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Technology

TECHNOLOGY-ENABLED INNOVATION

The introduction of new technologies into hospitals is not an unfettered good, said Steven DeMello, research program director at the Public Health Institute. “If you can’t identify ways in which you can improve practice, improve process, or improve business models, it does not have great value.”

DeMello focused on what he called technology-enabled innovation—changes in practices, procedures, or business models that have technology at their heart. He also proposed a high standard for new technologies. He asserted that their adoption should lead to transformative practice that simultaneously improves clinical quality and reduces costs at a scale that can drive value across large sections of practice and large sections of the country.

As shown in Table 4-1, five areas of technology are especially promising:

  1. Technologies related to ergonomics are very valuable and often overlooked. The combination of physically demanding work, an increasingly elderly and obese patient population, and an aging workforce is already producing high rates of work-related injuries. Patient lifting and transportation technologies, along with continued reductions in the size of diagnostic and therapeutic equipment, are unheralded but valuable advances that can be applied to nursing.



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4 Technology TECHNOLOGY-ENABLED INNOVATION The introduction of new technologies into hospitals is not an unfet- tered good, said Steven DeMello, research program director at the Public Health Institute. “If you can’t identify ways in which you can improve practice, improve process, or improve business models, it does not have great value.” DeMello focused on what he called technology-enabled innova- tion—changes in practices, procedures, or business models that have technology at their heart. He also proposed a high standard for new tech- nologies. He asserted that their adoption should lead to transformative practice that simultaneously improves clinical quality and reduces costs at a scale that can drive value across large sections of practice and large sections of the country. As shown in Table 4-1, five areas of technology are especially promising: 1. Technologies related to ergonomics are very valuable and often overlooked. The combination of physically demanding work, an increasingly elderly and obese patient population, and an aging workforce is already producing high rates of work-related inju- ries. Patient lifting and transportation technologies, along with continued reductions in the size of diagnostic and therapeutic equipment, are unheralded but valuable advances that can be ap- plied to nursing. 25

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26 FORUM ON THE FUTURE OF NURSING: ACUTE CARE TABLE 4-1 Areas of Promising Technology Innovation Area Issues Technologies Ergonomics Staff and patient safety Patient lifts, mobile D&T equipment Education and training Recruitment and retention E-learning, distance learning, simulation Productivity Communications and POCT, wireless, process streamlining RTLS, facility design Efficiency Use of scarce, highly Telemedicine, remote trained staff monitoring, care man- agement A-ICU,a family care Clinical practice New models of care units a Ambulatory Intensive-Caring Units (A-ICU) is a model of primary care developed by Arnie Milstein. “The model pairs high-performing clinical teams with high-risk pa- tients—those with chronic illnesses or socioeconomic issues that contribute to high healthcare usage. The aim is to prevent higher ‘downstream’ costs related to traditional primary care, specialty care and hospital admissions, by implementing these cost-saving features” (Shaw, 2009). NOTES: A-ICU = Ambulatory Intensive-Caring Units; D&T = Diagnosis and Treatment; POCT = Point-of-Care Testing; RTLS = Real-Time Location Systems. 2. Education and training technologies such as e-learning, distance learning, and simulation can provide better and more flexible opportunities for nurses and nursing students across the country to learn from nursing professionals—an especially important consideration given projected shortages of direct caregivers. 3. Technologies that can improve nursing productivity include in- novations related to better communications, streamlined proc- esses, and improved coordination among caregivers at all levels. Foundational innovations include point-of-care testing, wireless communications, real-time location systems, and software that incorporates workflow data into facilities design. Individually and collectively, these innovations can increase nursing time at the bedside while reducing repetitive communications and ad- ministrative burdens. In particular, improvements in wireless communications and real-time location systems hold great prom- ise in the next 2 to 5 years.

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27 TECHNOLOGY 4. Technologies that can improve nursing efficiency can make the best possible use of increasingly scarce human resources. Foun- dational technologies include telemedicine, remote physiological and environmental monitoring, and care management. For ex- ample, telemedicine could support networks of care sites that are managed by highly skilled nurses. Such technologies also could provide much greater levels of care in homes and non-acute set- tings, which would have the additional benefit of reducing the workload at acute care sites. 5. Technologies that can change basic models of practice could re- sult in much higher levels of bedside time and care management and decrease the burden of administration, communication, and documentation. For example, models of care could draw more heavily on other licensed and unlicensed caregivers, including family and friends, working under the direction of nursing care managers. Four specific technologies hold promise in the short term to help transform nursing through changes in practice mod- els: point-of-care testing, wireless communications, real-time lo- cation systems, and telemedicine. The development of these technologies is accelerating, and current capabilities will grow rapidly in the next few years. DeMello commented on the absence of electronic health records (EHRs) from this list of promising technologies. He said that EHRs are a foundational technology, but they are important to a much wider segment of the health care system than just nursing. In addition, EHRs should be seen as a floor, but not a ceiling; they are a base on which to build, but not the sole or even primary technological answer to improving care processes. He also expressed concern that the current focus on EHRs might have the unintended consequence of limiting the ability of care- givers and institutions to experiment with other technologies that could be extremely beneficial with or without an EHR. A painful lesson learned from past experiences is that the “what” of technology adoption often obscures the “how.” Specifically, how are technologies diffused within and across organizations? Diffusion de- pends not just on the technology, but on the regulatory and legal envi- ronment and on the investment that institutions make in diffusion. Laws and regulations related to scope of practice, supervision, and other as- pects of care can slow or halt the diffusion of technologies that influence roles, supervision, or communication. Inconsistent policies across states

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28 FORUM ON THE FUTURE OF NURSING: ACUTE CARE can make it difficult to know what is legal in each jurisdiction and can obviate the benefits to natural markets that span legal boundaries. Additionally, institutions often do not devote enough attention and resources to technology diffusion. “As an industry, we have gotten very skilled at trials, we are pretty spotty at initial implementation, and we are positively terrible at taking that implementation and replicating it consis- tently and appropriately across organizations,” DeMello said. As the health care industry simultaneously consolidates and becomes more complex, it will be important to have broad-based, consistent application of technologies to catalyze the transformation of nursing. TECHNOLOGY-ENABLED NURSING Nurses have been using time-saving and lifesaving technologies for years, said Dr. Pamela Cipriano, former chief nursing officer at the Uni- versity of Virginia Medical Center. In the 1970s, for example, nurses began to use technologies to monitor multiple critical care patients simul- taneously, “so nurses were exposed to technology very early on in terms of looking at the explosion of the use of electronics in the patient care setting.” But nurses have usually been passive consumers rather than ac- tive designers of technology. Rarely have they been involved in the de- sign, testing, or purchasing of equipment. Cipriano recalled working in a cardiothoracic and trauma intensive care unit when a patient arrived from open-heart surgery with a brand new balloon pump in tow that none of the nurses had seen before. “There was no manual, no technical expert from the company. It is my hope that that doesn’t happen anymore, al- though every once in a while we hear a horror story, which is why cur- rent regulations provide safeguards to prevent that,” she said. “Today nurses also ensure proper use by being engaged in selection and imple- mentation of patient care technologies.” By bringing value to nurses and patients, technology can save money, time, and lives. It can augment the delivery of nursing care, pre- serve the health of nurses, reduce unnecessary tasks, make it simpler and easier for nurses to conduct their daily activities, and reduce the potential for errors. One crucial benefit technology can provide is a single set of clinical data. “Right now we have multiple professionals and providers collecting data that get hidden away in a variety of places, and some electronic re- cords are difficult to navigate.” As with the fragmented health care system,

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29 TECHNOLOGY the result is fragmented documentation within electronic records, which multiplies the challenges of bringing all the information together to care for patients. By involving nurses in the design—and not just the use—of technol- ogy, new devices and systems can be integrated so that they are as easy to use as possible. Nurses are eager to see the functionality that exists in consumer technologies being built into point-of-care technologies. They should be voice activated, handheld, and portable, and they should use biometrics and offer translation, Cipriano said. Introducing equipment for equipment’s sake does not help the nurse. Equipment needs to add value and efficiency to nursing rather than forc- ing nurses to also nurse the equipment. The nursing workflow is com- plex, which poses challenges to the adoption of technology. Nurses have a tendency to skip steps and are very good at jumping ahead to the next task that needs to be done. They quickly figure out how to cut corners. Some do not have the computer skills that would be ideal in today’s nursing environment. If technologies are nurse-friendly, they can create safer, higher quality, and more efficient work environments and add value to the way that nurses coordinate and provide care. Greater nurse satisfaction leads to greater patient satisfaction. Changing the nursing workflow first is more important, Cipriano said, than introducing a technology and hoping that it will change the workflow. One way to embed new workflows into technology is to build evidence-based and best practices into information systems. For exam- ple, systems can prioritize messages about patient conditions and feed that information to nurses and other caregivers in handheld devices so they can respond quickly to changing clinical conditions. Yet technolo- gies also can be misused. For example, beds that vibrate do not mean that patients do not need to be turned. Nurses still do a considerable amount of transcription. “If we know that the nurse is writing down data like vital signs and then putting them into a system later, it is incredibly inefficient. There are wireless devices that not only collect the vital signs, but transmit and embed those data into the information system. This fundamentally needs to be everywhere, not just in the places that have chosen to purchase that equipment.” The recent Technology Drill Down study done by the American Academy of Nursing has examined a variety of workflow issues, includ- ing medication administration, communication, timely acquisition and tracking of equipment and supplies, wireless monitoring, electronic clini- cal documentation, and patient identification, that could reduce error

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30 FORUM ON THE FUTURE OF NURSING: ACUTE CARE rates to zero. As a specific case, Cipriano observed that wireless patient monitoring “is finally taking off.” Companies are doing the necessary work so that technologies integrated into a bed or mattress pad can moni- tor weight, blood pressure, heart rate, respiratory rate, or body move- ment. Such technologies also can be integrated into call or other communication system to alert nurses of patient changes. Another exam- ple of a smart system is a hospital bed that includes a translation feature so that routine questions can be asked in different languages. “Nurses have told us repeatedly that having translation at the point of care is be- coming more and more critical.” The Drill Down study also looked at the desired outcomes of tech- nology development and adoption. The most important were to reduce duplicative work, provide rapid access to other providers and resources, accomplish regulatory work, and improve the physical environment. Cipriano made four specific suggestions regarding technology: 1. Include nursing workflow as a focus of health care information technology funding to ensure that systems and devices will en- able nurses to be more efficient and produce safer care. 2. Advocate for nurses to be included in technology design and evaluation to enhance rapid adoption. 3. Ensure that nurses are seen as meaningful users of technology. 4. Support nurses in moving high-technology care into the hospital setting of the future—the home and community. Adopting these suggestions would “make sure that we are, in fact, transforming the way that we deliver care and are using technology as an adjunct to do that,” Cipriano said.

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31 TECHNOLOGY REACTIONS AND QUESTIONS Joseph Guglielmo asked why promising new models for nursing have not moved forward in many cases. He speculated that one reason is a lack of evidence about their effectiveness. The assumption is that new systems and technologies have undergone a quality assurance program, but that is not necessarily the case. “My take-home [message] is that we need more evidence, we need not to be afraid to ask questions, to say, ‘What is the true value?’” Furthermore, these assessments need to con- sider the workflow of all care providers, including nurses. Today’s patients know and like technology, said Julia Hallisy. Pa- tients realize that technology can improve their safety, help keep nurses at their bedside, and improve communication among the members of their care teams. Patients and families can be frustrated when a caregiver is not aware of a changed treatment plan or new order. Patients know that such communication failures can be avoided through something as easy as a wireless phone. The result for nurses is that patients and family members can become agitated, which places a burden on nurses. “Pa- tients are going to expect it and they are going to demand it,” she said. In response to a question about the use of technology to provide real- time access and greater patient involvement, which was referred to by the questioner as more patient-controlled care, Kurt Swartout recounted his experiences with an electronic medical record system used in his hospi- tal for the past 14 months. He brings a computer to the patient’s bedside so they can review test results and other information together. In addi- tion, specialists on a care team can instantly have information about a patient and provide immediate input to decisions. “I don’t think we real- ized how valuable it is to have information . . . that everyone can look at,” he noted. The system also allows caregivers to gain information from nurses, “so it has increased the sophistication of our conversation.” One challenge, Swartout continued, is to reduce the time spent on documentation while improving its quality; nurses spend about 35 per- cent of their time on documentation. One way to do so is through auto- correct options that reduce the amount of typing needed. Voice recognition technology also can allow caregivers to dictate information to a computer without having to type that information. A viewer of the webcast of the forum wrote to point out that technol- ogy can not only collect patient data, but assist with the analysis and re- view of that data. DeMello agreed and extended the argument to technologies that are less clinical in nature, but still can improve health

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32 FORUM ON THE FUTURE OF NURSING: ACUTE CARE care. An example is a set of databases that track which caregivers are associated with which patients. A roadblock to the implementation of such technologies, he said, is managing the data behind the scenes that the technology generates. “We are much less far along in managing the complexity than we [should be].” Caregivers and health care institutions also need to be willing to use technology to interact with patients and families, Cipriano said. This should be a point of emphasis in education and training, so that future professionals are ready from the beginning of their careers to use tech- nologies at the point of care. In response to a question about whether some technologies have det- rimental rather than beneficial effects, Guglielmo agreed that many tech- nologies have unintended consequences. Indeed, all technologies have such consequences, but they are not well studied scientifically. DeMello divided such consequences into two categories: technologies that do ac- tive harm or are not consistent with good care, and technologies that de- liver minuscule benefits for massive investments. The latter case is even more important, more difficult to solve, and harder to reverse, he said. Cipriano observed that positive and negative consequences of new tech- nologies are part of the adoption curve of any technology. “It reinforces the fact that we do need to look at and measure the impact of technology so that we can make the right decisions and take it away if necessary,” Cipriano said. In response to a question about how technology could be used to shift acute care out of hospitals or keep patients from having to come to hospitals, Marilyn Chow discussed technologies that enable the “hospital at home.” In addition, Bernice Coleman described ways in which tech- nology can improve continuity of care. For example, in transitioning from a hospital to the community, care inside the hospital could be linked to virtual care outside the hospital. Not just patients and their families, but entire communities could be supported in the use of health care technologies. Nurses could be at the center of this transition, but they need to have access to information, technology, and support to fill this role. Cipriano also pointed to telehealth technologies that patients and families can use to manage chronic conditions that in the past would have required being in a hospital. For example, technologies such as cell phones can help teens to manage diabetes or nutritional choices. “There are nurse-led programs around the country that are making a difference

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33 TECHNOLOGY in being able to inform consumers at any age and allow them to partici- pate in the management of their health care,” Cipriano said. Similarly, the Veterans Administration (VA) has been working on the home management of chronic diseases with “terrific results,” DeMello said. The VA “spent a considerable amount of time figuring out the logistics—how they could use multiple units, how they could make sure people in the home were supported, how the education happens. It is an interesting blueprint for what’s possible.” A final comment from a webcast observer noted that technology only works as well as the person using it. If a health care organization does not maintain a technology, or a nurse distrusts it, a technology will not be effective.

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