f inding the w ay f orward for e - h ealth and n ursing nancy staggers, phd, rn, faan university of...
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FINDING THE WAY FORWARD FOR E-HEALTH AND NURSING
Nancy Staggers, PhD, RN, FAAN
University of Maryland
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Professor, Informatics, University of Maryland Former IT executive, led enterprise Electronic Health Record (EHR)
projects Foundational work in nursing informatics
NI definition, Scope & Standards for NI, NI competencies 25 years in the Army, primarily working on HIT Research program in the user experience (usability, human factors) for
clinical products Clinical nursing on medical-surgical units
Nancy Staggers
YOUR PRESENTER
GREETINGS FROM UTAH, USA
TO YOUR BEAUTIFUL COUNTRY
TODAY’S PRESENTATION
Discuss two possible visions to organize our thinking about e-Health
Outline three contemporary informatics topics that all nurses need to know
Analyze implications for e-Health competencies
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e-Health is critical to the practice of nursing Slow infusion of e-health in the past Disparate efforts world-wide
Formal, organized efforts needed Education Practice
Must think futuristically Current collection of NI competencies
based upon the past Current trends must be incorporated
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WHY SHOULD YOU CARE?
E-HEALTH VISIONS
LEARNING HEALTH SYSTEM
Connects care quality, knowledge, costs using Health IT
Converts data about care and operations into knowledge Translates into evidence-based clinical practice and
health system transformation (Health Affairs, 2013) New knowledge captured as a by-product of
care (Institute of Medicine, 2012) Continuous improvement and innovation Includes best practices
LEARNING HEALTH SYSTEM – UNITED KINGDOM
https://www.gov.uk/government/publications/the-health-and-care-system-explained/the-health-and-care-system-explained
COMMONALITIES, UNDERSTANDINGS
Patient-centered Engaged patients, consumers
Assumes interconnectivity (interoperability) across agencies, entities, persons
Only possible with robust Health IT Mandates good data quality Requires specific competencies for providers
Ability to evaluate information sources Advanced analytic skills New levels of decision making
PERSON-CENTERED CARE
Patient-centered care
Person-centered care
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Patient-Centered Information
Primary Care Clinic
Home
Specialty Clinic
IMC Step-down
PACU
SICU
OR
Rehab
Med-surg/Acute care
ED
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Person-Centered Information
Primary Care ClinicHom
eSpecialty Clinic
IMC Step-down
PACU
SICU
OR
Rehab
Med-surg/Acute care
ED
Person-Centered Care
PERSON-CENTERED CARE
“Keep-you-well” care delivery system Care wherever the person is
Work, school, home With whatever device
Mobile device, telehealth Integrated care team
Community worker, nurse, health coach Health care technology assistant Information at the point of care Hospital at home (for common diagnoses)
Cortese, 2013, JAMA
PERSON-CENTERED CARE
Information owned by the person Implies engagement, self-efficacy E-patients
E-patient Dave (Bronkhart) TED talk – at
http://www.ted.com/talks/dave_debronkart_meet_e_patient_dave.html
Dave RileyHis own EEG, home laboratoryEngaged in his own healthcare, partner to his
providerTailored his biochemistry to improve his own diabetes
care
PATIENTS LIKE ME
CONTEMPORARY INFORMATICS TOPICS
CONTEMPORARY INFORMATICS TOPICS
mHealthNanotechnology, nanomaterials
(emerging technologies)User experience, usability
MHEALTH
mHealth = mobile health “There is an app for that.” 400 health-related apps being developed each
month1
Healthy eating (Ruder-Finn, 2012 survey) Fitness, knowledge (West et al., 2012) Calorie counting Pain management Asthma management (32 apps not supported by
evidence or contrary, Huckvale, et al., 2012) Smoking cessation (little adherence to guidelines,
Abroms, et al., 2011)1. House Energy and Commerce Subcommittee, Health IT, 2013
MHEALTH
mHealth Summit
mHealth community (HIMSS) Wedded to the phone
CONTEMPORARY INFORMATICS TOPICS
mHealthNanotechnology, nanomaterialsUser experience, usability
NANOMATERIALS
What? The design and use of tools and devices in the
range of 1-100 nanometers Who?
Engineering, chemistry, pharmacy, biology, biomedical, electronics
Where? Nearly everywhere Lotions, sunscreens, tennis rackets Titanium dioxide in sunscreen iPod Nano
UNIQUE ASPECTS OF NANOMATERIALS
Increased strengthAdhere tightly with cell membranes in vivo
Increased resilience Increased electrical conductivity Changed light refraction Enter cells in vivo and in vitro Cross the blood-brain barrier Increased surface area to interact
UNIQUE ASPECTS
Interact differently in living systems than current products and materials Due to their small size and higher surface
area More easily absorbed
Lotions, sunscreens penetrate the top layer of cells more readily
Xudong Wang, Ph.D.,Z. L. Wang, Ph.D.
NANO-APPLICATIONS IN HEALTH
Treating infections Nanoviricides (Hogle, 2009) Wound dressings with silver nanoparticles Textiles with nanoparticles (Thompson, 2011)
Surgical procedures (Janin, 2008, Huang, 2010) Nanoneedles, molecular machines Nanosurgical forceps to extract DNA bits Self-assembling gels to stop intraoperative bleeding
NANO-APPLICATIONS IN HEALTH
Regenerative science Skin, bone, cartilage (European Technology Platform, 2008) Structure and mechanics at the nanoscale (Guo, 2008) Nanoceramics (Simchi et al., 2011)
Nanorobots Propelling systems (Kostarelos, 2010)
Nephrology (Saini et al., 2012) Human nephron filter developed by researchers Could lead to a wearable artificial kidney
Theranostics (Puri & Blumenthal, 2011) Combined nanoimaging, sensors, treatment delivery Sensors and insulin release
CONTEMPORARY INFORMATICS TOPICS
mHealthNanotechnology, nanomaterialsUser experience, usability
CAUTIONS
With new technologies, come unintended consequences and new issues Nanotoxicity Ethics Regulation Workplace safety Nursing issues?
CONTEMPORARY INFORMATICS TOPICS
mHealthNanotechnology, nanomaterialsUser experience, usability
USER EXPERIENCE
All aspects of users’ interactions with product, system, service
Includes perceptions, responses (ISO 9231-11) Multiple disciplines involved
Psychology Engineering Graphical design Industrial design Informatics Interface design Domain experts
ROLE OF USABILITY
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Copyright © 2010 Lisa Battle, Jasmin Phua & Duane Degler
VALUE OF USABILITY TO ORGANIZATIONS
HIMSS, 2011
IMRI OR INTRAOPERATIVE MRI
Operating room configuration that allows imaging during surgery
Useful for neurosurgery
USABILITY ISSUES AND PATIENT SAFETY
Ignoring the magnet proximity alarm during patient positioning. This could potentially injure the patient by crushing their arms
Surgical instruments left behind when the iMRI magnet comes out. The instruments will become a projectile and fly to the center of the magnet (which is where the head of patient is positioned).
Delayed patient resuscitation in the event of a code while the patient is the iMRI chamber. The iMRI OR doors are on lock down during the iMRI
procedure. There is a 2 minute delay before the iMRI magnet can go back to the cage and staff can open the OR doors.
JUST GO MOBILE! MHEALTH IS THE ANSWER
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CONTEXT AND TASKS MATTER MORE!
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USABILITY = PATIENT SAFETY
Brick, 2012
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USABILITY = PATIENT SAFETY
Nancy to get electronic example of growth chart
Brick, 2012
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USABILITY = PATIENT SAFETY
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Guo, et al., 2011
NURSING SUMMARY REPORT
Staggers, Clark, Blaz & Kapsandoy, 2012
NURSING SUMMARY REPORT
No visual trend
Staggers, Clark, Blaz & Kapsandoy, 2011
NURSING SUMMARY REPORT
Orders truncated
No visual trend
Staggers et al., 2011
NURSING SUMMARY REPORT
Orders truncated
Hand-written gridfor medications due across patients
No visual trend
Staggers et al., 2011
NURSING SUMMARY REPORT
Orders truncated
Hand-written gridfor medications due across patients
No visual trend
Missing information
Staggers et al., 2011
NURSING SUMMARY REPORT
Orders truncated
Hand-written gridfor medications due across patients
No visual trend
Missing information
Static information
Staggers et al., 2011
Preferred Tool
OBSERVE USERS TO UNDERSTAND WORKFLOW AND TASKS
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SET USABILITY GOALS & BENCHMARKS
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IMPROVE ORGANIZATIONS WITH THE HIMSS USABILITY MATURITY MODEL
52Phase 1-Unrecognized
Phase 2- Preliminary
Phase 3-Implemented
Phase 4-Integrated
Phase 5-Strategic
Focus on Users
ManagementProcess &
InfrastructureResources Education
Free!!Just browse using “HIMSS usability maturity”
IMPLICATIONS
IMPLICATIONS
Systematic consideration of emerging technologies Safety for consumers, workers Integration into work and workflow Impact on productivity Evaluation for user experience issues, goals
Efficiency Effectiveness
Workflow Satisfaction
IMPLICATIONS – E-CARE SYSTEMS
Information capture relayed from sensors, personal data, genomics, nanomaterials Input/output standardization
Inventive architecture Sense and transfer data automatically to systems
Individually tailored data and information Massive storage capability Current systems (electronic orders,
documentation) do not accommodate this type of individualized data New methods to accommodate intentional variability in
patient-centered data and individualized orders
IMPLICATIONS – E-HEALTH SYSTEMS
No longer electronic health records as we know them
Distributed information Vast networks of networks?
Trust Data quality Data transfer
Who owns the data? Who assures accuracy, security?
IMPLICATIONS – DATA ANALYTICS
“Big data” Large amounts of available data (2.5 quintillion bytes every day
by an IBM estimate) Inexpensive storage makes this possible Example for molecular biology, experimental data, published
literature Developing interactive, integrated, modeling technologies now
Data analytics Making sense of large data stores Developing models, insights Data visualization
At the intersection of computing, human perception, design Special tools, techniques, issues
Fowlkes et al. 201153
Fowlkes, et al, 2011
IMPLICATIONS - PUBLIC HEALTH
Could change the whole structure and functioning of Public Health (Hogle, 2009) Vaccines versus nanotreatment of actual disease Big data analyses of worldwide, chronic conditions
Surveillance and reporting systems Personal data, sensor data, nanotoxicity reporting? Who will monitor?
Informatics support Communication & integration of information Public health decision support
IMPLICATIONS - CONSUMERS
Patient monitoring for sensors, nanomaterials Diagnosing faster
Finding familial diseases
Treatment and monitoring for specific needs Chronic diseases
Treatment at the microscopic level Personalized medicine
Treating diseases explicitly and precisely to individual consumers
Beyond genomics Implications for provider-patient communication
technology
IMPLICATIONS - CONSUMERS
Person-centered monitoring Crosses traditional boundaries Data access by patients first Interpretation perhaps by patients first Change in the “first responder” to data Change in power base from provider to consumer
Consumer education Have consumers heard of nanotechnology, sensors? Products not yet labeled as having nanomaterials embedded
Consumer policy Health insurance for some countries
IMPLICATIONS - CONSUMERS
Cognitive support and interface design for consumers as “first responders” Likely a role change for patients
Increased responsibilities for patients, caregivers and clinicians
What about patients who are unable or unwilling to accept these new responsibilities?
IMPLICATIONS - CLINICIANS
Today’s concepts of routine care may no longer exist
Absolute individualized care, disease management exquisitely customized
No longer a standard approach for a given health condition
Demands even greater information synthesis New interdisciplinary teams with new
members and different functions
Staggers et al., 2008
IMPLICATIONS - CLINICIANS
A patient presents with mysterious symptoms or a new disease directly related to the embedded technology
How will we diagnose and treat it? How do we differentiate it? Consider interactions between nanoparticles, devices
Consider “bugs” in software or a circuit How will we troubleshoot it?
New safety considerations How will we provide protection for the clinicians delivering
the therapy to avoid accidental or inadvertent ingestion or absorption?
Impact on clinicians productivity?
IMPLICATIONS - CLINICIANS
Increasing power of patients, social media, e-patients Expands a role change that began with consumers
accessing information on the internet and bringing it to their appointments – questioning and challenging the clinicians
Health care providers may have a role change from expert to participant, coordinator, or coach
IMPLICATIONS - CLINICIANS
Critical thinking and decision making More, perhaps better targeted data, information,
and knowledge about patients and disease processes
Sheer amount of data could create information overload and issues of data synthesis
Could there be an over-reliance on devices? Assumption all data is received when it may not be Inaccuracies with monitoring devices may be hard
to detect and require different problem solving techniques
IMPLICATIONS - DECISIONS
Monitoring individuals’ decision making Consequences of poor decision making Clinician responsibility in consumers’ choices?
Insurance company decisions Will they monitor your health at a cellular level and
deny care or coverage based on poor genetics or poor lifestyle choices…
IMPLICATIONS - EDUCATION
Devices will need to be understood by both caregivers, patients, and those in their immediate care circle
Curricular design and clinical education changes
Differing capabilities and limitations of care providers and the consumers
How to collate, correlate and interpret the data In essence, how will we teach information synthesis
at this level?
CONCLUSIONS
The future of e-health will be interesting Technology may develop faster than we can respond
with policy and health IT Competencies need to move beyond the basics to
include Emerging technologies and safety (genomics, nanomaterials) Usability Big data and critical thinking Person-centered health, mHealth
