Today, December 3, 2009, nurses are gathering in Philadelphia for the Forum on the Future of Nursing: Community Health, Public Health, Primary Care, and Long-Term Care. The forum dedicated to Education will be held on February 22. 2010 in Houston, TX

I had the privilege of testifying at the Acute Care Forum held on October 19^th at Cedars-Sinai Medical Center.  There was a cause for celebration as RWJF/IOM called for input on Quality/Safety, Technology, and Interdisciplinary Collaboration. It was great to hear nursing leaders around the country share their perspectives, as well as hear the testimonies provided by my dear colleagues Joyce Sensmeier for the Alliance for Nursing Informatics (ANI) and Dana Alexander on behalf of the Technology Informatics Guiding Education Reform (TIGER) – both of which I am proud to a part of and the contributions we are collectively making in supporting nurses throughout the country.

Among topics were innovative models used to improve quality and safety in acute-care settings. During this session, I discussed the Clinical Practice Model (CPM)™, which has been evolving since 1983 with the input of thousands of nurses and interdisciplinary clinicians via an international healthcare consortium. 

The CPM Resource Center supports a professional practice framework that addresses the fundamental elements of creating healthy healing work cultures keeping patients and nurses safe. The CPM Framework™, innovative in its inception, is fundamental today as nurses continue to face many complexities in acute care environments to provide interdisciplinary care and successfully integrate intentionally designed technology to support quality care and outcomes. 

The CPM Framework was created to address the primary barriers nurses face in maximizing quality and safety. Identified in a six-year, multi-site pilot, these barriers include a lack of shared purpose, clarity on scope of practice, evidence-based clinical tools and resources at the point of care, dialogue, healthy relationships and effective engagement processes and infrastructures. The CPM Framework partners with organizations to implement and sustain these foundational elements of care. As a result, CPM Consortium sites have demonstrated statistically significant improvement in care based on national quality/safety standards and sustained them over long periods of time. 

The CPM Framework has developed innovative technologies by leading Intentionally Designed Automation (IDA)™ at the point of care in partnership with multiple HIT companies. IDA is intentionally designed by nurses to assure that the technology supports professional practice – the workflow and thought-flow of professional nurses providing care in acute-care settings. It includes components of the CPM point-of-care documentation that assure capturing the patient’s story, developing an evidence-based plan of care utilizing Clinical Practice Guidelines, individualizing the plan for a patient’s  values/situation, providing assessments and interventions within the context of the patients diagnosis and situation, evaluating progress toward goals and education.

Having innovative technologies and a standardized common framework at the point of care for nurses and allied health clinicians to deliver their professional services is critical to practice interoperability and improvement measurements. There are more than 125 acute-care settings that have nurses and interdisciplinary teams using IDA today who use the CPM Framework. Outcome measurements include:  reduced patient falls, reduced pressure ulcers, exceeding core measure national and regional benchmarks by 85-95%, increased nursing satisfaction and more. CPM Consortium sites have been national exemplars for the TIGER Initiative, Sigma Theta Tau International and ANCC Magnet Designated Hospitals.

Barriers to the adoption and use of innovative technology, however, remain. These barriers center on a lack of understanding of the need to do the fundamental work of embedding a professional practice framework inside technology and how to unitize an implementation science for effective and sustainable adoption. 

Thus I proposed that, in the spirit of the IOM report “Knowing What Works in Healthcare: A Roadmap for the Nation (IOM -2008),” we focus on “what works” and stop recreating the wheel – looking to better understand and utilize the  best practices and technologies at hand. This includes the CPM Framework™, which is grounded in complexity science and chaos theory and has been proven in many, many acute-care to work and be replicated.

Having innovative technologies and a standardized common framework at the point of care to deliver professional services is critical to practice interoperability and improvement measurements. They also are an integral part of the solution – not only to our current healthcare crisis but also the meaningful use of healthcare tools and funds going forward and sustainability.

Stay tuned for more on the Forums….and please speak up!

Half of patients infected with the new MRSA strain died within 30 days compared to just 11 percent of patients infected with other MRSA strains, according to the study presented at the 47th annual meeting of the Infectious Diseases Society of America (IDSA) in Philadelphia earlier this month. 

The CDC was quick to refute the evidence due to the size of the study, and Paul G. Auwaerter, a clinical director at Johns Hopkins who was on the IDSA panel when the study was released, agreed. Carol Moore, PharmD., the study’s primary author, did acknolodge that another factor could be the age of patients, who are 64 years old, as compared with 52 years old for other MRSA-infected patients.

Given the virulence and lethal nature of MRSA, infectious disease specialists, government leaders and healthcare executives are calling for programs to better prevent, monitor and manage MRSA. For example, several states, including California, Illinois, New Jersey and Pennsylvania, have enacted legislation that requires hospitals to screen patients for MRSA. The CDC has also launched a massive national campaign to prevent MRSA skin infections (http://www.cdc.gov/ncidod/dhqp/ar_mrsa.html. And, Albert Einstein Health Network in Philadelphia has decreased MRSA infections rates 62 percent by stuffing used hospital gowns into disposable gloves.

Additionally, HHS will also make $50 million in grants funded by the American Recovery and Reinvestment Act (ARRA) to states fighting against hospital-acquired infections (HAIs). Forty million will be available through competitive grants to states for hospital infection prevention and reporting, while $10 million will come in the form of state grants to improve inspections for outpatient surgery centers (http://www.hhs.gov/news/press/2009pres/05/20090506a.html). 

Overall, HAIs are rising, making them among the top ten leading causes of death in the U.S. and adding up to $20 billion dollars to healthcare costs annually, according to the 2008 National Healthcare Quality Report (http://www.ahrq.gov/qual/nhqr08/nhqr08.pdf).  The CDC says HAIs cost as much as $45 billion annually.

While hospitals and health systems must tap multiple strategies to prevent, monitor and manage new and emerging strains of MRSA and other HAIs, they must also influence care at the bedside in real-time through technology that functions as a patient-specific early warning system. 

Technologies such as MEDAI’s Pinpoint Review pull data from sources as diverse a pharmacy, lab and electronic health records, capture the events of a patient’s hospital stay in a single, concise record, and run the data through a predictive modeling engine.  Once clinicians receive real-time predictions about a patient either on their mobile device or desktop, they can make faster, more accurate decisions about care plans, discharge planning, and order sets.  They can also identify patients whose risk level has changed and, even more important, develop strategies for prevention through a review of risk drivers.  

Hospitals can not afford to manage HAIs with a grab bag of tools and techniques. Instead, they must invest in technologies that deliver real-time information to enhance patient care at the bedside.

The other key point Blumenthal stressed was that the two most frequently used words:  “meaningful use”….is “not about a technology project” . . . but more of a “change management project”.  Last week in Chicago, the CPMRC International Consortium Summit dedicated a whole day to Foundations in Polarity Management™ in which groups uncovered the dilemmas we must manage as healthcare leaders in regards to technology innovations & practice innovations, framework-driven change & project/initiative driven change, individual & integrated competency, etc.  To achieve Meaningful Use we must see the whole and parts with their dynamic tensions as we move to true transformation to achieve a higher purpose.  The CPMRC learning healthcare community also worked together on leading the implementation science of healthcare transformation and advancement of interdisciplinary integration.  Collaborating and learning together are key to success and sustainability.  There are many collaborative groups here at AMIA as well such as NIWG and TIGER…with a commitment to stretch our thinking and actions in the new world.  These are opportunities of new dimensions and if we “focus on the end-product” it will be a fun, hard, challenging and rewarding ride.

Stay tuned . . .

At a recent workshop (http://healthit.hhs.gov/cds) held at the Health and Human Services headquarters in Washington, Paul Tang, director of the committee that formulates proposals on meaningful use for the Office of the National Coordinator, pointed out that the use of CDS is both explicit and implied in many of the meaningful use recommendations.  According to the meeting summary of Dr. Tang’s remarks, “without CDS, measures of health priorities as defined by meaningful use are less likely to meet quality targets or improve over time.”

 I’m extremely pleased to see this great opportunity for CDS to affect care and health outcomes for the better, for a much larger segment of the population.  But that also means it’s time to take a 2009 look at a question we all think we knew the answer to years ago – what is CDS?  More specifically, do we need to rethink what we know about CDS, if we really want to turn all of this increased technology into better results?  CDS has been very successful in improving quality measures and reducing errors in many institutions, but not all.  What CDS will make the greatest positive difference in the greatest number of practices?

For many, CDS equals alerts – most commonly, alerts about drug allergies and interactions, but also alerts about a variety of potential hazards and opportunities.  Yet, alerting is one of the most intrusive forms of CDS, and not always one of the most useful.  In a recent editorial in Pediatrics (http://www.pediatrics.org/cgi/content/full/124/1/375 ) Dean Sittig of Memorial-Hermann Health (and three others, including me – but the major credit has to be given to Dean) pointed out a number of circumstances under which alerts would likely be ineffective and/or poorly accepted, “compared to other intervention types such as facesheet displays, order sets, patient education handouts, and end-of-visit forms.”  Depending on the clinical objective and where you are in the workflow of care, different CDS intervention types might fit the job best, including intelligent data displays, guideline helpers, context-sensitive reference information, smart documentation forms, procedure guides, performance dashboards, and more.

Given all of this, I have had to broaden the definition of CDS that I use when lecturing, to “provision of information to the healthcare professional, patient or family, filtered for the current situation and presented for greatest impact on the task at hand.”  The ideal CDS intervention helps you get through your current task, answer your current question or need, as correctly and efficiently as possible.  In many cases, the best CDS is something nontraditional – perhaps a video on your iPhone to refresh your memory about that procedure you’re about to do, or a predictive report of your hospitalized patient’s risk of falling. The best CDS is often  something that would not have immediately come to mind if someone asked “what is CDS”?

Costs continue to rise and quality measurements remain flat. The US currently spends more than twice as much on each person for healthcare as most other industrialized countries, but it has fallen to last place among those countries in preventing deaths through the use of timely and effective medical care. According to the WHO, the US proudly ranks as the 37th best health system in the world – just ahead of Slovenia.

Below the surface, it gets much, much worse. We are bombarded with stories on CNN and The New York Times about healthcare reform, electronic medical records, and “universal” healthcare, but industry fragmentation and poor coordination of services portends a further decay of our healthcare system.

According to a 2008 study by the Commonwealth Fund, 47 percent of adults reported serious failures of care coordination including: specialists not receiving basic medical information from primary care physicians, test results not being available at the time of an appointment; and, not being contacted or needing to repeatedly call to obtain test results.

Despite the individual technological advances that have been adopted throughout the industry, the system itself remains terribly siloed, and thus ineffective. Currently, seventy-five cents of every health care dollar we spend is on treatment of chronic disease, most of which is preventable if evidence-based medicine is practiced.

Predictive modeling offers a solution that directly addresses these issues. By aggregating data from multiple stakeholders and combining it with advance data mining and forecasting abilities, we can now successfully identify the specific individuals who will account for a majority of future health-care costs. With early detection comes early intervention.

Proactive identification of patients not following evidence-based treatment protocols, and the provision of that information to providers and patients leads to more effective and efficient care, particularly around chronic diseases. Leveraging a technology like predictive modeling across the care continuum will simultaneously address fragmentation, provide stakeholders with what they need to know when they need to know it, and facilitate physician engagement — all leading to improved quality and decrease spending.

The past several months have been energizing as healthcare organizations and companies get clear on the promise of improving (dare I say “transforming”?) the US healthcare system with health information technology (HIT) via ARRA funding for meeting “Meaningful Use” criteria.  Here at Elsevier I have the privilege of leading and collaborating with a team of experts on clinical decision support (CDS) who are committed to supporting our customers and HIT vendor partners with value-added products and services to successfully achieve “meaningful use” of their HIT investments.

What do you see when you study the most recently approved HIT Policy Committee’s recommendations for “Meaningful Use” (Meaningful Use Matrix)?

The most logical way to approach this for meeting the ultimate goal as well as achieve funding across the spectrum is to follow that old Stephen Covey leadership principle…. “Begin with the end in mind”.

The end is all about Clinical Outcomes, Efficient Care, Safe Care, Patient/Family Engagement, Clinical Summaries, Care Coordination, Population Management, and Surveillance Measures.

These outcomes call for the marriage of HIT and advanced CDS supporting evidence-based practice as key enablers for every healthcare profession to utilize in their daily practices at the point of care.  They call us to think critically and in new ways about the goals and measurements of each meaningful use criteria to achieve the end in mind!

Stay tuned for deeper exploration of key considerations and successful steps meeting the latest HIT Policy and Standards Committees efforts to achieve true “Meaningful Use”.