technology as they assimilate quickly to the high-technology world of critical care. They are not afraid of the EMR but are quite suspicious of those big notebooks that contain the traditional patient data. Nursing is blessed with a multigenerational workforce, unique in many ways, but essential as we are propelled into technology. Often, it is a new nurse, student, or our own kids who introduce us to a technique on the keyboard, shortcut, blog, tweet, or app that changes how we do things. Learning how to use technology is a gift we are bringing to patient care!
References 1. US Gov. What is meaningful use? http://www.healthit.gov/ providers-professionals/meaningful-use-definition-objectives. Accessed February 12, 2014.
2. Adler-Milstein J, Kvedar J, Bates D. Telehealth among US hospitals: several factors, including state reimbursement and licensure policies, influence adoption. Heath Aff. 2014;33(2): 2017-215. doi:10.1377/hlthaff.2013.1054 3. Health Affairs Conference Proceeding. Early evidence, future promise of connected health; February 5, 2014; Washington, DC. http://www.healthaffairs.org/events/2014 _02_05_early_ evidence_future_promise_of_connected_health/. Accessed February 12, 2014. 4. Sackett DL, Rosenberg WM, Gray M, Haynes BR, Richardson SW. 1996 Evidence based medicine: what it is and what it isn’t. Br Med J. 1996;312:71-72. http://www.bmj.com/cgi/content/ full/312/7023/71 5. Pittman D. Hospitals use tablets as extension of EHRs. The Gupta Guide. February 10, 2014. http://www.medpagetoday.com/ PracticeManagement/InformationTechnology/44239. Accessed February 12, 2014. 6. Keeping-Burke L, Purden N, Frasure-Smith N, Cossette S, McCarthy F, Amsel R. Bridging the Transition from hospital to home: effects of the VITAL telehealth program on recovery for CABG patients and their caregivers. Res Nurs Health. 2013; 36:540-553. 7. Honey M, Schweingruber H, eds. National Academy of Engineering and National Research Council, STEM Integration in K-12 Education: Status, Prospects, and an Agenda for Research. Washington, DC: The National Academies Press; 2014.
Kathleen Ahern Gould, PhD, RN Editor in Chief Dimensions of Critical Care Nursing Adjunct Faculty William F. Connell School of Nursing Boston College Chestnut Hill, Massachusetts The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article.
May/June 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
107
