[Evelyn will get back to us this evening with her changes.]

Transcription

1 Page 1 of 10 Introduction Hello, my name is Mary Burke, RN. I have more than 20 years of experience as a nurse; primarily in outpatient and clinic settings. I m now at the University of Iowa Hospitals and Clinics where I have worked in Nursing Informatics. I am pursuing my Masters in Medical Informatics from Northwestern University through distance learning. And I am the Chair of the HIT Committee of the Nurse Alliance of SEIU Healthcare. The Nurse Alliance represents 85,000 RNs in 23 states; among more than 1 million SEIU healthcare worker members, including physicians, interns and residents. I would like to start out by thanking the HIT Advisory Committee for allowing me this opportunity to testify about the use of HIT in ambulatory care settings to promote effective care coordination. I've had the privilege of connecting with many RNs and other healthcare users of HIT, including SEIU members, members of other unions and nonunion healthcare professionals. I want to especially thank AFT Healthcare nurses and AFSCME nurses for sharing their HIT insights and experience. I am here today to testify on behalf of all frontline caregivers and raise the issues healthcare workers see as most important to HIT implementation in ambulatory care settings. I d like to start with our principles and recommendations related to effective HIT in the Ambulatory Care Environment and Care Coordination; and the real life experiences of end users. Basic Challenges in Ambulatory Care

2 Page 2 of 10 Health care for our patients is fragmented. Many older adult patients are seen in at least four to five ambulatory settings annually, which might include a primary care medical office, cardiologist, podiatrist, rheumatologist, neurologist, endocrinologist, ophthalmologist, gynecologist, oncologist, and the list goes on. Care for many patients is not coordinated and information is not easily shared. It takes many phone calls and faxes just to get a small piece of information. The information is often outdated, which leads to inefficiency, redundancy, preventable errors, and delayed care. And it increases the cost of care and workload for providers. No matter how careful providers are about collecting all available patient information, they are often called upon to contact other offices in the middle of clinic hours while patients are waiting to be seen. Healthcare providers want the benefit that collaboration offers without spending the time it currently takes. While we are concerned about patient privacy and believe that patients deserve to be fully informed about their health, we are not doing a good job of either. We need to utilize health information technology in an effective way to create a more cohesive, effective health care system. Principles: HIT Offers Potential to Improve Quality We support ONCHIT s patient- centered approach, efforts on quality data reporting, and providing patients with timely access to their records. We believe that:

3 Page 3 of 10 HIT can be a powerful tool for patients and caregivers that promotes safety, security, quality, efficiency, communication coordination, empowerment and control. HIT offers immense potential benefits for care coordination, e.g. reduction in medication errors, improved quality of care, increased quality of medical record, and ease of getting information. Our healthcare reform goals absolutely require us to increase effective care coordination. HIT on its own, however, does not guarantee quality results, nor does it create care coordination. HIT impacts quality and coordination of care, documentation, medication administration, care planning, accessing patient records, and workload How Frontline Workers Can Help HIT Realize Its Potential Our experiences both positive and negative, provide evidence that HIT is successful (and the investment in HIT is cost effective) when frontline, practicing RNs and other healthcare workers are sitting, as equal partners, at decision- making tables with employers, determining: readiness, selection, design, planning training, implementation, evaluation, and expansion. [Evelyn will get back to us this evening with her changes.] Evelyn Cipriaso, RN, a Maryland VA nurse who serves on our Nurse Alliance Leadership Committee gave us very positive feedback on the involvement of frontline nurses in the HIT process at the VA from the beginning, resulting in well- developed systems and integration of in- patient and out- patient services.

4 Page 4 of 10 Sherri Moore, RN, our Michigan Nurse Alliance Director, reported on her positive experience as a Trinity Health Ambulatory Surgery staff nurse. She says the nurses participated in developing forms. Changes were made based on their input. In addition to training all staff, key frontline nurses were taken off duty, and taught the entire system as super- users their unit s experts. A training module was available on the desk- tops before the go- live so that staff could go in any time to practice. Once the system went live the clinic deliberately overstaffed. Super- users were pulled off the patient care schedule, and walked through the unit on every shift to help for 30 days. It s not been a perfect experience, but, as Trinity Health adds facilities on to the system, it continues to involve frontline end- users in ongoing changes, evaluating training, and now expanding into bar coding of meds. Joanne Spetz, Ph.D., University of California, San Francisco, School of Nursing & Center for the Health Professions, has done an extensive literature review on specific impacts of HIT on nurses; a national study of the VA HIT system; visited 7 sites; and analyzed hundreds of thousands of patient records, including a single- site implementation of HIT in a rural hospital. She found that, in a large organizational deployment, [the organization] needs [to be] very stable and fault tolerant. An institution has to have good leadership to articulate the nursing position. Implementation is a big culture change. "Training is a process, not a class." Sites that recognized there would be setbacks and intentionally pushed through them did better. Sites that were successful demonstrated a willingness to accept and deal with problems. And, trust of staff counted towards success.

5 Page 5 of 10 Recommendations To effectively advance care coordination in the ambulatory care environment, including clinics connected to hospitals and stand- alone ambulatory settings, we recommend that ONCHIT encourage HIT adopters to include these best practices or guidelines in a written plan. Involvement 1. Successful implementation must involve frontline practicing nurses and other healthcare workers, as equal partners, at decision- making tables, determining HIT readiness, selection, design, planning, training, implementation, evaluation, and expansion. Decision Making 2. Effective planning and implementation require that frontline end users are trained and educated so that they can serve in decision- making capacities with management, and make informed choices. This ensures the development of systems that are responsive to the needs of patients and their providers. All members of the healthcare team have much to contribute, including Advanced Practice Registered Nurses, Physician Assistants, Registered Nurses, Licensed Vocational Nurses, Medical Assistants, Billers, and Coders, etc. 3. Frontline end- users should be consulted on the types of hardware and software systems under consideration for acquisition. They should be included in simulations and testing of systems and devices under consideration for purchase or lease; at the point of RFP from vendors; to

6 Page 6 of 10 assist with defining the system requirements that the EHR vendors must meet, and on the appropriate placement and users of mobile, handheld, and stationary devices for inputting and viewing EHRs. End users should be included at all stages of the system life cycle on specifications, selection, development, training methodologies, deployment planning, and post deployment long- term support structures. Design 4. We cannot stress enough the importance of frontline worker involvement in the design of HIT. Technology is intrinsic to health care worker tasks and work flow. Systems must be designed to accentuate the skills, scope, and abilities of every member of the team. If built this way, everyone has a hand in escorting the patient through the health care maze and supporting them in the process through clinical practice collaboration and communication. When the whole clinical team is involved in development and design, workarounds are avoided, and the power of the system and Meaningful Use are realized. We have quite a number of comments from nurses on design issues. In one case, due to design issues, the HIT system go- live in Outpatient took place a year after the system was put into the hospital. One frontline user reported that the system is geared to patient billing not patient care. It's not frontline- user friendly." In another case, RNs are now spending an additional hour and a half every day just on the 2- stage log- in process, signing- in and signing- off, since our screen disappears when not in use for more than a few minutes." We heard from a number of frontline workers who had to go through a dozen or more different screens to record simple changes in a patient s condition.

7 Page 7 of 10 Preparation 5. Frontline workers should be included in the preparation for the roll- out plan, including a schedule of training; with additional staffing, and HIT support on all shifts during and after the go- live. Training 6. Effective frontline user involvement can be assured by building a training committee of frontline end users and managers to develop and monitor training; and its presentation, evaluation, expansion and improvement. Active oversight is important to ensure that frontline practicing nurses are a part of any decisions to make changes in approach or content as the training progresses. A training committee is a good place to engage frontline end users in educating IT professionals on work processes and workarounds. 7. The timing of training can have a significant impact on accessibility for the end- users. Make it on work time; available to all shifts; close enough to implementation of the technology that it will be useful and people won t have forgotten everything they have learned. Back- fill for nurses in training is essential so that they are not distracted by patient care concerns. Similarly, keeping training on regularly scheduled work days means that people with child care or other responsibilities outside of work have real access. And while those with little computer experience might be able to take a course on word processing, actually getting them comfortable with the computer requires pre- training and/or real access during training.

8 Page 8 of Frequent training should be offered across all shifts to relevant clinicians; as close as possible to the go- live date. Frontline practicing nurses should be involved in providing the training to end- users. 9. Training should place the technology in the context of all of the changes taking place today- - healthcare reform and quality improvement- - and it should warn about potential negatives from the technology, i.e. "side effects" to look for. 10. It is important from a quality patient care perspective to ensure that the training is effective and the trainers are qualified. In the new and rapidly changing world of HIT, new skills and knowledge are required to operate and to integrate it into the work process. While there is often training when new computer systems are introduced, the training is too often insufficient, not designed for the target audience, done at the wrong time and too narrowly defined. While a good training program can help ensure smoother implementation of new technologies and increased involvement of the workforce, a poor training program can, among other things, lead to stress, discipline, additional work, and barriers to quality patient care. We know that health information technology will continue to accelerate in our health care workplaces. This means that the significance of training will also increase. Training programs can be an important mechanism for maintaining advancement opportunity, promoting equity and keeping skilled jobs. HIPAA 11. All members of the care team should be retrained on the HIPAA privacy rules, their application to EHRs, and the key aspects of security of the new

9 Page 9 of 10 HIT system and protect patient s privacy. End- users should be trained to identify breaches in privacy and security. ONCHIT could provide or support the creation of a data base of privacy breaches, to ensure that frequent problems are identified and best practices are disseminated. Ambulatory Care nurses told us that managing secure access is incredibly difficult. "If we were involved at the beginning, we could have helped to make sure that only legitimate users had access to patients health information through different computers and portals... We could have helped to make sure that unauthorized access was prevented via wireless internet connections, etc." Technical Support 12. End- users should also be guaranteed access to clearly identified, adequate, prompt, 24/7 technical support for go- live and a significant period of time thereafter, and should be well- versed in backup systems and plans in the event that the electronic EHRs systems go down. Learning Environment 13. Protocols should be developed to assure a blame- free environment and to create an environment for learning, along the lines of the Federal Aviation Administration learning environment approach. The information gathered from electronic health records will be effectively used for quality improvement only if health care workers can report errors and near misses without fear of discipline or retaliation. Finally, as you can tell from this testimony, the Nurse Alliance views effective training as central to the success of HIT implementation. While it s clear that there are large needs for appropriations, we would still like to see ONCHIT work

10 Page 10 of 10 with HHS to ensure there is dedicated funding for training of frontline end- users available to all Meaningful Users. We greatly appreciate this opportunity to speak with you on behalf of what the workforce can do to help make HIT successful. This is a top priority of the Nurse Alliance. We would like to continue this conversation and we plan to submit comments on regulations for the Stages 2 and 3of Meaningful Use.