Healthcare information technology and economics.

At the 2011 American College of Medical Informatics (ACMI) Winter Symposium we studied the overlap between health IT and economics and what leading healthcare delivery organizations are achieving today using IT that might offer paths for the nation to follow for using health IT in healthcare reform. We recognized that health IT by itself can improve health value, but its main contribution to health value may be that it can make possible new care delivery models to achieve much larger value. Health IT is a critically important enabler to fundamental healthcare system changes that may be a way out of our current, severe problem of rising costs and national deficit. We review the current state of healthcare costs, federal health IT stimulus programs, and experiences of several leading organizations, and offer a model for how health IT fits into our health economic future.

AMIA Board white paper: definition of biomedical informatics and specification of core competencies for graduate education in the discipline.

The AMIA biomedical informatics (BMI) core competencies have been designed to support and guide graduate education in BMI, the core scientific discipline underlying the breadth of the field's research, practice, and education. The core definition of BMI adopted by AMIA specifies that BMI is 'the interdisciplinary field that studies and pursues the effective uses of biomedical data, information, and knowledge for scientific inquiry, problem solving and decision making, motivated by efforts to improve human health.' Application areas range from bioinformatics to clinical and public health informatics and span the spectrum from the molecular to population levels of health and biomedicine. The shared core informatics competencies of BMI draw on the practical experience of many specific informatics sub-disciplines. The AMIA BMI analysis highlights the central shared set of competencies that should guide curriculum design and that graduate students should be expected to master.

A brief history of nursing informatics in the United States of America.

From the beginning of modern nursing, data from standardized patient records were seen as a potentially powerful resource for assessing and improving the quality of care. As nursing informatics began to evolve in the second half of the 20th century, the lack of standards for language and data limited the functionality and usefulness of early applications. In response, nurses developed standardized languages, but until the turn of the century, neither they nor anyone else understood the attributes required to achieve computability and semantic interoperability. Collaboration across disciplines and national boundaries has led to the development of standards that meet these requirements, opening the way for powerful information tools. Many challenges remain, however. Realizing the potential of nurses to transform and improve health care and outcomes through informatics will require fundamental changes in individuals, organizations, and systems. Nurses are developing and applying informatics methods and tools to discover knowledge and improve health from the molecular to the global level and are seeking the collective wisdom of interdisciplinary and interorganizational collaboration to effect the necessary changes. NOTE: Although this article focuses on nursing informatics in the United States, nurses around the world have made substantial contributions to the field. This article alludes to a few of those advances, but a comprehensive description is beyond the scope of the present work.

Informatics in the doctor of nursing practice curriculum.

In 2006, The American Association of Colleges of Nursing approved a new doctoral degree for clinical leaders, the Doctor of Nursing Practice. These new advanced practice leaders will need sophisticated skills in informatics to acquire and use data, information, and knowledge in their roles. This paper proposes a foundational course for all Doctor of Nursing Practice students and some strategies for integrating informatics throughout the curriculum.

Integrating "best of care" protocols into clinicians' workflow via care provider order entry: impact on quality-of-care indicators for acute myocardial infarction.

OBJECTIVE: In the context of an inpatient care provider order entry (CPOE) system, to evaluate the impact of a decision support tool on integration of cardiology "best of care" order sets into clinicians' admission workflow, and on quality measures for the management of acute myocardial infarction (AMI) patients. DESIGN: A before-and-after study of physician orders evaluated (1) per-patient use rates of standardized acute coronary syndrome (ACS) order set and (2) patient-level compliance with two individual recommendations: early aspirin ordering and beta-blocker ordering. MEASUREMENTS: The effectiveness of the intervention was evaluated for (1) all patients with ACS (suspected for AMI at the time of admission) (N = 540) and (2) the subset of the ACS patients with confirmed discharge diagnosis of AMI (n = 180) who comprise the recommended target population who should receive aspirin and/or beta-blockers. Compliance rates for use of the ACS order set, aspirin ordering, and beta-blocker ordering were calculated as the percentages of patients who had each action performed within 24 hours of admission. RESULTS: For all ACS admissions, the decision support tool significantly increased use of the ACS order set (p = 0.009). Use of the ACS order set led, within the first 24 hours of hospitalization, to a significant increase in the number of patients who received aspirin (p = 0.001) and a nonsignificant increase in the number of patients who received beta-blockers (p = 0.07). Results for confirmed AMI cases demonstrated similar increases, but did not reach statistical significance. CONCLUSION: The decision support tool increased optional use of the ACS order set, but room for additional improvement exists.

Decision support for patient care: implementing cybernetics.

The application of principles and methods of cybernetics permits clinicians and managers to use feedback about care effectiveness and resource expenditure to improve quality and to control costs. Keys to the process are the specification of therapeutic goals and the creation of an organizational culture that supports the use of feedback to improve care. Daily feedback on the achievement of each patient's therapeutic goals provides tactical decision support, enabling clinicians to adjust care as needed. Monthly or quarterly feedback on aggregated goal achievement for all patients on a clinical pathway provides strategic decision support, enabling clinicians and managers to identify problems with supposed "best practices" and to test hypotheses about solutions. Work is underway at Vanderbilt University Medical Center to implement feedback loops in care and management processes and to evaluate the effects.

Development of a provisional domain model for the nursing process for use within the Health Level 7 reference information model.

OBJECTIVE: Since 1999, the Nursing Terminology Summits have promoted the development, evaluation, and use of reference terminology for nursing and its integration into comprehensive health care data standards. The use of such standards to represent nursing knowledge, terminology, processes, and information in electronic health records will enhance continuity of care, decision support, and the exchange of comparable patient information. As part of this activity, working groups at the 2001, 2002, and 2003 Summit Conferences examined how to represent nursing information in the Health Level 7 (HL7) Reference Information Model (RIM). DESIGN: The working groups represented the nursing process as a dynamic sequence of phases, each containing information specific to the activities of the phase. They used Universal Modeling Language (UML) to represent this domain knowledge in models. An Activity Diagram was used to create a dynamic model of the nursing process. After creating a structural model of the information used at each stage of the nursing process, the working groups mapped that information to the HL7 RIM. They used a hierarchical structure for the organization of nursing knowledge as the basis for a hierarchical model for "Findings about the patient." The modeling and mapping reported here were exploratory and preliminary, not exhaustive or definitive. The intent was to evaluate the feasibility of representing some types of nursing information consistently with HL7 standards. MEASUREMENTS: The working groups conducted a small-scale validation by testing examples of nursing terminology against the HL7 RIM class "Observation." RESULTS: It was feasible to map patient information from the proposed models to the RIM class "Observation." Examples illustrate the models and the mapping of nursing terminology to the HL7 RIM. CONCLUSION: It is possible to model and map nursing information into the comprehensive health care information model, the HL7 RIM. These models must evolve and undergo further validation by clinicians. The integration of nursing information, terminology, and processes in information models is a first step toward rendering nursing information machine-readable in electronic patient records and messages. An eventual practical result, after much more development, would be to create computable, structured information for nursing documentation.

Training the next generation of informaticians: the impact of "BISTI" and bioinformatics--a report from the American College of Medical Informatics.

In 2002-2003, the American College of Medical Informatics (ACMI) undertook a study of the future of informatics training. This project capitalized on the rapidly expanding interest in the role of computation in basic biological research, well characterized in the National Institutes of Health (NIH) Biomedical Information Science and Technology Initiative (BISTI) report. The defining activity of the project was the three-day 2002 Annual Symposium of the College. A committee, comprised of the authors of this report, subsequently carried out activities, including interviews with a broader informatics and biological sciences constituency, collation and categorization of observations, and generation of recommendations. The committee viewed biomedical informatics as an interdisciplinary field, combining basic informational and computational sciences with application domains, including health care, biological research, and education. Consequently, effective training in informatics, viewed from a national perspective, should encompass four key elements: (1). curricula that integrate experiences in the computational sciences and application domains rather than just concatenating them; (2). diversity among trainees, with individualized, interdisciplinary cross-training allowing each trainee to develop key competencies that he or she does not initially possess; (3). direct immersion in research and development activities; and (4). exposure across the wide range of basic informational and computational sciences. Informatics training programs that implement these features, irrespective of their funding sources, will meet and exceed the challenges raised by the BISTI report, and optimally prepare their trainees for careers in a field that continues to evolve.

The Nursing Terminology Summit Conferences: a case study of successful collaboration for change.

The Nursing Terminology Summit, a series of invitational conferences and ongoing collaboration, has played both initiating and contributing roles to bring about a second-order change in the development and integration of standards for nursing terminology. What factors enabled this success? What factors made change difficult? This paper examines the structure and process of the Nursing Terminology Summit using concepts, principles, theories, and strategies identified in Lorenzi and Riley [Organizational Aspects of Health Informatics: Managing Technological Change, Springer, 1995]. As a case study, this critical analysis offers practical lessons for informaticians in managing change across disciplinary, organizational, and national boundaries.

Reference terminology for therapeutic goals: a new approach.

Participants at the Nursing Terminology Summit Conference 2002 developed proposed terminology models and information models for findings, goals, and outcomes and described the relationships among these concepts. At Vanderbilt University the author has dissected items in a controlled vocabulary of goals in accordance with the terminology model for findings. The concept-based dissections are linked to pre-coordinated phrases in a relational database, providing unambiguous definitions of clinical expressions and enabling concept-oriented searching of the terms database and of the goal achievement database.