The need for nursing informatics in LTC
Patricia P. Sengstack DPN, RN-BC, CPHIMS
The last decade in healthcare has seen an increasing transition, from a focus in the acute care setting to a broader perspective encompassing ambulatory, home health, hospice and long-term care settings. As payment models increasingly reward quality outcomes, the need to address care across all settings has become an imperative.
The hospital profit base 10 years ago was 64% inpatient and 35% outpatient. “Today, that's flipped,” said Brian Silverstein, M.D., of research firm Sg21. The technology to support these post-acute settings has been evolving as well. It's now difficult to find any of these post-acute settings lacking some type of technology to assist in care delivery or improvement in quality and safety.
It is estimated that around 30% of the nation's long-term care facilities now have some type of an electronic record system, despite the fact that the Meaningful Use program under the HITECH act of 2009 excludes them from receiving incentive payments for adoption. The trend continues upward. The data now being collected in these systems has the potential to make our LTC facilities part of the “learning health system” which was not possible in the pen and paper days. Ensuring that our care teams in these facilities are able to optimize these systems and provide quality care is where nursing informatics will play a pivotal role for years to come.
Currently, the number of nurses who work in this specialty area is relatively low, but predicted to increase substantially over the next several years. Integrated delivery networks providing services that encompass care from the acute to long-term settings will need the expertise from nurses trained in the art and science of informatics. Nursing informatics has been recognized as a specialty with a unique body of knowledge since 1992 with board certification via the American Nursing Credentialing Center. Additionally, the American Nurses Association publishes the Nursing Informatics Scope and Standards of Practice, with a recent edition that came out in 2015. The standards contained in this document apply to all care settings and illustrate the breadth and depth of nursing informatics' impact on care delivery. With much of the care in the post-acute setting being delivered by nursing, it only makes sense that there is a strong presence of informatics support to ensure the effective use of technology.
Informatics expertise in all phases of the system development lifecycle is needed for the emerging modalities of technology in the long term care setting. Understanding how technology and clinical systems move through each of these phases, and being part of the team that shapes the work around each phase is central to success and a key informatics contribution. Even when a technology vendor states that their product is “plug and play”, all of these phases (Assess & Plan, Design & Build, Test & Train, Implement, Maintain & Optimize, and Evaluate) must be addressed.
Consider the electronic record in the long-term and post-acute care settings. Transitioning from a paper-based system to an electronic system has multiple advantages: Legibility, remote access to resident information, evidence-based and regulatory-based documentation templates, alerts indicating potentially unsafe practices, reminders for health maintenance screenings, to name a few. And don't underestimate the value of the data contained within the electronic record's database and its ability to drive practice improvements. Analytics derived from the data can be used for performance improvement initiatives in three ways:
- Looking at historical data to evaluate how well an intervention has impacted an area of care delivery
- Providing data in real time to care providers so action can be taken at the patient's bedside
- Predictive modeling to assess the patient's future health needs so action can be taken proactively.
Success in each of these beneficial areas listed does not happen by chance. It requires informatics expertise and focused attention to the people, processes and technology that drive clinical transformation.
Another emerging technology trend in LTC that will require informatics expertise is the use of telehealth. Organizations are beginning to experiment with physician – resident “visits” via technologies that resemble Skype allowing real time “face-to-face” interactions between providers and residents even though they are geographically distant. These visits frequently use videoconferencing technologies and can use special instruments such as a video otoscope (to examine the ear) or an electronic stethoscope operated by a nurse or technician at the consulting provider's direction to remotely perform a physical examination2.
These visits can potentially reduce the need for readmission or emergency room visits. Organizations using these types of technology can market their effectiveness to potential residents, patients and providers. And while payment issues are still being addressed, the landscape is changing as the federal government has begun to see the value and provide reimbursements, specifically in remote settings. This trend is predicted to continue as the value and effectiveness is realized.
To implement and manage telehealth systems, again, informatics expertise will be required, from assessment and planning all the way to evaluation. Beginning with system selection from the many emerging vendors to conducting a strong outcomes assessment, the informatics specialist will be integral to the success of the program.
In the book Mastering Informatics: A Healthcare Handbook for Success, Arellano and Gagnon write a chapter on informatics in the non-acute setting. They focus not only on the importance of a strong informatics presence in the long term and post-acute settings but provide information specific to this unique environment to guide informatics specialists through this evolving journey. It's one that we've needed to take for some time and promises to improve care to populations where a real difference can be made.
Patricia P. Sengstack, DPN, RN-BC, CPHIMS, is the chief nursing informatics officer for the Bon Secours Health System. She serves on the curriculum advisory board for the University of Maryland's Nursing Informatics program and is an informatics lecturer at Vanderbilt University's School of Nursing at both the master's and doctoral levels. She is the president of the American Nursing Informatics Association and has served on its board of directors since 2012. She is one of the authors of Mastering Informatics: A Healthcare Handbook for Success.
Smith, C. & Ricci, C. (2015). Healthcare Trends 2015: Healthcare Leadership White Paper. Available from: https://www.besmith.com/sites/default/files/B.%20E.%20Smith%20White%20Paper%20-%20Healthcare%20Trends%202015.pdf
A LeadingAge CAST (2014). Telehealth and remote patient monitoring for long term and post-actue care: a primer and provider selection guide 2014. Available from: http://www.leadingage.org/uploadedFiles/Content/Centers/CAST/Resources/2014_CAST_Telehealth_and_RPM_for_Long-Term_and_Post-Acute_Care_Whitepaper.pdf
Arellano, M. & Gagnon, R. (2015). Informatics in Non-Acute Settings. In Sengstack, P. & Boicey, C. Mastering Informatics: A Healthcare Handbook for Success. Sigma Theta Tau International. Indianapolis, IN.