As the President and CEO of the American Academy of Nursing, I am very interested in the direction and potential of HIT. Of course, the issue of meaningful use is at the center and of tremendous importance. But the definition as it currently stands does not go far enough.

What follows are recommendations put together by a working group of the Academy’s technology and informatics experts for The Department of Health and Human Services.

To Meet the Needs of Patients, the American Academy of Nursing
Says we need to go Beyond Meaningful Use

The American Academy of Nursing (AAN) is an advocate for improved patient safety, cost-effective care management of acute and chronic conditions, and the effectiveness of nursing and interdisciplinary care. The Academy strongly supports health care reform that goes beyond the prevention, diagnosis, and treatment of disease to include assisting persons to manage their own and their family’s health as well as possible. Such reform must capitalize on the contributions of all health care disciplines. This aggressive approach to broad health care reform will only be achieved and sustained if information systems are collaboratively designed by the “meaningful users” to address data elements that reflect the work of all health care disciplines.

The AAN recommends that future electronic health records (both EHR’s and PHR’s) not only provide for documentation of the services provided by all disciplines but also address the shifting of care from acute and ambulatory care settings to home and community-based settings. To achieve its intended role in health care reform, comparative effectiveness research (CER) must include accurate data collection and data exchange, address health as well as illness content, and be interdisciplinary versus physician-centric.

To assure meaningful use of health care information and information systems by all health care disciplines, the AAN therefore respectfully requests the following:

1. The “Meaningful User” Definition should specifically include advanced practice registered nurses (APRNs), registered nurses (RNs), and other interdisciplinary health care clinicians as providers, particularly in hospital settings, but also in most ambulatory and home care [or community-based] settings where the nurse may collect key demographic data, conduct the initial screening, and support implementation of the medical regimen, and whose documentation will largely determine if the overall encounter meets the various mandatory guidelines for effective and efficient patient care. In creating the definition of “meaningful user”, CMS must include all essential contributors to the care episode documentation if those contributions provide critical evidence of the effectiveness of care.  (See Sample Definition Matrix at end)

2. The “Meaningful Use” definition should include inpatient documentation by nurses and other patient care providers. Likewise, ambulatory care including community and home based settings where nurses and other key patient care providers deliver services that will impact the quality and outcomes the care should be included in the definition. The use of the EHR by nurses and other key providers is essential in supplementing and expanding the meaningful use by physicians. In the majority of situations, especially in the inpatient sector, physician design of the EHR and the population of the information fields will be incomplete and the data collection not comprehensive without the meaningful involvement and contributions of nurses and other key providers.

3. The following recommendations should be made by the ONC to CMS regarding data elements, reports, and reimbursement requirements:

a. That APRN’s (particularly nurse practitioners), RNs, and other key clinicians, be identified as “meaningful users” or providers separately from physicians for accurate and valid CER. Since one of the major purposes of this research is to address cost and quality issues, health disparities, and chronic care management, it is important to understand the differences in provider care management practices and effective practice patterns within disciplines.

b. That separate identification also should be applicable to Certified Nurse Midwives, Physician Assistants, and other interdisciplinary health care providers who may be “billed” under the physician number and whose services influence the quality of care received by the patient.

4. There must be equal access to funding to support the deployment of information systems within both primary care and public settings. For example, in schools, community clinics, and mobile medical units, care is most commonly managed by nurses, not physicians. In rural areas, a nurse practitioner may be the only primary care provider. Patient care provided solely by nurses in these settings frequently applies to the underserved, minority, and elderly populations and is responsible for reducing health disparities, extending access to primary care and preventive services, and improving cost-effective chronic care management. Providing safe and effective care to the populations served in these settings is essential to health care reform. Ensuring that these services are documented and that information is accessible to hospitals and clinicians who will encounter these patients in the future is of paramount importance as a part of the electronic medical record.

5. Health and medical electronic data systems must include patient-centered documentation elements from all disciplines, enabling nurses and other clinicians to capture critical data linked to improved decision-making, improved cost, quality outcomes, and greater comparability to standardized quality data sets. These data include not only medical diagnoses, procedures, and medications, but also patient demographics, health history, health status, health assets and deficits, information on family caregivers, and interventions provided to address any of the 14 physical and physiological functions that the patient is unable to perform independently or without assistance from devices. These data are not typically captured in current information systems designed only to support the prevention, diagnosis, and treatment of disease, but they are vital to optimizing patient health and functioning. Content related to transitional care issues are most frequently documented by nurses, social workers, and other allied health providers. Patient safety will be enhanced and can be better tracked when appropriate data (frequently non-physician data elements) are entered into the electronic health and medical record. Practice standards must integrate with HIT standards needed to ensure secure exchange of patient and clinician information.

6. Additionally, systems designed for meaningful use of information should be able to capture data about problems, interventions, and outcomes related to functionality and other clinical issues beyond treatment of disease for comparative effectiveness research.

7. Information systems should be designed to include real-time evidence-based decision support for choosing interventions most likely to achieve the desired patient outcome, with consideration for patient characteristics and preferences. Gathering and monitoring data in real-time is much more cost-effective. Abstracting data from charts retrospectively is costly and may burden already sparse numbers of nurses and other personnel. Use of decision support guides the provider to optimal treatment (prevention or intervention) for a patient when it is needed.

8. New CCHIT certification should encourage and/or require an interdisciplinary review of electronic health and medical systems for future effective adoption in large health science(s) centers, critical access facilities, rural hospitals, and community-based healthcare facilities. The professionals who participate in the design, evaluation and implementation of certified systems must include the critically important “meaningful users” who will be responsible for the “meaningful use” of the information systems across all sites and users. This is critical because:

a. The workflow patterns of nurses and other health care providers should be strongly considered in evaluating systems for adoption. Ascertaining physician preferences is necessary but not sufficient, since care is also provided by other disciplines.

b. Language should describe patients’ problems, interventions, and outcomes from the perspective of all the disciplines involved in care. Involvement of multidisciplinary leaders and providers in the design and decisions surrounding information systems certification criteria ensures critical aspects of care will be adequately represented, resulting in effective documentation structures, complete information, and comprehensive data for comparative effectiveness research.

c. Clinical decision support and documentation must be relevant to nursing and other interdisciplinary providers at the point of care, as well to the physician attending to the patient. Integration of functional, nurse-sensitive measures and interdisciplinary evidence-based practice (beyond but including evidence-based medicine) is decisively important for improved patient safety, enhanced outcomes, and better health for populations.

Sample Definition Matrix

This entry was posted on Friday, October 2nd, 2009 at 7:36 am and is filed under Health Reform, HIT/Health Gaming. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.