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!

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”?

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”.