I often read or hear about "physician buy-in"—as I'm sure most of you do too—as the key component to successfully implementing many IT projects, including computerized physician order entry. While I agree that physicians need to join the effort for CPOE to be successful, I also think there is a lot more behind the successful implementations—like dogged persistence.
I recently spoke with Cynthia D. Burton, RN, who is the chief nursing officer and CPOE champion, if you will, at Rockcastle Regional Hospital and Respiratory Care Center in Mt. Vernon, KY, about her organization's switch to electronic health records and CPOE. Rockcastle, which had a completely paper clinical record, opted for a big bang approach in its switch to an EHR and went live with its CPOE system in November 2007. Today, the 26-bed acute-care facility has 100% of its orders entered through its CPOE system and 75% of those orders are entered directly by physicians. Yet, if given the choice today, there are still a handful of physicians who would jump at the chance to stop placing orders electronically, says Burton.
"Do they like it? No. Would they go back in a minute? Yes," she says, clarifying that that sentiment is solely for CPOE. The physicians would not want to go back to paper after using the electronic health record system and being able to access lab results with the click of a mouse, she says.
So how did Rockcastle get its physicians on board and more importantly using CPOE?
"We were going to do CPOE from the very beginning, so every time we talked about the record we constantly talked about how we are going to do this," Burton says. "We continued to say we could do it. I think it was just that constant positive discussion about it."
Here are five lessons Burton learned along the way.
Lesson 1: Sell the advantages. "We kept talking in a positive manner," says Burton, while acknowledging that, yes, it will be hard. Burton played up the fact that physicians would no longer have to look through paper charts for lab results, for example.
Lesson 2. Physicians don't like to train in groups. Rockcastle, which has about 25 physicians, including 12 primary-care doctors who are there most of the time, had a group training session with the physicians to show what the system would look like. Then the system arranged training sessions with no more than two physicians at a time. "They were more likely to ask questions or admit weaknesses when alone rather than in groups," says Burton.
Lesson 3. Provide support—especially early on in the process. Rockcastle identified three nurse champions to help physicians initially and that number grew to four. They were involved in physician training sessions so they could answer questions and assess the doctor's computer skills. "The nurses' job was to smooth the way for the physicians," says Burton. "Pick up questions and get them the answers that they needed." When the system went live the nurses were there around the clock for two weeks. For the first few days, if a doctor was using the system, there was a nurse at their elbow, says Burton. "When you start the process you have to have plenty of resources, so when physicians get on the computer there is someone right there to answer questions because it is frustrating if they can't get the assistance they need."
Lesson 4. Provide a private area for physicians to use the system. Rockcastle built a physicians lounge, complete with four computer terminals and a terminal for the PACS system so that doctors would have a private area to enter orders without being interrupted. "We also purchased small computers that they could use at home and that was a benefit that we sold them on because they could access records from home," says Burton.
Lesson 5. Keep the lines of communication open. The physicians at Rockcastle have a monthly meeting that every doctor attends—one of the perks of being a small hospital. Burton would typically sit in on that meeting on a quarterly basis. After the system went live in November, however, she started going every month to assist the doctors, answer questions, or make changes to the CPOE system. By the March, the comments changed from "we can't do this" to "can the system do this," says Burton, adding that that was when she knew she could stop going every month. "They reached the point where they were comfortable with it," she says.
Burton is very happy with her physicians' acceptance of CPOE. "We didn't have anyone pitching fits, stomping, leaving the building. They grumbled, but did it," she says. "We tried to be there and listen and reinforce that we could do it."
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Health leaders spend most of their time in their own silos. Health insurance executives attend events with other health plan leaders, physician leaders talk with other physicians, and the hospital C-suite stays focused on hospital business.
This communication breakdown has left health leaders heavily guarded in their bunkers with hurt feelings and often times not understanding the other healthcare pillars. This has also led to health leaders from the different groups having quite different opinions about healthcare and how to improve services while reducing costs.
One only needs to view the current health reform debate to show there are varying opinions on how best to proceed.
With our publication and Web site, HealthLeaders Media is able to break down those silos and let hospital, physician, and health plan leaders learn about what the others think.
This is especially true in the annual HealthLeaders Media Industry Survey. Last year's survey saw hundreds of health leaders offer their thoughts on important industry questions—and for the first time, health insurance leaders took part.
The annual survey includes responses from key benchmark questions for all health leaders, including health insurance executives, physician leaders, and hospital CEOs, CFOs, and CIOs. With those results, we compare each area's priorities—and most notably see where there is disagreement.
The 2009 survey found two large disagreements between health plans and physician leaders:
Health plan executives thought there were two ways payers could improve relationships with providers: pay-for-performance programs that focus on certain health measures and speeding up processing, fixing, and paying claims. Only 19% of health plan respondents thought increasing reimbursements would help the situation. However, when physician leaders were asked the same question, more than half of respondents pointed to increased reimbursements while only 7% agreed with the health plan's top response—pay for performance.
Forty-two percent of health plan respondents thought consumer-directed health plans offered the best hope for healthcare, while more than half of physicians chose a government intervention.
Some of the other interesting results from the health plan survey included:
Though a slight majority believed consumer-directed health plans both saved health plans money and empowered consumers, the remaining respondents did not believe the plans empowered consumers and nearly a fifth said CDHPs didn't save money for health plans. This meant that nearly half of health plan respondents were not sold on consumer-directed plans—though at the same time nearly half of health plans said they were the best hope for healthcare. What will this year's respondents say?
Health plan leaders supported population health management in the 2009 survey. More than 40% of respondents said population health saved money and improved outcomes in some cases, depending on the disease state, and another 38% said population health saved money and improved health outcomes in all cases. Less than 5% of respondents didn't think it saved money or improved health outcomes.
This year, we have kept most of the benchmark questions and added a few more on topics, including the erosion of the employer-based market and the growth of the individual market, as well as questions about health reform efforts and the economy.
I'm looking forward to seeing what health insurance leaders think—as well as comparing the benchmarking questions to see where there is agreement and disagreement. HealthLeaders Media will provide analysis of the results in the February 2010 issue of the magazine and I will also comment on the results in my columns.
Health leaders have until Oct. 28—next Wednesday—to respond to the 15-minute survey. Please take the time to go to the survey and let the larger health industry know what you think about these pressing issues.
American Medical Association President J. James Rohack, MD, says budget neutrality in the healthcare reform debate should not derail the push to abolish what he says is an obsolete Medicare physician fee schedule that will carve out up to $245 billion in payment reductions for physicians.
"From a practical standpoint, this problem predates any discussion of health system reform by this current president," Rohack tells HealthLeaders Media. "This problem was adopted in 1997. The first problems in cuts started in 2001. This is a leftover problem that should be standing on its own and should be fixed on its own and not be considered part of a new package that a new president is considering."
Rohack is in Washington this week to lobby the Senate in support of the Medicare Physician Fairness Act of 2009, or S. 1776.
Budgetary rules require Congress to offset any increased spending for healthcare reform under a sustainable growth rate formula that was implemented in 1997. S. 1776, sponsored by Sen. Debbie Stabenow, D-MI, would reset the SGR formula to zero and eliminate what is estimated to be up to $245 billion debt that has accumulated during the past six years as a result of Congress' annual fixes to ensure physician payments were not reduced.
The AMA, the American Academy of Family Physicians, and other physicians' organizations have banded together in support of the bill.
Rohack says the new emphasis on cost-saving, patient-centered, preventative care makes the SGR formula obsolete. Abolishing the formula, he says, would allow Congress to develop a new payment system that rewards efforts to treat and control chronic diseases, and reduce hospitalization. "This formula is designed to make cuts as volumes go up. It's an old formula that doesn't reflect what 21st medicine is and will become even more in the future," he says.
"Unfortunately, the Band-Aids Congress has applied to this problem have created a deeper and deeper hole. That is why we believe it is time to fill the hole and move forward as discussions on health system reform are looking at new ways to incent physicians by paying for care coordination and trying to make sure that patients stay healthy, by keeping them out of the hospital through prevention and screening. All of those things, care coordination, prevention, screening, under the Medicare program causes this formula to make deeper cuts."
Before the bill can reach the Senate floor, it must have at least 60 votes on each of three procedural votes, with the first vote expected some time this week. Rohack says Congress already understands the issue because physicians have lobbied them for the past seven years to "kick the can" on the formula-mandated funding cuts and delay them.
"The feedback we are getting is 'we know this is a problem. We've just got to figure out how to fix it,'" he says. "We need to get this taken care of now because in two short years the baby boomers hit Medicare and knowing how the boomers change social policy, they ain't going to be happy if they don't have access to their physician. That is why we are trying to anticipate the problem by fixing it now instead of waiting to fix it later on down the road."
When a professional fighter allegedly went haywire in a Nevada hospital and attacked nurses, it briefly brought some national attention to a long-standing problem: violence against healthcare workers.
Of course, it's not just famous people or athletes who can cause trouble, which makes the challenge of protecting hospital employees daunting.
Ultimate Fighting Championship (UFC) star Junie Browning was arrested by police October 6 after the incident at St. Rose Dominican Hospital's Siena Campus in Henderson, NV, according to the Las Vegas Review-Journal.
Friends of Browning brought him to St. Rose's fearing he may have purposely overdosed on an anti-anxiety drug. While at the hospital, Browning allegedly became angry, pushed a female nurse, and punched a male nurse in the face, according to police report details UFC fired Browning following his arrest.
If your security team hasn't reviewed hospital violence procedures recently, it's time for you to start such an assessment because ER problems may get worse soon, said Fredrick Roll, MA, CHPA-F, CPP, president and principal consultant at Healthcare Security Consultants, Inc., in Frederick, CO.
Federal healthcare reform could increase wait times in ERs across the country, and prolonged wait times are the No. 1 reason for violence in those settings, Roll told attendees at the American Society for Healthcare Engineering's annual conference in August in Anaheim, CA.
Some simple precautions can keep healthcare workers safe should they find themselves in a violent situation. The trick is all in what they wear, said Barbara Bisset, PhD, MPH, MS, RN, executive director of the Emergency Services Institute at WakeMed Health & Hospitals in Raleigh, NC, who spoke to HCPro's Healthcare Security Alert earlier this year.
Below are five easy steps your staff members can take:
Store stethoscopes in pockets. Although it's traditional to see physicians and nurses with stethoscopes slung around their necks, they can become a choking device if aggressive patients get their hands on the stethoscopes.
Don't wear dangling earrings. A violent or confused patient might cause injury by pulling on the jewelry.
Keep long hair up or pulled back. "It's long and flowing, it looks beautiful, but working in [a hospital], it's not appropriate from an infection control perspective and from a safety perspective," Bisset said.
Don't wear ties. Yes, ties look professional, but there are again risks of being choked by the accessory. Bisset recommended clip-ons if staff members feel a necktie is needed.
Wear a breakaway lanyard. Staff members may be accustomed to hanging a fabric cord around their necks to display ID badges or keep access cards handy. If this is the case in your hospitals, make sure the lanyards are breakaway-style so that the fabric and cards can't immediately be used as weapons.
National health IT coordinator David Blumenthal emphasized that the ability of clinicians to amass, analyze, and report healthcare quality measures lays at the heart of his office's strategy for using IT to transform the U.S. healthcare system. "The key to meaningful use is to know how to measure for performance and to be able to give feedback to providers," Blumenthal said Oct. 15 at a conference sponsored by the National Quality Forum.
In this Q&A with iHealthBeat, U.S. Chief Technology Officer Aneesh Chopra discussed how health 2.0 aligns with the Obama administration's larger health reform goals, the federal stimulus package, the administration's open government initiative, and shareable intellectual property. "Health 2.0 is a key pillar of where we believe innovation will take place in the nation's healthcare system," Chopra told iHealthBeat. As we look to shape the market conditions— the incentives to reward wellness and prevention—I have great confidence that the health 2.0 community will rise up to the challenge and engineer game-changing ideas to deliver the results our policymakers in Washington are keen to deliver."
With the economic crisis affecting the healthcare arena, hospitals large and small must tighten the budgetary belt. This difficult task weighs heavily on hospital CEOs across the nation. Should leadership positions be eliminated? Should nursing FTE's be cut?
Historically, one of the first hospital departments to experience the crunch is the nursing education department. Reimbursement for seminars and out-of-facility education is an easy expense to eliminate and monies once budgeted for training are frozen. With a short-term perspective, it's easy to believe these cuts will have little effect on hospital operations and those currently employed within the facility, but unfortunately, this is a false assumption.
The future of ongoing improvement in quality healthcare has a strong dependency on life-long learning that is hosted and encouraged by staff development departments and their educators across the country. It is a Joint Commission requirement that the competency of all clinicians be validated at least once per year, but without needed equipment and budgeted salaries for qualified practitioners to validate competency, that mandate cannot be met.
Each day there are evidence-based changes and updated techniques surfacing as the result of clinical research and testing of best practices around the world. Communicating these changes and teaching new techniques to clinical staff in healthcare facilities is the responsibility of staff development professionals and clinical educators. Positive patient outcomes rely directly on the skills and knowledge of the clinicians caring for them.
During the past year, several sentinel events and near misses have been reported related to the administration of Heparin. As a result, safety measures have been created and implemented in healthcare facilities around the world, such as a double check system in which two clinicians independently calculate the dosage of Heparin and then compare the calculated dose, and a tighter control of the anticoagulant by the hospital pharmacy. The need for clinician education and post-education validation was mandatory. Without this education, future critical events and deaths are likely to occur.
The Joint Commission defines negligence as a “failure to use such care as a reasonably prudent and careful person would use under similar circumstances.” The cost of nursing negligence by far outweighs the savings that staff development budget crunching results in, let alone dangers to our patients from medical errors caused by incompetent clinicians.
In light of these concerns, too stringent cuts from the staff development department's budget during economic hardship should be a warning sign. Consideration must be given to future costly litigation fees as a result of substandard care and the difficulty of launching new quality improvement initiatives without educated staff development professionals to oversee them.
Deanna R. Miller, RN, MSN/HCE, is the manager of critical care and staff development at University Hospitals Geneva Medical Center in Geneva, OH.For information on how you can contribute to HealthLeaders Media online, please read ourEditorial Guidelines.
Getting staff nurses involved in nursing research is not easy. Along with the additional time and work required to complete a project, it's difficult to find mentors who have the extra hours to guide nurses through the process.
"After achieving [ANCC Magnet Recognition Program® (MRP)] designation, to move forward and maintain [status], we knew we needed to involve staff nurses in research, quality improvement, and patient safety projects," says Maureen Cavanagh, RN, C-EFM, MS, MAHCM, an advanced practice nurse (APN) at St. Peter's Health Care Services—a 2005 MRP recipient—in Albany, NY. "And the people who had the skills to really lead and mentor nurses for those projects were the APNs."
Cavanagh and colleague Patricia Newell-Helfant, RNC, MS, CPNP, also an APN, are helping St. Peter's meet the nursing research participation expectation under Component IV: New knowledge, innovations, and improvements by pairing APNs with staff nurses. In the past two years, the new relationships have resulted in six national research presentations by staff nurses—six more than the facility had seen in the previous 25 years.
Get APNs on board
Although St. Peter's, a 442-bed facility, has an APN for every clinical area, they weren't all on board to be research mentors. But with the help of organizational support, many APNs were able to take on the new time commitment.
"The role of the APN had been focused heavily on education and orientation, and we needed it to move toward research and quality improvement," Cavanagh says. "So with organizational support, [administration] discovered other ways to accomplish education and orientation activities to allow APNs, who had skills in research and quality improvement, more time to mentor nurses."
But APNs were not the only ones who felt that lack of time was an issue with research—staff nurses felt the same way. That's where the nurse manager came in.
"The nurse managers have really been the unsung heroes," says Cavanagh. "They have been excellent with trying to help staff nurses carve out time to conduct research projects."
Be a mentor
Cavanagh first used her leadership skills to help shape the hospital's research council. She achieved this by sharing each step of her research project on moral distress with the council, which consists of staff nurses and APNs. Throughout her project, Cavanagh shared how to:
Develop a timeline
Develop a demographic tool
Look at data
Analyze data
Display results
"Every time I got to a new phase of the project, I went back to the research council and basically did a show-and-tell of what was taking place," says Cavanagh. "This was to help people on the council who had a research idea use my template to begin their project."
Just as Cavanagh displayed during her research project, APNs are happy to help nurses at a moment's notice. "There are a few appointments, but most of the time it's 'Do you have a minute?' and you don't say no," says Newell-Helfant. "It's about being available to them all the time."
APNs still focus on education and orientation, but there is a greater concentration on being a research mentor with the expectations of:
Leading nurses in research projects
Mentoring nurses in the research process and use of evidence-based practice (EBP)
Collaborating with other disciplines to implement EBP
Helping nurses submit abstracts for poster or podium presentations at national conferences
Helping and encouraging nurses to publish research outcomes
Showcase research
In addition to mentoring staff nurses throughout their research projects, APNs focus on helping them create posters, write abstracts, and showcase their research outcomes.
APNs hold nurses accountable for their research projects by consistently checking in and asking:
Where are you with your project?
Are you falling off your timeline?
What can I do to help you?
"We use nurses' projects as a vehicle to get staff out of the organization to national conferences to present and exchange ideas and bring others' ideas back to the hospital to implement them," says Cavanagh.
But the APNs didn't always know how to create a poster or write an abstract. They taught themselves by searching the Web and using sites such as www.postersession.com. The site is user-friendly and features a variety of poster templates to choose from, says Cavanagh.
APNs work alongside staff nurses to create posters and write abstracts. In the past two years, six staff nurses have presented at national conferences—a huge jump after "not having a staff nurse attend a conference in 25 years," says Newell-Helfant.
Despite the struggling economy, St. Peter's pays for all travel expenses if a nurse gets a poster or an abstract accepted.
"This is a huge incentive for staff who have never been to a conference before," says Newell-Helfant. "I now come into work and I hear staff nurses talking about the abstracts they are writing. It's been a lot of growth for all of us."
The staff nurses' projects are showcased during the hospital's Nursing Day Inquiry.
During this event, local or national speakers come to the hospital to present on nursing research or EBP, and all nursing projects, whether completed or in motion, are showcased.
See success through outcomes
Cavanagh and Newell-Helfant are pleased with the results they've seen from pairing APNs with staff nurses.
"It's been good to be able to have some documented patient outcomes for us APNs," says Cavanagh. "Staff become excited about their outcomes, so that fuels an enthusiasm within the division for people to really embrace projects when they know that they can be successful. And I think it improves morale."
Shelley Cohen, RN, BS, CEN, president of Health Resources Unlimited and nationally-recognized triage trainer, discusses how to help emergency departments prepare for increased demand in services from patients with suspected H1N1 infection.
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It's not very often that one gets a chance to contribute to a nationwide public debate that just might result in changes to your profession. But that's what the Robert Wood Johnson Foundation, in collaboration with the Institute of Medicine, is calling for as part of a major study on the future of nursing. As well as securing the opinion of nursing experts from around the country, the study will also be examining testimony submitted from individuals and organizations in the field.
"In a reformed healthcare delivery system, what would be the future role of nursing?" asks Linda Burnes Bolton, Dr.PH, RN, FAAN, vice president for nursing, chief nursing officer, and director of nursing research at Cedars-Sinai Medical Center in Los Angeles. "That's our charge, so we're looking at acute care, community health, school health, public health, and what we need to reform the education system."
Burnes Bolton is the vice chair of the new Initiative on the Future of Nursing, which was launched earlier this year with a goal of producing a report in 2010 detailing how nursing should evolve so it can meet the demands of an ever-changing health system. The committee is spending the next few months examining evidence from around the country, debating and reviewing that evidence, and then coming up with a blueprint for change. They plan to make broad recommendations about the delivery of nursing services, changes to public and institutional policies, and even ways to solve the nursing shortage.
The committee is officially charged with examining the following areas:
Reconceptualizing the role of nurses
Expanding nursing faculty, increasing the capacity of nursing schools, and redesigning nursing education
Care delivery and health professional education
Attracting and retaining well-prepared nurses
As part of the committee's evidence collection, Burnes Bolton says they are actively seeking public testimony—including innovations/models and barriers/opportunities—from around the country. Some of the most interesting testimony will become part of the debate at three national forums on the future of nursing, the first of which was held yesterday at Cedars-Sinai Medical Center in Los Angeles.
Yesterday's program concerned the topics of quality and safety, technology, and interdisciplinary collaboration. Marilyn Chow, DNSc, RN, FAAN, vice president, patient care services, program office, at Kaiser Permanente, program director for the RWJF Executive Nurse Fellows Program, and presenter at the first forum, says she hopes the forums provide an opportunity to think about issues in a different way.
"The problem is that nurses are misused and underutilized" in the current system, says Chow. She adds that as information and knowledge grows at warp speed, the acute care environment will be shaped by the intersection of technology, business models, and human needs. As such, now is the time to design new models to meet the needs of the future.
One of the issues being considered is the economic approach to the value of nursing care. "How would you bill for nurses to spend time with patients?" asks Chow. "If we don't do anything, the alternative is to continue in the current model where all human aspects are really done in spare time."
Chow proposes four concepts that will drive change in nursing:
Leveraging the power of the electronic health record
Balancing technology, business models, and human needs
Using rapid translation teams
Using rapid design teams
The last two categories concern the need to create new models and ideas for healthcare delivery, and she says they need to include people outside of healthcare, such as engineers and ethnographers, who can provide alternative ways of thinking about how we do things.
"There is technology on the horizon that will change how we do things. There are business models that are changing the way we do things. But what is not changing is the focus on human needs," says Chow. "So we have to design that with an intelligent use of tech and business models."
The focus on human needs was a theme of yesterday's debate. In his opening remarks, Thomas Priselac, president and CEO of Cedars-Sinai and current chair of the American Hospital Association, noted that historically nurses have always been at the forefront of the healthcare system, and will remain at the forefront even as healthcare delivery changes.
"It still comes down to the personal touch of the person providing care," said Priselac at the forum. "For the most part that personal touch comes from a nurse; they are quite simply the face of healthcare today."
The next stage of public discussion takes place on December 3 in Philadelphia and examines primary care, long-term care, community health, and public health. The third forum is on February 22, 2010 in Houston and will look at nursing education.
To be a part of the discussion, you can submit testimony for the committee's consideration—and potential presentation at a future forum—at www.iom.edu/nursing or by e-mailing nursing@nas.edu.
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