Every day, America's nurses bring compassion, leadership, skill and vision to our health care system. They take care of the sick, comfort the dying and serve as the glue that holds the patient experience together.
They also are leading the prevention-focused, quality-oriented paradigm shift associated with the most sweeping changes to the U.S. health care system in more than 40 years.
Indeed, the recently passed Patient Protection and Affordable Care Act ushers in an era of broad health insurance coverage and the first wave of substantial health care payment reform. The private sector also has unleashed a complementary wave of changes in provider reimbursement approaches.
While these payment reform efforts are diverse, they share several characteristics:
- Providers will be asked to measure and report the quality, safety and efficiency of care delivered.
- A significant portion of reimbursement will be based on these measures; providers will face material financial risk if their care is deemed to be substandard.
- Reimbursement is evolving to include episodes and bundles. Payment will be based on the holistic care of a patient, be it a single payment for hip replacement surgery and rehabilitation care, or a single payment for care delivered to a diabetic over the course of a year.
- Regardless of care performance, reimbursements will decrease.
- Greater transparency of provider quality scores and costs will be required, enabling purchasers of care and consumers to make more informed choices as they seek care.
- Efforts will be made to compare the effectiveness of new programs and treatments with that of current programs and treatments; those that fail to demonstrate quality outcomes will not be reimbursed.
- Provider organizations will be made accountable for the care of patient populations, with these providers establishing such new arrangements as accountable care organizations and patient-centered medical homes.
For providers to achieve the level of care that will become the new standard, they must employ a solid foundation of health information technology. It is not possible to achieve the necessary levels of quality performance, conform to evidence-based medicine or manage increasingly complex reimbursement arrangements without such a foundation.
The federal government understood the need for this foundation when it passed the HITECH Act in 2009, which provides financial incentives for hospitals and eligible professionals that demonstrate they are meaningful users of electronic health records. In effect, the government, as the largest purchaser of health care in the world, was saying clinicians must use the technology to enter orders, document care and exchange data with other providers if they are to address effectively the changes introduced by the PPACA.
As providers embark on their journeys to comply with the requirements of HITECH, savvy nurse executives see this as a time for their profession to shine. They understand that nursing will play a key role in determining their organization's success in this era of accountable care.
Nursing at Center Stage
Nurses are at the center of efforts to coordinate patient care. They ensure that care delivery is delivered efficiently, that the care team is informed of the status of a patient and that transitions of care are managed effectively.
Moreover, nurses generate the majority of the documentation that makes up a patient's medical record. These data will be a source for measuring compliance with the law's quality reporting requirements, helping an organization qualify for federal incentive monies or avoid penalties. In fact, many organizations have found themselves in good standing for the meaningful use quality reporting requirements largely because of the data nurses already are capturing electronically in clinical practice.
Of particular importance to the nursing community is avoiding CMS's "never events," a set of hospital-acquired conditions the agency has deemed preventable and thus not reimbursable. Technological tools alert clinicians so they can prevent never events from occurring. Using technology to support clinicians in day-to-day care delivery can make a measurable impact on the outcome of care.
Regardless of where an organization lies along the technology adoption curve, there is reasonable certainty about the major health information system applications our nation's nurses will encounter in the era ahead:
- an integrated electronic health record that spans inpatient, outpatient and emergency department care;
- a revenue cycle system that also spans this care continuum and is well integrated with the electronic health record;
- workflow engines that help to improve the performance of core clinical processes, e.g., patient discharge, chronic-disease management and infection management;
- rules engines that critique a specific clinician decision, e.g., drug-drug interaction checking after the entry of a medication order;
- business intelligence and analytics technologies that enable providers to measure the quality, safety and efficiency of their care, monitor clinical performance, and understand the resulting reimbursement ramifications;
- interoperability technologies that enable providers to exchange such clinical data as patient allergies, problems, medications and information on events (e.g., an unplanned emergency room visit) with other providers as they jointly manage the care of the patient;
- patient-oriented technologies like the personal health record and online patient communities that assist patients in managing their own care.
The Road Ahead
Benefiting from these health care IT investments is as much a function of leadership as it is the right technology and strategic partner. There is no better time for nurses to exert their leadership and become intimately familiar with their respective organization's strategic IT vision, especially the implications it will have on the patient care environment.
A successful nurse executive who has anticipated new technologies is positioning his or her organization to thrive in the era ahead by doing the following:
Secure a seat on the organization's IT advisory board or steering committee. Make it a priority to evaluate the IT roadmap and contribute to decisions about which applications will be rolled out and how those tools will integrate into clinical practice. Assist in completing gap analyses with regard to meeting meaningful use criteria and prioritizing projects.
Seek out opportunities to become an executive champion. Some of the most successful IT initiatives spring from an alignment between the CIO and executive champions like the CNO and CMO. Each group remembers to "walk in each other's shoes," influencing the project's key stakeholders and bringing their concerns and recommendations to the project leaders.
Foster interdisciplinary collaboration. Be the ambassador who breaks down the typical organizational silos — dietary, laboratory, occupational therapy — that exist in most health care facilities. Help others embrace a shared leadership model that fosters interdisciplinary collaboration throughout the IT implementation.
Be open to the voice of front-line nurses. Bedside nurses are keenly aware of the challenges associated with handoffs of information and care transitions. Provide ample opportunity for nurses to give input into the design of the system.
Create a sense of nursing ownership. Assuming front-line staff have venues for providing input, be sure that when requested changes are made, nurses see them firsthand. Creating this type of feedback loop is empowering for end users.
Contribute to a communication plan that follows the implementation progress. Doing so will help ensure that all stakeholders understand the organization's strategic objectives and each discipline's role in bringing them to fruition. Share implementation highlights so that team members are aware of progress.
Establish a set of guiding principles for end users as they adopt new technologies. Perhaps these will support the culture change the technology is expected to drive; perhaps they outline how the IT staff will work with and solicit feedback from the nursing staff, for example.
Continuously assess readiness for change and adoption. Survey clinicians and understand that lower response scores will come from those who realize the new applications are affecting their workflow. Help staff members move from skepticism to hopeful realism, informed optimism and, eventually, satisfaction with the new technology and processes.
Show other nurses the way by sharing best practices. As technology continues to make it easier to implement evidence-based practice and protocols, take advantage of the many opportunities the industry offers for sharing successes and learning from others.
Don't underestimate the power of technology in nurse recruitment efforts. There isn't a nurse joining the profession who wouldn't want to use a bar-coding solution to help ensure the safety of the patient during medication administration.
Providing Consistency Amid the Chaos
It is difficult to be certain about the impact of the PPACA on the nation's health care system in the decade ahead. There are dozens of new approaches to payment, and their effectiveness at a national scale or across all populations is unclear. Moreover, it is not possible to attempt to transform the largest and most complex sector of any economy and have a complete understanding of the mature forms of the new health care system. We are in for a decade of experimentation, chaos and uncertainty.
Through the challenging years ahead, the nursing community must remain the backbone of care delivery. The community must be active, thoughtful and vigorous contributors to reshaping the health care system. They also must be skilled and effective in their application of information technology to improve care. To a large degree, the future of health care depends on nursing and its sophisticated use of information technology.
John Glaser, Ph.D., is the CEO of Siemens Health Services in Malvern, Pa. He is also a regular contributor to H&HN Daily. Gail E. Latimer, M.S.N., R.N., F.A.C.H.E., F.A.A.N., is the vice president and chief nursing officer of Siemens Health Services.