Development, Validation, and Implementation of a Clinic Nurse Staffing Guideline.

Ensuring that the level of nurse staffing used to care for patients is appropriate to the setting and service intensity is essential for high-quality and cost-effective care. This article describes the development, validation, and implementation of the clinic technical skills permission list developed specifically to guide nurse staffing decisions in physician clinics of an academic medical center. Results and lessons learned in using this staffing guideline are presented.

The State of Nursing Home Information Technology Sophistication in Rural and Nonrural US Markets.

OBJECTIVE: To test for significant differences in information technology sophistication (ITS) in US nursing homes (NH) based on location. METHODS: We administered a primary survey January 2014 to July 2015 to NH in each US state. The survey was cross-sectional and examined 3 dimensions (IT capabilities, extent of IT use, degree of IT integration) among 3 domains (resident care, clinical support, administrative activities) of ITS. ITS was broken down by NH location. Mean responses were compared across 4 NH categories (Metropolitan, Micropolitan, Small Town, and Rural) for all 9 ITS dimensions and domains. Least square means and Tukey's method were used for multiple comparisons. PRINCIPAL FINDINGS: Methods yielded 815/1,799 surveys (45% response rate). In every health care domain (resident care, clinical support, and administrative activities) statistical differences in facility ITS occurred in larger (metropolitan or micropolitan) and smaller (small town or rural) populated areas. CONCLUSIONS: This study represents the most current national assessment of NH IT since 2004. Historically, NH IT has been used solely for administrative activities and much less for resident care and clinical support. However, results are encouraging as ITS in other domains appears to be greater than previously imagined.

Barriers and facilitators to managing multiple chronic conditions: a systematic literature review.

The prevalence of multiple chronic conditions (MCC) is increasing, creating challenges for patients, families, and the health care system. A systematic literature search was conducted to locate studies describing patient's perceptions of facilitators and barriers to management of MCC. Thirteen articles met study inclusion criteria. Patients reported nine categories of barriers including financial constraints, logistical challenges, physical limitations, lifestyle changes, emotional impact, inadequate family and social support, and the complexity of managing multiple conditions, medications, and communicating with health care providers. Four facilitators were found, including health system support, individualized care education and knowledge, informal support from family and social systems, and having personal mental and emotional strength. Existing research on management of MCC from the patient's perspective is limited. Interventions are needed to improve management practices with particular attention to the knowledge and skills required by this unique population.

Effect of home telemonitoring on glycemic and blood pressure control in primary care clinic patients with diabetes.

OBJECTIVE: Patient self-management support may be augmented by using home-based technologies that generate data points that providers can potentially use to make more timely changes in the patients' care. The purpose of this study was to evaluate the effectiveness of short-term targeted use of remote data transmission on treatment outcomes in patients with diabetes who had either out-of-range hemoglobin A1c (A1c) and/or blood pressure (BP) measurements. MATERIALS AND METHODS: A single-center randomized controlled clinical trial design compared in-home monitoring (n=55) and usual care (n=53) in patients with type 2 diabetes and hypertension being treated in primary care clinics. Primary outcomes were A1c and systolic BP after a 12-week intervention. RESULTS: There were no significant differences between the intervention and control groups on either A1c or systolic BP following the intervention. CONCLUSIONS: The addition of technology alone is unlikely to lead to improvements in outcomes. Practices need to be selective in their use of telemonitoring with patients, limiting it to patients who have motivation or a significant change in care, such as starting insulin. Attention to the need for effective and responsive clinic processes to optimize the use of the additional data is also important when implementing these types of technology.

Implementing home blood glucose and blood pressure telemonitoring in primary care practices for patients with diabetes: lessons learned.

BACKGROUND: Prior telemonitoring trials of blood pressure and blood glucose have shown improvements in blood pressure and glycemic targets. However, implementation of telemonitoring in primary care practices may not yield the same results as research trials with extra resources and rigid protocols. In this study we examined the process of implementing home telemonitoring of blood glucose and blood pressure for patients with diabetes in six primary care practices. MATERIALS AND METHODS: Grounded theory qualitative analysis was conducted in parallel with a randomized controlled effectiveness trial of home telemonitoring. Data included semistructured interviews with 6 nurse care coordinators and 12 physicians in six participating practices and field notes from exit interviews with 93 of 108 randomized patients. RESULTS: The three stakeholder groups (patients, nurse care coordinators, and physicians) exhibited some shared themes and some unique to the particular stakeholder group. Major themes were that practices should (1) understand the capabilities and limitations of the technology and the willingness of patient and physician stakeholders to use it, (2) understand the workflow, flow of information, and human factors needed to optimize use of the technology, (3) engage and prepare the physicians, and (4) involve the patient in the process. Although there was enthusiasm for a patient-centered medical home model that included between-visit telemonitoring, there was concern about the support and resources needed to provide this service to patients. CONCLUSIONS: As with many technology interventions, careful consideration of workflow and information flow will help enable effective implementations.

Patient portal implementation: resident and attending physician attitudes.

BACKGROUND AND OBJECTIVES: Electronic patient portals are increasingly common, but there is little information regarding attitudes of faculty and residents at academic medical centers toward them. METHODS: The primary objective was to investigate attitudes toward electronic patient portals among primary care residents and faculty and changes in faculty attitudes after implementation. The study design included a pre-implementation survey of 39 general internal medicine and family medicine residents and 43 generalist faculty addressing attitudes and expectations of a planned patient portal and also a pre- and post-implementation survey of general internal medicine and family medicine faculty physicians. The survey also addressed email communication with patients. RESULTS: Prior to portal implementation, residents reported receiving much less e-mail from patients than faculty physicians; 68% and 9% of residents and faculty, respectively, reported no email exchange in a typical month. Residents were less likely to agree with allowing patients to view selected parts of their medical record on-line than faculty physicians (57% and 81%, respectively). Physicians who participated in the portal's pilot implementation had expected workload to increase (64% agreed), but after implementation, 87% of those responding were neutral or disagreed that workload had increased. After implementation, only 33% believed quality of care had improved compared to 55% who had expected it to improve prior to implementation. CONCLUSIONS: Residents and faculty physicians need to be prepared for a changing environment of electronic communication with patients. Some positive and negative expectations of physicians toward enhanced electronic access by patients were not borne out by experience.

A framework for analyzing data from the electronic health record: verbal orders as a case in point.

BACKGROUND: Investment in health care information technology is resulting in a large amount of data electronically captured during patient care. These databases offer the opportunity to implement ongoing monitoring and analysis of processes with important patient care quality and safety implications to an extent that was previously not feasible with paper-based records. Thus, there is a growing need for analytic frameworks to efficiently support both ongoing monitoring and as-needed periodic detailed analyses to explore particular issues. One patient care process-the use of verbal orders-is used as a case in point to present a framework for analyzing data pulled from electronic health record (EHR) and computerized provider order entry systems. METHODS: Longitudinal and cross-sectional data on verbal orders (VOs) were analyzed at University of Missouri Health Care, Columbia, an academic medical center composed of five specialty hospitals and other care settings. RESULTS: A variety of verbal order analyses were conducted, addressing longitudinal-order patterns, provider-specific patterns, order content and urgency, associated computer-generated alerts, and compliance with institutional policy of a provider cosignature within 48 hours. For example, at the individual prescriber level, in July 2011 there were 14 physicians with 50 or more VOs, with the top 2 having 253 and 233 individual VOs, respectively. CONCLUSIONS: Taking advantage of the automatic data-capture features associated with health information technologies now being incorporated into clinical work flows offers new opportunities to expand the ability to analyze care processes. Health care organizations can now study and statistically model, understand, and improve complex patient care processes.

Internet use by primary care patients: where is the digital divide?

BACKGROUND AND OBJECTIVES: Internet-based technologies such as personal health records and patient portals are increasingly viewed as essential for enhancing patient-provider communication and patient-centered care. We examined how primary care patients use the Internet, particularly patient characteristics associated with Internet use. METHODS: We surveyed patients in five primary care clinic waiting rooms. Patients who had used email or the Internet in the past month (Internet users) were asked how often they used a computer for a variety of tasks. Participants who reported not using the Internet were asked about several potential barriers to Internet use. RESULTS: We approached 713 patients, and 638 (89.6%) completed questionnaires; 499 (78%) were Internet users and 139 (22%) were non-users. Lack of computer access and not knowing how to use email or the Internet were the most common barriers to Internet use. Younger age, higher education and income, better health, and absence of a chronic illness were associated with Internet use. After controlling for age and other variables, chronic illness was no longer associated with Internet use. CONCLUSIONS: Internet use was high among our primary care patients. The major factor associated with Internet use among patients with chronic conditions was their age. If older adults with chronic illness are to reap the benefits of health information technology, their Internet access will need to be improved. Institutions that are planning to offer consumer health information technology should be aware of groups with lower Internet access.

Making the transition to nursing bedside shift reports.

BACKGROUND: For hospitalized patients, shift handoffs between the offgoing and oncoming nurses, as represented in nurse shift reports, must include all critical information about a patient's plan of care, and that information must be well communicated. Few studies have provided the longitudinal results of the transition to bedside shift reports, and most of the data concern relatively short follow-up periods. A 20-bed inpatient nursing unit in a Midwestern academic health center made the transition to conducting nursing shift reports at the patient's bedside. METHODS: Preparatory work for designing the bedside shift report process, which began in February 2009, included examining baseline patient satisfaction scores, reviewing the existing shift report processes, and identifying potential barriers and facilitators in moving to bedside shift reports. Unitwide implementation of the new bedside shift report process began in June 2009. In the redesigned process, off-going nurses were required to ask patients to write down any questions they would like to ask during the shift report. RESULTS: For the first six months following implementation of bedside shift reports, there were significant increases in six nurse-specific patient satisfaction scores (scores increased at least 8.7 points, and percentile rankings increased from the 20th to > the 90th percentile when compared with similar nursing units in peer institutions). Longer-term results reflected subsequent declines and substantial month-to-month variation. CONCLUSIONS: Although the transition to bedside shift reports met with some resistance, the transition was made smoother by extensive planning, training, and gradual implementation. On the basis of this pilot study, the decision was made to adopt bedside shift reports in all inpatient nursing units in each of the system's five hospitals.

CAH staff perceptions of a clinical information system implementation.

OBJECTIVES: This study examines staff perceptions of patient care quality and the processes before and after implementation of a comprehensive clinical information system (CIS) in critical access hospitals (CAHs). STUDY DESIGN: A prospective, nonexperimental design, evaluation study. METHODS: A modified version of the Information Systems Expectations and Experiences (I-SEE) survey instrument was administered to staff in 7 CAHs annually over 3 years to capture baseline, readiness, and postimplementation perceptions. RESULTS: Descriptive analyses examined 840 survey responses across 3 survey administrations and job categories (registered nurses [RNs], providers, and other clinical staff). Analysis of variance compared responses for main effects (ie, administration, staff position, hospital, and cohort) and interactions between groups over time. Correlations examined the relationships between variables. In general, the responses indicate a high level of positive perceptions regarding the processes and quality of care in these hospitals. For most of the items, responses were quite consistent across the 3 survey administrations. Significant changes occurred for 5 items; 4 reflecting information flow and increased communication, and 1 reflecting a decrease in improved patient care. Overall, providers had lower mean responses compared with nurses and other clinical staff. Significant interactions between administrations and job categories were found for 4 items. CONCLUSIONS: Even though staff had overwhelmingly positive perceptions of patient care quality and processes, significant differences between providers, RNs, and other clinical staff were observed. Variability was also found across CAHs. Research on CIS implementation in small hospitals is rare and needed to guide the identification of factors and strategies related to success.

Changing patient care orders from paper to computerized provider order entry-based process.

The purpose of this study was to describe the extent of change in patient care orders primarily for six diagnoses, procedures, or conditions in a not-for-profit Midwestern rural referral hospital. A descriptive method was used to analyze changes in the order sets over time for chest pain with acute myocardial infarction, degenerative osteoarthritis with hip joint replacement and degenerative osteoarthritis with knee joint replacement procedures, coronary artery bypass graft procedures, congestive heart failure, and pneumonia. Ten items about service-specific order sets were abstracted during pre- and post-EHR implementation and a year later. We then examined use 5 years later. The findings illustrate how the order sets evolved with multiple nested order sets to facilitate computerized provider order entry with a rate greater than 70% by physicians. The total number of available patient care orders within the order sets increased primarily because of linked nested order sets related to medications and diagnostic tests. Five years later, 50% of the orders were medication orders. In conclusion, this was important to deploy the order sets within smaller critical-access hospital facilities to train providers in adopting order sets internally.

Consistency of patient preferences about a secure Internet-based patient communications portal: contemplating, enrolling, and using.

Internet-based secure communication portals (portal) have the potential to enhance patient care via improved patient-provider communications. This study examines differences among primary care patients' perceptions when contemplating using, enrolling to use, and using a portal for health care purposes. A total of 3 groups of patients from 1 Midwestern academic medical center were surveyed at different points in time: (1) Waiting Room survey asking about hypothetical interest in using a portal to communicate with their physicians; (2) patient portal Enrollment survey; and (3) Follow-up postenrollment experience survey. Those who enroll and use a patient portal have different demographic characteristics and interest levels in selected portal functions (eg, e-mailing providers, viewing medical records online, making appointments) and initially perceive only limited improvements in care because of the portal. These differences have potential market implications and provide insight into selecting and maintaining portal functions of greater interest to patients who use the portal.

A review of verbal order policies in acute care hospitals.

BACKGROUND: Although verbal and telephone orders (VOs) are commonly used in the patient care process, there has been little examination of the strategies and tactics used to ensure their appropriate use or how to ensure that they are accurately communicated, correctly understood, initially documented, and subsequently transcribed into the medical record and ultimately carried out as intended. A systematic review was conducted of hospital verbal and telephone order policies in acute care settings. METHODS: A stratified random sample of hospital verbal and telephone order policy documents were abstracted from critical access, rural, rural referral, and urban hospitals located in Iowa and Missouri and from academic medical centers from across the United States. FINDINGS: Substantial differences were found across 40 acute care settings in terms of who is authorized to give (including nonlicensed personnel) and take VOs and in terms of time allowed for the prescriber to cosign the VO. When a nonphysician or other licensed prescriber was allowed to communicate VOs, there was no discussion of the process to review the VO before it was communicated in turn to the hospital personnel receiving the order. Policies within several of the same hospitals were inconsistent in terms of the periods specified for prescriber cosignature. Few hospitals required authentication of the identity of the person making telephone VOs, nor the use of practices to improve communication reliability. CONCLUSION: Careful review and updating of hospital VO policies is necessary to ensure that they are internally consistent and optimize patient safety. The implementation of computerized medical records and ordering systems can reduce but not eliminate the need for VOs.

A diabetes dashboard and physician efficiency and accuracy in accessing data needed for high-quality diabetes care.

PURPOSE: We compared use of a new diabetes dashboard screen with use of a conventional approach of viewing multiple electronic health record (EHR) screens to find data needed for ambulatory diabetes care. METHODS: We performed a usability study, including a quantitative time study and qualitative analysis of information-seeking behaviors. While being recorded with Morae Recorder software and "think-aloud" interview methods, 10 primary care physicians first searched their EHR for 10 diabetes data elements using a conventional approach for a simulated patient, and then using a new diabetes dashboard for another. We measured time, number of mouse clicks, and accuracy. Two coders analyzed think-aloud and interview data using grounded theory methodology. RESULTS: The mean time needed to find all data elements was 5.5 minutes using the conventional approach vs 1.3 minutes using the diabetes dashboard (P <.001). Physicians correctly identified 94% of the data requested using the conventional method, vs 100% with the dashboard (P <.01). The mean number of mouse clicks was 60 for conventional searching vs 3 clicks with the diabetes dashboard (P <.001). A common theme was that in everyday practice, if physicians had to spend too much time searching for data, they would either continue without it or order a test again. CONCLUSIONS: Using a patient-specific diabetes dashboard improves both the efficiency and accuracy of acquiring data needed for high-quality diabetes care. Usability analysis tools can provide important insights into the value of optimizing physician use of health information technologies.

Nurses' perceptions of how clinical information system implementation affects workflow and patient care.

There is a little evidence of the impact of clinical information system implementation on nurses' workflow and patient care to guide institutions across the nation as they implement electronic health records. This study compared changes in nurse's perceptions about patient care processes and workflow before and after a comprehensive clinical information system implementation at a rural referral hospital. The study used the Information Systems Expectations and Experiences survey, which consists of seven scales-provider-patient communication, interprovider communication, interorganizational communication, work-life changes, improved care, support and resources, and patient care processes. Survey responses were examined across three administrations-before and after training and after implementation. The survey responses decreased significantly for eight of the 47 survey items from the first administration to the second and for 37 items from the second administration to the third. Perceptions were more positive in nurses who had previous experience with electronic health records and less positive in nurses with more years of work experience. These findings point to the importance of setting realistic expectations, assessing user perceptions throughout the implementation process, designing training to meet the needs of the end user, and adapting training and implementation processes to support nurses who have concerns.

Evaluating clinical decision support rules as an intervention in clinician workflows with technology.

The implementation of electronic health records in rural settings generated new challenges beyond those seen in urban hospitals. The preparation, implementation, and sustaining of clinical decision support rules require extensive attention to standards, content design, support resources, expert knowledge, and more. A formative evaluation was used to present progress and evolution of clinical decision support rule implementation and use within clinician workflows for application in an electronic health record. The rural hospital was able to use clinical decision support rules from five urban hospitals within its system to promote safety, prevent errors, establish evidence-based practices, and support communication. This article describes tools to validate initial 54 clinical decision support rules used in a rural referral hospital and 17 used in clinics. Since 2005, the study hospital has added specific system clinical decision support rules for catheter-acquired urinary tract infection, deep venous thrombosis, heart failure, and more. The findings validate the use of clinical decision support rules across sites and ability to use existing indicators to measure outcomes. Rural hospitals can rapidly overcome the barriers to prepare and implement as well as sustain use of clinical decision support rules with a systemized approach and support structures. A model for design and validation of clinical decision support rules into workflow processes is presented. The replication and reuse of clinical decision support rule templates with data specifications that follow data models can support reapplication of the rule intervention in subsequent rural and critical access hospitals through system support resources.

A regional assessment of information technology sophistication in Missouri nursing homes.

OBJECTIVE: To provide a state profile of information technology (IT) sophistication in Missouri nursing homes. METHOD: Primary survey data were collected from December 2006 to August 2007. A descriptive, exploratory cross-sectional design was used to investigate dimensions of IT sophistication (technological, functional, and integration) related to resident care, clinical support, and administrative processes. Each dimension was used to describe the clinical domains and demographics (ownership, regional location, and bed size). RESULTS: The final sample included 185 nursing homes. A wide range of IT sophistication is being used in administrative and resident care management processes, but very little in clinical support activities. CONCLUSION: Evidence suggests nursing homes in Missouri are expanding use of IT beyond traditional administrative and billing applications to patient care and clinical applications. This trend is important to provide support for capabilities which have been implemented to achieve national initiatives for meaningful use of IT in health care settings.

Implementation of a telepharmacy service to provide round-the-clock medication order review by pharmacists.

Purpose The implementation of a telepharmacy service to provide round-the-clock medication order review by pharmacists is described. Summary Seven critical access hospitals (CAHs) worked collaboratively as part of a network of hospitals implementing the same electronic health record (EHR), computerized prescriber-order-entry (CPOE) system, and pharmacy information system to serve as the health information technology (HIT) backbone supporting round-the-clock medication order review by pharmacists. Collaboration permitted standardization of workflow policies and procedures. Through the HIT backbone, both onsite and remote pharmacists were given access to the medication orders, the pharmacy information system, and other patient-specific clinical data in patients' EHRs. Orders are typically reviewed within 60 minutes of when they are entered into the system. The reviewing pharmacists have remote access to the EHRs in each CAH. After completing the clinical review, the pharmacist selects the appropriate medication to dispense from the CAH's formulary. If the medication order is not made using the CPOE system, the order is scanned into a document and sent via e-mail to remote pharmacists. The pharmacist enters the necessary information into the EHR and pharmacy information system. The medication order review process from this point forward is identical to that used for medications ordered via CPOE. The new medication order is then entered into the EHR, and the CAH nurse can proceed with the order. Conclusion The implementation of a telepharmacy model in a multihospital health system increased access to pharmacy services, allowing for round-the-clock medication order review by pharmacists.

Impact of health information technology on detection of potential adverse drug events at the ordering stage.

PURPOSE: The impact of implementing commercially available health care information technologies at hospitals in a large health system on the identification of potential adverse drug events (ADEs) at the medication ordering stage was studied. METHODS: All hospitals in the health system had implemented a clinical decision-support system (CDSS) consisting of a centralized clinical data repository, interfaces for reports, a results reviewer, and a package of ADE alert rules. Additional technology including computerized provider order entry (CPOE), an advanced CDSS, and evidence-based order sets was implemented in nine hospitals. ADE alerts at these hospitals were compared with alerts at nine hospitals without the advanced technology. A linear mixed-effects model was used in determining the mean response profile of six dependent variables over 28 total months for each experimental group. RESULTS: Overall, hospitals with CPOE and an advanced CDSS captured significantly more ADE alerts for pharmacist review; an average of 336 additional potential ADEs per month per hospital were reviewed. Pharmacists identified some 94% of the alerts as false positives. Alerts identified as potentially true positives were reviewed with physicians, and order changes were recommended. The number of true-positive alerts per 1000 admissions increased. CONCLUSION: The implementation of CPOE and advanced CDSS tools significantly increased the number of potential ADE alerts for pharmacist review and the number of true-positive ADE alerts identified per 1000 admissions.

A network collaboration implementing technology to improve medication dispensing and administration in critical access hospitals.

We report how seven independent critical access hospitals collaborated with a rural referral hospital to standardize workflow policies and procedures while jointly implementing the same health information technologies (HITs) to enhance medication care processes. The study hospitals implemented the same electronic health record, computerized provider order entry, pharmacy information systems, automated dispensing cabinets (ADC), and barcode medication administration systems. We conducted interviews and examined project documents to explore factors underlying the successful implementation of ADC and barcode medication administration across the network hospitals. These included a shared culture of collaboration; strategic sequencing of HIT component implementation; interface among HIT components; strategic placement of ADCs; disciplined use and sharing of workflow analyses linked with HIT applications; planning for workflow efficiencies; acquisition of adequate supply of HIT-related devices; and establishing metrics to monitor HIT use and outcomes.