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Methods of Information in Medicine

An International Recommendation Framework of Core Competencies in Health Informatics for Nurses

Ursula Hübner, 1, Correspondence address Toria Shaw, ² Johannes Thye, ¹ Nicole Egbert, ¹ Heimar de Fatima Marin, ³ Polun Chang, ⁴ Siobhán O'Connor, ⁵ Karen Day, ⁶ Michelle Honey, ⁷ Rachelle Blake, ⁸ Evelyn Hovenga, ⁹ Diane Skiba, ¹⁰ and Marion J. Ball ¹¹

Summary

Background: While health informatics recommendations on competencies and education serve as highly desirable corridors for designing curricula and courses, they cannot show how the content should be situated in a specific and local context. Therefore, global and local perspectives need to be reconciled in a common framework.

Objectives: The primary aim of this study is therefore to empirically define and validate a framework of globally accepted core competency areas in health informatics and to enrich this framework with exemplar information derived from local educational settings.

Methods: To this end, (i) a survey was deployed and yielded insights from 43 nursing experts from 21 countries worldwide to measure the relevance of the core competency areas, (ii) a workshop at the International Nursing Informatics Conference (NI2016) held in June 2016 to provide information about the validation and clustering of these areas and (iii) exemplar case studies were compiled to match these findings with the practice. The survey was designed based on a comprehensive compilation of competencies from the international literature in medical and health informatics.

Results: The resulting recommendation framework consists of 24 core competency areas in health informatics defined for five major nursing roles. These areas were clustered in the domains "data, information, knowledge", "information exchange and information sharing", "ethical and legal issues", "systems life cycle management", "management" and "biostatistics and medical technology", all of which showed high reliability values. The core competency areas were ranked by relevance and validated by a different group of experts. Exemplar case studies from Brazil, Germany, New Zealand, Taiwan/China, United Kingdom (Scotland) and the United States of America expanded on the competencies described in the core competency areas.

Conclusions: This international recommendation framework for competencies in health informatics directed at nurses provides a grid of knowledge for teachers and learner alike that is instantiated with knowledge about informatics competencies, professional roles, priorities and practical, local experience. It also provides a methodology for developing frameworks for other professions/disciplines. Finally, this framework lays the foundation of cross-country learning in health informatics education for nurses and other health professionals.

Keywords: Health informatics competencies, nursing, inter-professional care, education, curriculum, workforce development, recommendations, methodology

1. Introduction

1.1 Health Informatics versus Nursing Informatics?

Identifying informatics competencies in nursing has had a long history and pertinent activities have increased over the last 15 years, with peaks between 2006 and 2009, staying at a high level afterwards [ 1 ]. This continued interest in education correlates with the advancement of information technologies, their implementation to support healthcare processes and the potential to make a difference in patient outcomes, and the health IT knowledge and skills gap in nursing [2 ]. Over the years, the focus on competency recommendations has shifted to reflect changing technical and other priorities in healthcare. For example, in 2001, educators distinguished between computer and informatics skills [3 ] and focused on technologies such as relational databases [4 ]. Although these recommendations have not become obsolete, the two examples highlight the need for continuously monitoring and updating informatics competencies in order to keep pace with on-going technical developments and their use.

As observed in other clinical informatics sub-specialties, informatics competencies in nursing belong to a cohesive field of its own known as "nursing informatics". However, the notion has grown that there has to be a common foundation with input from a variety of healthcare professions [ 5 ]. In this sense, the term "health informatics" comprises informatics for different disciplines and professions and recognizes inter-professionalism as an intrinsic feature of informatics [6 ]. This view matches activities to reshape healthcare from a silo dominated field to a process and patient oriented service, which requires health information technology (IT) to support inter-professional care across the continuum, based on proper process management and inclusive of quality management [7 , 8 ].

Informatics , which focuses on data, information, knowledge, the applications and the users themselves, is to be distinguished from Information Systems which focuses on the organizational use of health IT and from Information Technology , which primarily addresses systems development and system life cycle management issues [9 ]. Due to its focus on data, information and knowledge, health informatics needs to balance requirements that are specific to professions or roles and those that are generic and applicable across the spectrum of healthcare professionals. "What health informatics competencies are relevant for a special group of health professionals (e.g. nurses) and for different professional roles?" is thus a valid question and needs to be answered for each group separately.

1.2 The Benefit of International Recommendations in Education

As health IT industry is increasingly working in a global arena, international recommendations in medical and health informatics education [ 10 , 11 ] have become more desirable. Other trends also speak in favor of a global perspective. While traditional education is always situated in a local context, new modes of teaching and learning for example, such as Massive Open Online Courses (MOOCs) [12 ], are emerging that fulfill a niche for hundreds of thousands of learners from diverging backgrounds, different settings and countries. Recommendations taking a global perspective therefore match the idea of MOOCs. Research and education form a strong alliance at all levels of the translational process to improve health practice. Research, which is defined by internationally valid standards, strongly depends on the collection, analysis and publication of electronic data, also from nursing [13 ] and from sites in different countries [14 ]. Thus, informatics competencies play an essential role in the education of health and nursing researchers in order to work successfully in an international environment.

Furthermore, international recommendations can foster harmonization of education and may increase workforce mobility across countries [ 15 ]. In this light, the European Union (EU) and the United States of America (USA), signed a Memorandum of Understanding (MoU) focused on health IT in 2010. The MoU agreed to further develop the workforce's health IT skills to fully utilize the potential of new and emerging technologies. This work took place from 2013-2015 under the direction of the EU-US Workforce Development Workgroup (WDW), which compiled the results of an analysis that mapped competencies in the form of the HITCOMP (Health IT COMPetencies) Tool and Repository [15 , 16 ].

1.3 Learning and Teaching: the Competency Based Approach

Competency based approaches have increasingly gained attention in the context of medical and nursing education over the last decades [ 17 , 18 , 19 ] to overcome the shortcomings of the pure topic related approach. In psychology, competencies are understood as "[...] a roughly specialized system of abilities, proficiencies, or skills that are necessary to reach a specific goal." [20 ]. Competencies as such embrace a set of behaviors and intent and cover cognitive, social and emotional aspects of performance [21 ]. Due to the close relationship between "demands, tasks, problems, and goals" [20 ] and respective competencies, competency based learning is always associated with a specific role, scenario or task domain. For example, there are specific competencies for the nurse leader role [22 ] or for inter-professional cooperation [23 ]. In this context, we will refer primarily to cognitive competencies, which encompass the acquisition and understanding of new knowledge through iterative mental processes of sensing, experiencing, thinking and reasoning/interpreting [21 ]. We will focus particularly on those cognitive competencies that contribute to the successful accomplishment of nursing roles within an organization. In accordance with management theory [24 ], which refers to entire organizations, we call them "core competencies" of the professional role.

There are various frameworks that breakdown and describe competencies. According to some frameworks, competencies consist of both knowledge and skills [e.g. 25, 26]. These frameworks either refer to different (academic) levels [ 10 , 27 ] or at a specific level, e.g. graduate programs [25 , 28 ]. Competencies can be graded along Bloom's modified six cognitive process dimension terms (i.e. remember, understand, apply, analyze, evaluate and created) referring to "factual knowledge", "conceptual knowledge", "procedural knowledge" and "metacognitive knowledge" [29 ] or as "prerequisite knowledge and skills", "fundamental knowledge" and "procedural knowledge and skills" [25 ].

Although health informatics knowledge is global and requires international recommendations, education is typically local and the competencies addressed in the study programs and courses have to be embedded into the environment where they will be used. These two controversial requirements have to be reconciled in order to assist teachers and learners effectively in their efforts. The primary aim of this study is to empirically define and validate a framework of globally accepted core competencies in informatics and to enrich this framework with exemplar information derived from local educational settings. The methodology for developing a framework of this type should be applicable for any kind of target group. Within this study, the framework was developed for nurses with a focus on the professional roles they typically hold. The study was performed within the TIGER ( Technology Informatics Guiding Education Reform ) Initiative that includes an international network of nursing experts and reaches out to the entire community of healthcare professionals.

2. Methods

2.1 The TIGER Approach

In response to the initial formation of the Office of the National Coordinator for Health Information Technology (ONC) in the United States of America in 2004, the TIGER Initiative was officially launched in 2006 when key nursing stakeholders convened to ensure nursing was included in the mandate for health informatics education and application.

TIGER is dedicated to enabling clinicians, particularly nurses, to better exploit the use of informatics tools, their principles and underlying theories to improve patient care [ 30 ]. In 2012, the TIGER International Committee was established to widen the reach of TIGER activities in the international scientific community. When TIGER transitioned from a standalone initiative to the Healthcare Information and Management Systems Society (HIMSS) in 2014, the scope was extended to include other clinical disciplines and to enter into an inter-professional space even beyond clinicians. Today, TIGER seeks to empower educators as change agents and learners to prepare the inter-professional, inter-disciplinary clinical workforce for the digital age [31 ]. Based on these goals, TIGER initiated the international informatics competency synthesis project, which seeks defining and validating a recommendation framework.

2.2 Overview of Methodological Steps

In order to achieve this aim, a mixed method approach was pursued that combined quantitative and qualitative methods and iteratively validated the core competency areas while enriching the framework.

Figure 1 provides an overview of the three steps used to launch and finalize this project inclusive of the methods applied and the perspective from which the information was captured.

2.3 Survey

In order to identify globally relevant core competency areas to be represented in the framework, a survey was conducted. This survey made use of an existing online questionnaire [ 32 ] that had been designed drawing upon international literature, that had been further refined in two workshops and tested in three countries [32 ]. The questionnaire was comprised of 24 core competencies areas in health informatics, which had been extracted from the international literature [10 , 11 , 18 , 25 , 33 , 34 , 35 ] and embraced 10 technological items (e.g. eHealth, telematics and telehealth), two legal and ethical items (e.g. data protection, ethics and IT), 11 IT related management items (e.g. project management, change management) and finally, biostatistics/statistics. Five professional roles of nurses were targeted in accordance with the methodology established prior to this study [32 ]: 1) clinical nursing (e.g. care planning), 2) quality management (e.g. organizational development), 3) coordination of inter-professional care (e.g. case management), 4) nursing management (e.g. ward or hospital management) and 5) IT management in nursing (e.g. introduction of new IT systems). A role-based approach was chosen because role specific training for different groups of health professionals had been identified as a highly desirable action in order to increase the health IT skills of the healthcare workforce [36 ]. The meaning of these roles was explained by examples (see ►Online Appendix A). Survey participants were asked to rate the relevance of the 24 core competency areas within the five roles on a scale from 0 to 100. In order to help survey participants to get a more detailed understanding of what these core competency areas meant, examples subsumed under these core competency listings were given (►Online Appendix A). We did not distinguish between the different cognitive process dimensions "factual knowledge", "conceptual knowledge", "procedural knowledge" and "metacognitive knowledge" or any other gradating categories because this specification would have required assumptions on the (academic) level of the learning and teaching activities. It is important to note that these level differences were out of the scope of this survey. The core competency areas were presented in alphabetical order.

A personalized link to the questionnaire was sent to 72 people from 24 countries in the Americas (6 countries), Europe (10 countries), Asia (6 countries), and Australia/Pacific (2 countries). Participants were either a member of or associated with the International TIGER Committee. As TIGER comprises primarily experts with an interest in education, the majority (46%) came from universities, 26% came from health IT industry, 14% from hospitals (including university hospitals), 13% from professional associations and 1% did not give any information about their affiliation. All survey participants are regarded as high profile experts in their countries. The survey was open from November 23, 2015 to January 18, 2016. Out of the 72 experts invited, we yielded 43 responders (response rate approximately 60%). They came from 21 countries: Americas (4 countries), Europe (10 countries), Asia (5 countries) and Australia/Pacific (2 countries) and had the following affiliation: 37% from universities, 21% from health IT industry, 35% from hospitals (including university hospitals) and 7% from professional associations.

2.4 Workshop

In order to validate the survey findings within a global expert community, a workshop was held at the 13 th International Congress on Nursing Informatics (NI2016) in Geneva on June 28, 2016 [37 ]. The aim was to find out if core competency areas were missing and how to cluster them. Twenty-eight experts from 13 countries on four continents attended the workshop (six of the experts had participated in the survey). Workshop attendees reported the following types of affiliation: 39% universities, 25% hospitals (including university hospitals), 18% health IT industry, 11% professional associations and 7% gave no information. Following an introduction to the aims and visions of the TIGER Initiative, the results of the international survey on core informatics competency areas were presented and made available to the audience as a handout. The workshop then focused on discussing informatics competency issues with workshop attendees. The discussion was stimulated with the following questions: (1) "What are the top 5 informatics competencies for nurses according to your experience?" and (2) "What is your opinion about the core competency areas just presented?". The discussion was recorded and all contributions were summarized utilizing the inductive categorization method. This work included five persons from the team of authors (UH, TS, MB, HM, PC) who additionally clustered the individual competencies making use of the greater domains also mentioned by the experts at the workshop. These domains were mapped to the 24 core competency areas by the same team members plus one other author (OS). Cronbach's alpha was computed to test the internal consistency of these domains across the five nursing roles. An alpha value of 0.70 and above was interpreted as "satisfactory" in accordance with the literature [38 ].

2.5 Case Studies

Local exemplar case studies, which were compiled for this study, should illustrate the use of the core competency areas selected to represent leading institutions of education in the field of nursing and health informatics. One case study per country was chosen covering Brazil (BR), Germany (GER), New Zealand (NZ), Taiwan/China (TW-CHN), the United Kingdom (UK) and the United States of America (USA). These countries were selected to mirror a variety of different (professional) cultures. While conducting this study, no case study from an African country was available to be included into this project. These case studies should provide background information on educational institutions, varying types of students, the academic level, teaching strategy and the educational format. They also should describe if and in which way informatics core competency areas were addressed by these courses and programs. Thus, they were meant to serve as exemplars of teaching and learning individual competencies included in the core competency areas and potentially beyond.

2.6 Ethical Considerations

The methodology of this study was presented to the Ethical Committee for Research at Hochschule Osnabrück Germany, which decided that there was not need to submit a full proposal to the Committee.

3. Results

3.1 Overview

The three-step methodology resulted in a recommendation framework that consists of globally accepted core competency areas:

1. sorted by relevance within five different professional roles in nursing based on the empirical findings of the survey,

2. clustered by coherent overarching domains identified in the workshop and verified by a reliability analysis and

3. illustrated and validated by educational programs and courses in various countries by case studies.

The framework provides recommendations for high priority core competency areas to be addressed when developing curricula for the five professional roles in nursing. It also gives advice regarding the cohesion of core competency areas. Finally, it allows insight into how these areas are broken down into individual competencies in different local settings and for different purposes. This approach resulted in very concrete recommendations but also demonstrates the feasibility of the methodological approach. Each study step is described in-depth in the following sections.

3.2 Global Relevance of Core Competency Areas for Professional Roles in Nursing

► Table 1 shows the priority list and outlines the core competencies areas per professional role. Each role was characterized by one to three lead core competency areas with (nearly) the same mean percentage of relevance (in italics ► Table 1 ) and by a specific profile of core competency areas. In this sense, the leading core competency area for clinical nursing and nursing management was nursing documentation . For the quality management role, it was quality management and for coordination of inter-professional care, it was data protection and security and information management and knowledge management in patient care . For IT management in nursing, there were three (nearly) equally important core competency areas: information systems and communication systems , principles of nursing informatics and data protection and security . There was a mixture of genuine IT competency areas (e.g. information systems and communication systems), IT related management areas (e.g. strategic management and leadership), and legal and ethical issues. Competencies in the areas of nursing documentation and information management and knowledge management in patient care could be found among the top 10 in all five roles. The same held true for competencies in the area of principles of nursing informatics . Data protection and security , process management as well as quality management were rated as highly relevant in four out of the five roles among the top 10 areas of competencies.

Table 1

Clinical Nursing (Direct Patient Care)

Core competency area

REL ± SD, n = 41

Quality Management

Coordination of Inter-professional Care

Nursing Management

IT Management in Nursing

Other core competency areas were rather distinctive, such as strategic management and leadership , which appeared among the top 10 only in nursing management, and assistive technology for ageing people , which belonged to the top 10 only in clinical nursing.

Besides these more role specific considerations, the survey results also revealed the importance and relevance of many health informatics core competency areas. Mean relevance values of core competency areas ranking at position 10 still ranged between 69.0 and 83.4 across all roles ( Table 1 ).

►Online Appendix B provides an overview of the ratings for all 24 core competency areas within the five roles.

3.3 Validation and Clustering of the Core Competency Areas

When asked about the highest priority of core competencies, workshop attendees mentioned a variety of different items and competencies including greater core competency areas. These different statements were analyzed with the aim of identifying similarities and differences with regard to the 24 core competency areas (validation) and with the aim of clustering these areas. Based on the consensus of five experts from the team of authors, four domains emerged from these statements. ► Table 2 (left column) shows the domains, the corresponding items and competencies resulting from summarizing the workshop findings and finally the associated core competency areas from the survey (right column). All statements could be matched with core competency areas.

Table 2

Domains of competency areas

Associated core competency areas (main similarities)

Data, information and knowledge (DIK) domain

1) know how to use data/information not only how to enter data

2) perform care planning and use of data

3) make use of indicators (information) for decision making

4) analyze what data are needed and are useful, link to data/information science

7) information governance

Information exchange and information sharing (IEIS) domain

1) continuity of care

2) sharing of information with the patient, work in partnership, learn to listen

4) health information exchange

Ethics and legal issues (EL) domain

1) ethics

Systems life cycle management (SLCM) domain

1) address requirements

3) design thinking

The four domains derived from the expert statements were used as an initial structure to cluster the 24 core competency areas. As there were some areas that could not be assigned to one of the four domains, two more clusters were introduced by the five experts from the team of authors, which then resulted in six final domains. Two core competency areas were assigned to two domains, i.e. assistive technology for ageing people and information and communication systems. Table 3 shows the clustering and the internal consistency values of these domains computed by Cronbach's alpha.

Table 3

Domains

Clinical nursing (n = 41)

Quality management (n = 41)

Coordination of inter-professional care (n = 41)

Nursing management (n = 43)

IT management in nursing (n = 41)

Principles of nursing informatics

Information and knowledge management in patient care

Nursing documentation (including terminologies)

Information management in research

Information management in teaching, training and education

Resource planning and logistics

Information and communication systems

Applied computer science/informatics

Strategic management and leadership

Change management and stakeholder management

Human resource management

All Cronbach's alpha values were 0.70 or larger ("satisfactory") [ 37 ] with the only exception of ethics and legal issues (EL) for nursing management, which reached a value of 0.67. In summary, the expert statements from the workshop attendees could be mapped to the 24 core competency areas of the survey (► Table 2 ) and provided a consistent structure for clustering the core competency areas (► Table 3 ).

3.4 Illustration of Core Competency Areas by Cases Studies and the Final Recommendation Framework

The selected exemplar case studies covered educational activities for nurses in six countries, including two case studies describing courses at the undergraduate level (BR, UK-SCO), two at the postgraduate level (NZ, USA) and two at the certificate level in continuing education (GER, TW-CHN). There were exemplar case studies that embraced single courses (BR, GER, NZ, TW-CHN, USA) and one that described a sequence of learning units embedded in a nursing program (UK-SCO). Similarly, four of the case studies focused on nurses (BR, GER, TW-CHN, UK-SCO), one primarily on nurses but also on informatics students (USA) and the other was entirely inter-professional (NZ). In all six cases, the courses were or are designed drawing on national recommendations [e.g. 32, 39, 40, 41] or developments (BR, GER, NZ, TW-CHN, UK-SCO, USA. The case studies are described in full length in ►Online Appendix C. Competencies tied to the core competency area in each exemplar case study are represented as building blocks. These building blocks contain competency descriptions in each area (► Figure 2 ).

Table 4 constitutes the recommendation framework consisting of the core competency areas, their mean relevance values, the associated domains and the case study building blocks referring to the core competency areas. It hereby shows the distribution of competency building blocks from individual exemplar case studies. It mirrors the breadth and depth of the courses described and the competencies associated.

Table 4

Roles

Clinical nursing (direct patient care)

Quality management

Coordination of inter-professional care

Nursing management

IT management in nursing

Core competency area

Domains

REL n = 41

Covered by case studies from

REL n = 41

Covered by case studies from

REL n = 41

Covered by case studies from

REL n = 43

Covered by case studies from

REL n = 41

Covered by case studies from

Information and knowledge management in patient care

DIK

82.2

83.2

85.4

84.0

86.1

Decision support by IT

DIK

70.2

72.7

70.0

74.7

85.4

Information management in research

DIK

51.0

72.4

60.5

63.3

71.5

Information management in teaching, training and education

DIK

61.7

67.1

66.1

70.0

74.4

Resource planning and logistics

DIK

56.6

65.4

71.7

76.0

71.7

eHealth. telematics and telehealth

IEIS

69.5

69.8

77.6

66.3

80.0

The case studies from Brazil and UK-Scotland were similar with regard to addressing undergraduate students in their role as clinical nurses, i.e. direct patient care. As these were beginner courses, they focused primarily on the informatics essentials of healthcare professionals. They differed with regard to the number of teaching hours. The Brazilian course, which was a single course, included 30 hours, whereas the Scottish course covers a set of learning units that is integrated into pre-registration nurse training. These competencies matched with the ones for clinical nursing in the top 10 priority list ( Table 1 ) closely.

The US course addressed core competency areas for graduate nurses working in different roles. As a self-paced online course, no specific information on its duration was given. It emphasized competencies associated with the selection, use and evaluation of different types of systems and the exploitation of data, information and knowledge for patient care and research. The New Zealand course covered a large range of informatics competencies for various roles, which corresponded with its design as an inter-professional series of four or eight courses towards a certificate or diploma in health informatics respectively (with 150 teaching and learning hours per course). The German continuing education course was highly specialized in nursing management and analytics while being restricted in its duration (30 hours). It embraced all core competency areas of the top 10 priority list (► Table 1 ) for the role of nursing management and included statistics. It also assumed that certain competencies were already available. The Taiwan-China course was an example how developments in one country (Taiwan) were transferred to another country (China). It spanned a large range of core competency areas that were manifested in a 7-day hands-on workshop focused on learning advanced spreadsheet management and programming.

These exemplar case studies also revealed areas only partly covered by the 24 core competency areas. The case study from the USA emphasized competencies that aim to enable health professionals to teach patient/citizen digital health literacy. This approach is closely associated with consumer health informatics. Furthermore, the Scottish case study considered health service literacy, which encompasses knowledge about the national healthcare system, its professionals, roles and processes, as informatics is embedded within this wider context which is critical to understand.

4. Discussion

4.1 Recommendation Framework

We propose a framework consisting of 24 core competency areas in health informatics and five major roles of nurses. The core competency areas were ranked by international experts in a survey, validated by a different group of experts in an international workshop and clustered into six domains. Four domains are equivalent to the domains derived from the workshop expert discussion, i.e. data, information, knowledge; ethical and legal issues; information exchange and information sharing and system life cycle management. The fifth domain summarizes the core competency area that focuses on management activities in the context of informatics. Finally, the sixth domain subsumes biomedical imaging, assistive technology for ageing people and signal processing and biostatistics/statistics . Nearly all domains have at least "satisfactory" or better values for internal consistency across all roles and can be therefore regarded as reliable. The constituents of these domains, the core competency areas, had been extracted from a comprehensive analysis of the international literature and had been validated in two workshops [32 ] prior to this study. In this study, the core competency areas were again validated in a workshop and also via the cases studies. From this multi-layered process, it can be concluded that these areas are valid.

The cells of the matrix framework contain the relevance ratings of international experts. From a global perspective, we recommend areas of core competencies with high relevance ratings in their respective role ( Table 1 ), the globally accepted core competency areas in health informatics for nurses. The interpretation of what is a "high" or a "low" relevance is not given by this framework intentionally to leave the meaning of these values open to the user. The resulting globally accepted areas are meant to function as a compass to show the direction towards areas of high relevance and/or towards domains of high internal consistency. They should help learners and teachers find their route through the large realm of information technology and its application in healthcare. These recommendations are complementary to the TIGER recommendations [35 ] focused on basic IT skills.

From a specific perspective, we recommend learning from the examples provided within the different exemplar case studies. They are detailed enough with regard to (academic) levels, cognitive process dimensions and competencies at the layer of cognitive activities [ 29 ]. They are also situated in a specific context defined by the national healthcare system, the educational system of nurses and other clinicians, status of health IT adoption and culture. The case studies, which refer to the core competency areas, demonstrate how these competencies are combined to form an entire curriculum or program. We recommend that readers construct their personalized set of objectives for learning and teaching from the core competency areas and case studies. The framework is instantiated by the case studies, which indicate the core competencies that are primarily addressed.

The exemplar case studies illustrate the need for diversity in learning and teaching. This may lead to the inclusion of some competencies outside the globally accepted informatics core competency areas, e.g. statistics in the German case study. Due to the fact that the globally accepted areas consist of many core competencies, which cannot be considered in one single course, a selection has to be made that reflects local or cultural differences. Also, the teaching and learning styles may differ. The Taiwan-Chinese course allows the nurses to dive deeply into technology; the USA course incorporates a clinical case, which acts as a red thread to exemplify the use of informatics; the Scottish program accompanies the baccalaureate nursing program in the sense of a spiral learning approach; the New Zealand course pursues a fully fledged inter-professional approach; and finally, the Brazilian course is strongly tied to the establishment of nursing education as such.

The mixed methods approach combined a survey with case studies to warrant the integration of different perspectives to build the recommendation framework.

4.2 Limitations and Strengths

We did not include the roles of nursing teachers and scientists because both roles are very much dominated by the roles they refer to when teaching nurses and clinicians and when conducting research. Thus, a nursing teacher working with students in quality management should dispose of similar competencies as quality managers themselves. Likewise, nursing scientists conducting research in clinical nursing should be familiar with competencies of nurses working at the point of care. Furthermore, information management in research is a core competency area of its own that directly addresses the needs of researchers. The role-based approach as such was neither questioned in the survey nor at the workshop. Clinical nursing [ 14 , 42 , 43 ], quality management [44 ], care coordination [45 ], nursing management, i.e. leadership [46 ] and IT management in nursing as informatics nurse specialist [47 ] or as chief nursing information officer [48 ] are roles with a high informatics affinity that are well accepted by the current literature and are generic enough to cover inpatient and outpatient settings. There are certainly more roles nurses can take on, which are not explicitly considered in this framework, for which the framework, however, could offer a rough orientation.

Although we regard communication as a highly desirable competence, particularly in the context of change management and inter-professional care, we argue that communication aligns better with social and horizontal competencies and is therefore out of the scope of the framework at this stage. Moreover, it also appears as a sub-competence in many core competency areas, particularly those that focus on innovation and change.

Our findings are corroborated by other studies. Competencies of nurse leaders [ 21 ] match - despite a different clustering - to a large extent with the core competency areas for nursing managers within our study. The same applies to other global compilations of competencies in nursing informatics [49 ] and clinical informatics [50 ].

This study does not provide a picture of competencies that distinguish health informatics in nursing from health informatics for other healthcare professionals because this study did not compile information about these other healthcare professions. Due to the role based approach it could be hypothesized that roles better define the need for a certain competency pattern than professions, e.g. the role "coordination of inter-professional care". However, a profession is constituted by its body of knowledge and methods thus the details within the domain "data, information and knowledge" should vary to some extent for different professions despite a potential similarity at the formal level.

It is very likely that new competency areas will emerge as the framework is constantly instantiated with more exemplar case studies (inclusive of African countries) and is used in real life. When the framework needs updating, formalized methodologies for the following tasks can assist with this process: a) identifying and updating core competency areas, b) measuring their relevance throughout the international community and c) adding international exemplar case studies that illustrate these core competency areas and provide insight into the competencies and local curricula.

4.3 Outlook

The procedure of conducting a survey, obtaining feedback in a workshop and including exemplar case studies provided knowledge about the validity of core competency areas and about new competencies to be included. In particular, we propose adding consumer health informatics as a core competency area due to the high importance of patient-centered healthcare and the requirement that healthcare professionals share data, information and knowledge with patients and citizens [51 ]. This addition would bundle competencies that are already included in the framework such as referred to by "telehealth" and "assistive technologies for ageing people" and would highlight this area. As not all core competency areas are yet covered by case studies, there is a need to integrate additional ones in the future.

5. Conclusions

This international recommendation framework for core competency areas in health informatics for nurses aims at providing a grid to embrace knowledge about competencies, professional roles, priorities and practical experience. The framework refers to the term health informatics in nursing to demonstrate its rooting in nursing informatics [45 , 52 ] and its openness towards other healthcare professionals and their interaction with nurses. We contend that learning and teaching on the individual level are active processes of constructing the educational space. Therefore, our recommendations should work as a framework that guides and stimulates learners and teachers alike. It should leave enough room for individual creativity, aspiration for innovation and personal fulfillment. Due to technology being a moving target, this recommendation framework should be revised and updated regularly. We propose a five-year period of validity.

Acknowledgment

We wish to thank all international experts who contributed to the survey and the workshop. We also thank Beth Elias, PhD, Term Associate Professor at Virginia Commonwealth University, Richmond, VA, USA, for her assistance in preparing this manuscript.

A preliminary version of this paper was presented at the multi-conference HEC2016 in August 2016 in Munich/Germany.

Funding Statement

Funding : This work was supported by the European Commission within Horizon 2020 grant number (Grant Agreement 727552 EUUSEHEALTHWORK), HIMSS North America, the HIMSS Foundation and the Federal Ministry of Education and Research (bmbf) Germany grant number (16OH21026).

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Articles from Methods of Information in Medicine are provided here courtesy of Thieme Medical Publishers

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Technology Informatics Guiding Education Reform - TIGER : An International Recommendation Framework of Core Competencies in Health Informatics for Nurses

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Background: While health informatics recommendations on competencies and education serve as highly desirable corridors for designing curricula and courses, they cannot show how the content should be situated in a specific and local context. Therefore, ...

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Interoperability of Electronic Health Records– Benefits and Opportunities

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The fact that technology is rapidly transforming health care should come as no surprise to anyone. From robotic arms that perform surgery to nanorobots that deliver drugs through the bloodstream , the days of being tended to by the human country doctor seem to have fully given way to machines and software more in keeping with the tools of Dr. McCoy from "Star Trek."

However, technology's evolutionary impact on health care isn't all shooting stars and bells and whistles. Some of health care's most important changes can slip beneath the radar due to their more pedestrian presentation, but that doesn't mean they aren't just as revolutionary as mini robots zipping through veins. Take the burgeoning field of health informatics , for example. A specialization that combines communications, information technology, and health care to improve patient care, it's at the forefront of the current technological shift in medicine. Here are six ways it's already transforming health care.

Health care isn't just expensive; it's wasteful. It's estimated that half of all medical expenditures are squandered on account of repeat procedures, the expenses associated with more traditional methods of sharing information, delays in care, errors in care or delivery, and the like. With an electronic and connected system in place, much of that waste can be curbed. From lab results that reach their destination sooner improving better an more timely care delivery to reduced malpractice claims, health informatics reduces errors, increases communication, and drives efficiency where before there was costly incompetence and obstruction.

There's a reason medicine is referred to as a "practice," and it's because health care providers are always learning more and honing their skills. Health informatics provides a way for knowledge about patients, diseases, therapies, medicines, and the like to be more easily shared. As knowledge is more readily passed back and forth between providers and patients, the practice of medicine gets better - something that aids everyone within the chain of care, from hospital administrators and physicians to pharmacists and patients.

3. Patient Participation

When patients have electronic access to their own health history and recommendations, it empowers them to take their role in their own health care more seriously. Patients who have access to care portals are able to educate themselves more effectively about their diagnoses and prognoses, while also keeping better track of medications and symptoms. They are also able to interact with doctors and nurses more easily, which yields better outcomes, as well. Health informatics allows individuals to feel like they are a valuable part of their own health care team, because they are.

4. The Impersonalization of Care

One criticism of approaching patient care through information and technology is that care is becoming less and less personal. Instead of a doctor getting to know a patient in real time and space in order to best offer care, the job of "knowing" is placed on data and algorithms.

As data is gathered regarding a patient, algorithms can be used to sort it in order to determine what is wrong and what care should be offered. It remains to be seen what effects this data-driven approach will have over time, but regardless, since care is getting less personal, having a valid and accurate record that the patient and his care providers can access remains vital.

5. Increased Coordination

Health care is getting more and more specialized, which means most patients receive care from as many as a dozen different people in one hospital stay. This increase in specialists requires an increase in coordination, and it's health informatics that provides the way forward. Pharmaceutical concerns, blood levels, nutrition, physical therapy, X-rays, discharge instructions - it's astonishing how many different conversations a single patient may have with a team of people regarding care, and unless those conversations and efforts are made in tandem with one another, problems will arise and care will suffer. Health informatics makes the necessary coordination possible.

The most important way in which informatics is changing health care is in improved outcomes. Electronic medical records result in higher quality care and safer care as coordinated teams provide better diagnoses and decrease the chance for errors. Doctors and nurses are able to increase efficiency, which frees up time to spend with patients, and previously manual jobs and tasks are automated, which saves time and money - not just for hospitals, clinics, and providers, but for patients, insurance companies, and state and federal governments, too.

Health care is undergoing a massive renovation thanks to technology, and health informatics is helping to ensure that part of the change results in greater efficiency, coordination, and improved care.

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6 Ways Health Informatics Is Transforming Health Care

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The fact that technology is rapidly transforming health care should come as no surprise to anyone. From robotic arms that perform surgery to nanorobots that deliver drugs through the bloodstream , the days of being tended to by the human country doctor seem to have fully given way to machines and software more in keeping with the tools of Dr. McCoy from "Star Trek."

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Interoperability is one of the most complex and challenging imperatives for healthcare. But it's a matter healthcare chief information officers and other health IT leaders must tackle.

A good way of understanding interoperability and how to solve it is by looking at where healthcare-provider organizations will be making interoperability investments in the future. That's what Healthcare IT News is doing in this second article in its latest feature series, "Health IT Investment: The Next Five Years."

For this series, we speak with health IT leaders, primarily chief information officers (CIOs), to learn from them the path forward through the priorities they set with their investments in six categories: AI and machine learning; interoperability; telehealth, connected health and remote patient monitoring; cybersecurity; electronic health records and population health; and emerging technology and other systems. Click here to read the first feature, on AI and machine learning.

This second feature focuses on interoperability. The health IT leaders sharing their plans for the next five years in this second installment in the series include:

Cara Babachicos, senior vice president and CIO at South Shore Health, a health system based in Weymouth, Massachusetts.

Matt Hocks, COO at Sioux Falls, South Dakota-based Sanford Health, a $6 billion health system serving a predominantly rural population over a four-state footprint with both payer and provider arms.

Dr. J. Michael Kramer, chief medical informatics officer at OhioHealth, a health system based in Dublin, Ohio.

Mike Mistretta, vice president and CIO at Virginia Hospital Center in Arlington.

B.J. Moore, CIO of Providence, a health system that operates 52 hospitals across seven states - Alaska, Montana, Oregon, Washington, California, New Mexico and Texas.

Michael Restuccia, senior vice president and CIO at Penn Medicine in Philadelphia, Pennsylvania.

Dr. Umberto Tachinardi, CIO at Regenstrief Institute in Indianapolis, Indiana.

These experts offer board members, fellow C-suite officers, IT managers and workers in the trenches invaluable guidance in this latest feature article in the series.

A big, huge, whopping 'yes'

Mistretta of Virginia Hospital Center says it's a big "yes" when it comes to investing in interoperability over the next five years - but not in the manner one might expect.

"Most of our spend is not going to be [on] exchanging results with other providers; I think we have come about as far as we are going to get with a national patient identifier being put into place, and that doesn't appear to be a priority for our government," he stated. "Where I see the spend taking place is putting more power into the hands of our patients.

"The bi-directional transfer of patient information where they can upload and download on demand and access their information will continue to be enhanced in the next five years."

COVID-19 provided a huge proving ground for device interoperability since patients were looking for low-contact solutions to minimize exposure, Mistretta said.

"We started this initiative earlier this year with the rollout of our branded app," he noted. "We also have a product called OB Connect we are giving to low-risk expectant mothers where we provide a scale and ultrasound at home to self-monitor their progress.

"Prior to their scheduled checkup appointment, they record information that is reviewed by a midwife at their practice, and if there are no issues, they skip that appointment," he continued. "I see more of these technologies emerging moving forward with other diagnoses that will be huge patient satisfiers. The care-at-home market is where investments are going to be made."

Another area that has seen a tremendous amount of progress but is only beginning to mature in this space is direct addressing, he said.

"Using this capability to transmit data between different points of care can bring tremendous value, especially at the physician practice level," he observed. "The issue is most independent and small practices simply don't understand the technology in order to use it.

"We have had physicians provide Gmail addresses in their credentialing applications when we request their address for patient exchange purposes, which shows we haven't done an effective job in the industry rolling this out," he continued. "Look for this simple exchange method to grow and take off in the next five years."

Standards and APIs

Moore of Providence has been eyeing standards and APIs as a place of investment to help with the problem of interoperability.

"Obviously, things like FHIR [Fast Healthcare Interoperability Resouces] and other standards help with interoperability," he stated. "But we don't just see standards moving data around as a way of solving interoperability. We focus on the simplified side of things.

"So use PACS as an example," he continued. "We have kind of islands of PACS [picture archiving and communication systems] throughout our enterprise; where images are locked up is proprietary, or you need to use a proprietary reader. We're in the process of moving all of those images to Microsoft Azure and then using vendor-neutral readers to read that."

So one can solve interoperability through application programming interfaces (APIs) and standards, but this is an example where there is no reason to get 300 systems to talk with each other when one can just change the core underlying technology, he added.

The importance of interoperability is growing

Interoperability is a crucial part of healthcare and continues to become more so as data volume grows and healthcare becomes more global and interconnected, said Tachinardi of Regenstrief Institute. Additionally, the pandemic has highlighted the importance of being able to exchange data understandably, accurately, securely and quickly, he added.

"Since 1994, Regenstrief Institute has been home to LOINC, a system of universal terms created at Regenstrief to uniformly identify laboratory test results and health observations," he noted. "This standard allows information to be seamlessly exchanged and understood across systems.

"The system is used in nearly every country in the world, demonstrating the value of exchanging information," he continued. "LOINC joined an international council of standards organizations that work together to facilitate global interoperability moving forward."

Regenstrief Institute will continue to dedicate time and resources to OpenHIE, a community that provides strategic guidance and other supporting resources to low- and middle-income countries for developing interoperability plans in resource-constrained areas. The institute expects this work to grow, improving healthcare in settings where deploying sustainable health information exchange is challenging.

"Institute research scientists also are investing significant resources to develop and disseminate innovative solutions to improve patient matching," Tachinardi said. "The ability to accurately integrate patients' healthcare records from different providers and electronic medical record systems will improve patient care and safety."

The EHR is the foundation

Within healthcare, interoperability has many definitions, and at times, has become akin to a four-letter word within the industry, said Restuccia of Penn Medicine.

"At Penn Medicine, we view interoperability as the ability to appropriately share data internally and externally among differing systems, networks, facilities and so on," he explained. "For us, the foundation that makes the required level of interoperability possible is our common, integrated electronic health record. With this foundation in place, sharing and transmitting data becomes a more straightforward effort.

"Our interoperability capabilities are driven by a solid data foundation based upon system integration," he continued. "The belief that one common integrated system across all care settings serves to not only enable patient care and clinician satisfaction, but also facilitates the ability to seamlessly share data across multiple settings."

Many areas of investment

OhioHealth has invested heavily in interoperability over the years.

"A good bit of interoperability is required by the 21st Century Cures Act and federal interoperability programs; these are the table stakes," Kramer said. "Despite the regulation and incentives, organizations have not reliably connected or fully implemented.

"For example, many have yet to ingest or publish secure direct messaging addresses to the National Provider and Payer Enumeration, to be required by CMS in January," he continued. "We see direct benefits of interoperability such as reducing administrative burden like faxing, improving population health and, of course, improved care."

In addition to interoperability to benefit clinical care, payer interoperability will help providers understand costs, utilization and populations, he added.

"These all have been major areas of investment in our interoperability plan," Kramer said. "A final area of interoperability may be at the community level with data and community organizations. How can aggregated and integrated EHR data improve community health needs?

"This is unexplored territory worthy of investment," he noted. "We are hoping that implementing Epic COSMOS across the state of Ohio, including at OhioHealth, might drive a greater view of the needs of our community."

Interoperability improves the experience for all

South Shore Health plans to continue to make investments in interoperability because making systems as seamless and complete as possible improves the health experience for all, Babachicos said.

"Interoperability is sharing the right information at the right time, and it is the true promise of digital transformation," she stated. "If an organization outsources care or consults with another party for some of the care, it's not okay to have that care documented outside of the primary electronic health record because it wasn't considered as part of the deal or because it's inconvenient.

"From the provider perspective, they want to see the care documented in one place, and from the patient perspective, they want a comprehensive record of their care."

Additionally, South Shore Health wants to make the use of its systems convenient for its caregivers, whether that's through features such as single-sign-on, contextual linking, or any other tactic that will help to reduce the number of passwords and the login time while at the same time secure interoperability and lower cybersecurity risk, she said.

"In the call center world, we also plan to see more of an emphasis on interoperability as we enhance the user experience through lower call wait times and more options for self-service," Babachicos said.

"Through the use of CRM systems, pop screens and smarter call technology, we plan to increase customer satisfaction by routing calls and services more efficiently or by directing calls to more options to obtain answers to questions."

Significant funding

Sanford Health will continue to invest significant resources in interoperability over the next five years.

"We currently are partnering with industry-leading vendors to integrate technology that provides timely access to healthcare information, reduces the administrative burden on our providers, and allows our care teams to focus on what's most important - patient care," said Hocks of Sanford Health. "We will continue to look at investments that offer our providers better access to real-time data during a clinic or hospital visit to support collaborative clinical decision making."
Twitter: @SiwickiHealthIT
Email the writer:bsiwicki@himss.org
Healthcare IT News is a HIMSS Media publication.

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Interoperability: Where it's headed, and where IT leaders will be investing

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Interoperability is one of the most complex and challenging imperatives for healthcare. But it's a matter healthcare chief information officers and other health IT leaders must tackle. A good way of understanding interoperability and how to solve it is by looking at where healthcare-provider organizations will be making interoperability investments in the future.

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The Future of Healthcare Data Exchange (Interoperability & Democratized APIs) - CES 2018

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New York State is going paperless, at least when it comes to drugs.

A deadline imposed by the New York State Department of Health is rapidly approaching, to make New York State one of the first to axe state-issued prescription pads. By March 27, 2015, all prescriptions in the state of New York must be filed electronically.

The last arm of New York's 2012 I-STOP legislation, universal electronic prescribing is meant to control, track, and monitor the distribution of drugs on a completely new level: where the drugs are prescribed vs. when and where someone picks them up. The former pad-and-pen system, derided for doctors' notoriously bad handwriting and ease of forgery, suddenly seems archaic and insecure when put next to the ubiquity of computer systems.

When the Internet System for Tracking over-Prescribing (I-Stop) legislation was signed into law in 2012, it developed several aspects. The most visible of these is a controlled-substance prescription database, where prescribers search for a patient's history with painkillers and other controlled substances. The legislation also includes drug awareness education and drug return programs. The last arm of the bill is universal e-prescribing for all prescriptions.

"The reason why e-prescribing came into the package was a realization that there was a market for the paper prescriptions, for both controlled substances and other drugs that were deriving from the paper itself," Paul Mahoney, Chief Assistant in the Medicaid Fraud Control Unit in the New York State Attorney General's Office, told The Daily Beast.

Mahoney helped author the I-STOP legislation based on data his office collected in regard to fraud. "We were finding people in possession of thousands of paper prescriptions," he said. "The paper makes it very easy to commit controlled substance offenses and to steal other drugs because the paper conveys a right to have the drugs."

A 2011 New York Department of Health memo stated that at least 1.4 million prescription pads had been stolen from area hospitals in the three years previous, for the purpose of obtaining prescription drugs for illegal sale. In February of this year, the Manhattan DA's office slapped charges on a ring of criminals operating out of a gang-controlled Bronx clinic that had falsely prescribed at least 5 million painkillers for profit. The National Institute of Drug Abuse released astounding prescription drug statistics back in May of this year, including that 100 Americans die per day from the stuff. In July, the Centers for Disease Control said more specifically that opioid painkillers kill someone every hour.

In the case of non-controlled substances, an elaborate fraud scheme was concocted with paper prescriptions, so that crooked pharmacists could reap Medicaid funds for coveted prescriptions. Some medicines, like HIV drugs, are very expensive, as most them are under brand names. Crooks saw this as a lucrative opportunity-unscrupulous pharmacies would buy the prescription paper from patients that had it, say for $100, then use the prescription to bill the Medicaid program for a few thousand dollars, and never dispense the drug. This not only defrauds the state out of thousands of dollars, but also deprives the patient who needs the drugs.

Though the office of the New York State Attorney General is reluctant to put a dollar figure on the amount of fraud, the office likes to single out the Bronx-based Benizio ring, which they say defrauded that state out of hundreds of thousands of dollars.

A closer look at the updated law shows there are provisions of exemption for both "economic hardship" and " technological limitations that are not reasonably within the control of the practitioner." But these must be proven under a signed and sworn statement and judged reasonable by the DOH. Veterinarians may continue prescribing the old-fashioned way, without exemption, as can prescriptions to be filled out of state.

"No one has really made a case yet that they can't afford it," New York State Senator Kemp Hannon said. Hannon has long been an outspoken opponent of prescription drug abuse for years, in 2012 notably helping to outline the prescription drug crisis in the state. "There are a few physicians who so rarely prescribe that I'm sure there's a safety valve for it-mainly psychiatrists who say they only prescribe once a year or never prescribe so shouldn't be subject to the law. About 50 doctors asked for an exemption under I-STOP and about half of those were granted."

Carmen Catizone, Executive Director for the National Association of Boards of Pharmacies, had an equally cutthroat attitude to the practices that could not assimilate.

"It's a question we face all the time, when we put in a new requirement," Catizone said. "And the state of New York has looked at it, and it actually enhances patient safety. Then they have to make a decision to say, if a practice can't meet a certain level of care that's in the best interest of the patient, should that practice be in business? Why should that practice be allowed to exempt out from that standard?"

What's more, the Federal Department of Health and Human Services offers "implementation grants" to applicants, in some cases "to adopt and utilize health information technology in medically underserved communities," according to the law.

The New York State Department of Health could not be reach for comment.

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No More Paper Prescriptions: Docs Fight Fraud by Going Electronic

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New York State is going paperless, at least when it comes to drugs. A deadline imposed by the New York State Department of Health is rapidly approaching, to make New York State one of the first to axe state-issued prescription pads. By March 27, 2015, all prescriptions in the state of New York must be filed electronically.

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Relying on paper charts, phone calls and fax machines to send and receive patient health information between care providers is unreliable and time-consuming and often leaves providers with an incomplete picture of their patients' medical history. This wastes time and resources and can lead to medical errors. These old methods of communication are rapidly being replaced by Health Information Exchange (HIE). Using nationally recognized communication protocols and safety standards, HIE is the secure electronic transfer of Protected Health Information (PHI) among organizations.

HIE allows doctors, nurses, pharmacists and other providers to share patient information in a secure, timely and efficient manner. This enables them to collaborate and consider their patients' full medical history, medications, and other data to make informed decisions, improve diagnosis, avoid duplicative testing, and reduce medical errors and re-admissions. The electronic exchange of actionable information improves the quality, safety and efficiency of health care.

There are three progressive levels of HIE implementations:
1. To coordinate care,
Directed Exchange enables providers to send and receive secure information electronically. 2. For unplanned care,
3. F Query-based Exchange adds capabilities to find or request information from other providers. or patient control, Consumer-Mediated Exchange allows patients to aggregate and control their health information.

The HIE capabilities are typically provided by organizations specialized in networking technology. The organizations design and support the infrastructure needed to securely transfer clinical information between the multiple disparate Electronic Health Record ( EHR) systems used in a provider network.

Besides available commercial solutions, many U.S. states provide HIE alternatives on a statewide level to support the Meaningful Use requirements. In the Commonwealth, the Mass HIway, is the statewide HIE .

Information on the nationwide Health Information Exchange strategy, including the alternatives, capabilities and advantages of HIE can be found on HealthIT.gov.

The HIE Toolkit provides tools and use case examples for guiding an organization through the HIE process.

The searchable HIway Connections Map lists all organizations connected to the Mass HIway, either directly or via a HIway Trusted HISP

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Relying on paper charts, phone calls and fax machines to send and receive patient health information between care providers is unreliable and time-consuming and often leaves providers with an incomplete picture of their patients' medical history. This wastes time and resources and can lead to medical errors.

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Welcome to the Mass HIway

The Mass HIway, the Massachusetts Health Information Exchange (HIE), is a secure Health Information Services Provider (HISP). The HIway is available to all healthcare systems in the Commonwealth, and can be used to cost-effectively improve care coordination, care quality, patient satisfaction, and public health reporting via Direct Messaging. To learn more, click here.

HIway Account Management

The Mass HIway supports providers in connecting and using the Mass HIway. This support is provided by our HIway Account Management team. To learn more, click here.

Statewide ENS Framework

To enable utilization of Event Notification Services (ENS) across Massachusetts, EOHHS and the Mass HIway have developed the Statewide ENS Framework to create an interoperable ENS network that serves all care providers in the Commonwealth. To learn more about the framework, click here.

HIway Connection Requirement

Certain provider Organizations are subject to the HIway Connection Requirement. Currently, Acute Care Hospitals, Community Health Centers, and Medium/Large Medical Ambulatory Practices are subject to this requirement. Acute Care Hospitals must also participate in the Statewide ENS Framework.

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Massachusetts Health Information HIway - HOME | MASSHIWAY Target

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The Mass HIway, the Massachusetts Health Information Exchange (HIE), is a secure Health Information Services Provider (HISP). The HIway is available to all healthcare systems in the Commonwealth, and can be used to cost-effectively improve care coordination, care quality, patient satisfaction, and public health reporting via Direct Messaging.

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Normally, doctors and other health care providers care for their patients in person at a facility such as a medical office, clinic, or hospital. But thanks to computers, smartphones, and other new digital technologies, medical professionals can now diagnose, treat, and oversee their patients' care virtually.

Telehealth is defined as the delivery of health care services at a distance through the use of technology. It can include everything from conducting medical visits over the computer, to monitoring patients' vital signs remotely. Its definition is broader than that of telemedicine, which only includes the remote delivery of health care. Telehealth also includes the training and continuing education of medical professionals.

Telehealth can be delivered in one of three ways:

Synchronous-when the doctor communicates with the patient in real time via computer or telephone

Asynchronous-when data, images, or messages are recorded to share with the doctor later

Remote patient monitoring-when measurements such as weight or blood pressure are sent to the health care provider

Advantages of telehealth

Using technology to deliver health care has several advantages, including cost savings, convenience, and the ability to provide care to people with mobility limitations, or those in rural areas who don't have access to a local doctor or clinic. For these reasons, the use of telehealth has grown significantly over the last decade. Currently, 76 percent of hospitals in the U.S. connect doctors and patients remotely via telehealth, up from 35 percent a decade ago.

Telehealth has become even more essential during the coronavirus ( COVID-19) pandemic. Fears of spreading and catching the virus during in-person medical visits have led to a greater interest in, and use of, technology to provide and receive health care.

Almost three-quarters of Americans surveyed said the pandemic has made them more eager to try virtual care. And one in four Americans over age 50 said they'd had a virtual health care visit during the first three months of the pandemic, up from just four percent of older adults who'd had a remote visit the previous year.

What you can do with telehealth

All of the following activities and services are possible with the help of telehealth:

Recording measurements like your weight, food intake, blood pressure, heart rate, and blood sugar levels either manually, or through a wearable device, and sending them to your doctor.

Having a virtual visit with your doctor or a nurse over your computer or smartphone.

Using an online portal to check your test results, request prescription refills, send your doctor a message, or schedule an appointment.

Sharing information such as your test results, diagnoses, medications, and drug allergies with all of the providers you see.

Coordinating care between your primary care provider and any specialists you visit-including the sharing of exam notes and test results between medical offices in different locations.

Getting email or text reminders when you're due for mammograms, colonoscopies, and other screenings, or routine vaccinations.

Monitoring older adults at home to make sure they are eating, sleeping, and taking their medications on schedule.

Downsides to telehealth

Telehealth offers a convenient and cost-effective way to see your doctor without having to leave your home, but it does have a few downsides.

It isn't possible to do every type of visit remotely. You still have to go into the office for things like imaging tests and blood work, as well as for diagnoses that require a more hands-on approach.

The security of personal health data transmitted electronically is a concern.

While insurance companies are increasingly covering the cost of telehealth visits during the COVID-19 pandemic, some services may not be fully covered, leading to out-of-pocket costs.

Image: RichLegg/Getty Images

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Telehealth: The advantages and disadvantages - Harvard Health

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Among the greatest barriers to broader telehealth adoption are assumptions among policymakers that allowing greater telehealth access will lead to higher utilization and costs. This opinion is especially prevalent for FFS Medicare. Recent data provided to the TTP challenge some of these assumptions.

A small silver lining of the pandemic has been the generation of first-ever Medicare fee-for-service data that allows budget analysts, including the Congressional Budget Office (CBO), the Office of Management and Budget and the CMS Actuary to begin to assess telehealth's impact on Medicare more accurately.

Policymakers will, of course, want further analysis of how much COVID-induced care avoidance may have contributed to telehealth's impact on utilization during the pandemic. However, data generated from provider organizations and the federal government to date show that total healthcare utilization remained steady during telehealth's expansion and did not substantiate concerns about supply-induced demand.

For example, an HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE) Medicare FFS telehealth report found that from mid-March through early-July more than 10.1 million traditional Medicare beneficiaries used telehealth. That includes nearly 50% of primary care visits conducted via telehealth in April vs. less than 1% before COVID-19.

However, the net number of Medicare FFS primary care in-person and telehealth visits combined remained below pre-pandemic levels. As in-person care began to resume in May, telehealth visits dropped to 30% but there was still no net visit increase. The effects of the COVID-19 pandemic on patients seeking or avoiding care still need further analysis, but these data suggest that telehealth substituted for in-person care without increasing utilization.

Other sources mirror ASPE's findings. The U.S. Department of Veterans Affairs researchers found that, from March to May 2020, a 56% decline in in-person visits was partly offset by a 2-fold increase in telephone and video visits. At least during that period of the pandemic, telehealth replaced in-person visits but did not increase overall utilization.

The TTP obtained initial findings from health systems and independent practices across the country, including Johns Hopkins, Stanford Health Care, Ascension, Intermountain Healthcare, Nemours Children's Health System, University of Rochester, Northwestern, and Aledade. The TTP also received input from the American Academy of Actuaries' Telehealth Subcommittee, an advisor to the HHS Secretary, a former Medicare leader and a former Congressional Committee staffer who dealt regularly with the CBO. Using these data, we narrowed our focus to 5 key topics that can impact costs.

1. Substitution of in-person care.

2. Preventing more costly care.

3. Lower no-show rates.

4. Greater transitional care management.

5. Lowering skilled nursing facilities transfers.

Substitution Effects. It is essential to distinguish between the extent to which telehealth serves as a substitute for in-person care as opposed to an add-on. One study estimates that virtual care could substitute for up to $250 billion of current U.S. healthcare spending, and the emerging data from the pandemic shows this could be correct. It is still too soon for large-scale, academically rigorous analysis of what is happening that properly discount pandemic effects, but the evidence from March to July is promising for telehealth.

Data gathered by the TTP indicate that telehealth largely substituted for in-person care and did not increase the total number of visits. Again, policymakers will want further analysis of the separate phenomena of cost related to COVID-induced care avoidance and cost related to widespread access to telehealth. However, as with ASPE, health systems surveyed by the TTP found that telehealth simply represented a change in care delivery modality with steady overall utilization. Total visits, including in-person and video, never went above pre-pandemic levels, even as clinics reopened to in-person care broadly across the health system.

Preventing More Costly Care: Telehealth facilitates access to healthcare for individuals who might otherwise skip or avoid important services. It also allows care delivery more quickly and efficiently in lower cost settings. The TTP found evidence that telehealth can help reduce more costly urgent and emergency department (ED) care, as well as use of costly and often overused services such as imaging.

Ascension Health found that, from March to May of this year, nearly 70% of patients would have gone to either urgent care or the ED had they not had access to virtual care. These patients would have used more costly options without access to telehealth.

Nemours found that 67% of parents who used its 24/7 on-demand virtual care service before COVID-19 reported they otherwise would have visited an ED, urgent-care center or retail health clinic had telehealth not been available.

A pre-COVID-19 Anthem study of Medicare Advantage claims data for acute and non-urgent care utilization found savings of 6%, or $242 per episode of care costs by diverting members to telehealth visits who would have otherwise gone to an ED. The study also found less use of imaging, lab tests and antibiotics.

In a pre-COVID-19 study of 40,000 Cigna beneficiaries, the 20,000 beneficiaries who used the MDLive telehealth platform had 17% lower costs when compared with non-virtual care. Virtual care users also experienced a 36% net reduction in ED use per 1,000 people compared to non-virtual care users.

No-Show Rates: Policymakers need to consider telehealth's impact on no-show rates. Missed appointments decrease care plan compliance which can lead to more expensive care needs. In 2012, CBO determined that prescription drug legislation cost estimates must account for the offsetting effects of medication adherence. Telehealth's similar offsetting effects on no-show rates and better care plan adherence contribute to downstream cost savings and are thus important cost factors. For example, in diabetes care management, routine visits can help prevent long-term costly effects.

"We saw many more farmers getting behavioral health services during COVID that didn't before. When we talked to them, they were brutally honest, "There's no way in heck I'm going into a building that says behavioral health, but if I can do it on my iPad at home, I'm okay doing it." Chris Meyer, Director of Virtual Care, Marshfield Clinic

Health systems and clinician practices consistently report lower no-show rates with telehealth, especially in behavioral care where telehealth removes the stigma of visiting a behavioral clinic. For example, the baseline no-show rate for psychiatry services is between 19 and 22 percent of appointments - while MDLive reports no-show rates of only 4.4-7.26 percent for its behavioral health telehealth visits. Dr. E. Ray Dorsey, MD, MBA, professor of neurology and director of the Center for Health and Technology at the University of Rochester Medical Center, commented that patients are more likely to show up to virtual appointments - with no-show rates down about 10% during the pandemic. For the Marshfield Clinic, office visit no-show rates pre-COVID-19 were roughly 5%; they dropped to 3.8% with telehealth during COVID-19.

Improved no-show rates are likely due to telehealth's convenience, especially its impact on travel burdens that create barriers to care in accessing transportation, taking time off from work and finding childcare. In 2018, CMS estimated that telemedicine saves Medicare patients $60 million on travel, with a projected estimate of $100 million by 2024 and $170 million by 2029. CMS also noted that estimates tend to underestimate telemedicine's impact. Higher projections estimate $540 million in savings by 2029.

Transitional Care Management (TCM): While the TTP did not have time to collect enough data to fully analyze TCM, we received anecdotal evidence that TCM code billing increased during COVID-19. This suggests that clinicians, other providers and patients are more robustly utilizing TCM services. Previous analysis has suggested that increased TCM usage can lower readmissions, thereby reducing health care costs.

TCM service use increased from roughly 300,000 claims during 2013, the first year of TCM services, to nearly 1.3 million claims in 2018. This resulted in significantly lower readmission rates, significantly lower mortality, and significantly decreased health care costs. The analysis also found that TCM use is low when accounting for the number of Medicare beneficiaries with eligible discharges. CMS cited this study in its 2020 physician fee schedule rule, noting that increasing medically necessary TCM utilization could positively affect patient outcomes. Readmissions are particularly detrimental for patients and hugely costly to providers and payers-in 2019 roughly 83% of hospitals incurred readmission penalties.

Lowering Skilled Nursing Facilities (SNF) Transfers. SNF patient hospital readmissions cost Medicare over $4 billion each year. The TTP received data from Third Eye Health, a platform that triages patients via telehealth who may need to be transferred to the hospital, showing that their consultations between March-July successfully treated patients in SNFs at an overall rate of 91%, including for high-cost falls with injury (84.79%), shortness of breath (66.67%) and acute or chronic pain (95.96%). While much more evidence needs to be collected, the TTP believes telehealth in SNFs may decrease readmissions, as well as hospitalizations and ED visits, yielding significant savings.

Telehealth and RPM's impact on reducing strain on the estimated 41 million family caregivers also merits consideration. In 2017, family caregivers furnished $470 billion worth of care, more than total out-of-pocket spending on health care that year ($366 billion) or the total spending for all sources of paid long-term services and supports, including post-acute care in 2016 (also $366 billion).

Telehealth and RPM also create opportunities for additional communication and information sharing between patients, caregivers and clinicians. Accelerating adoption of value-based payment models, which have shared financial risk to incentivize prevention, chronic disease management and efficiency, can integrate telehealth.
"On the fee-for-service side, the technical fees paid to in-person and telehealth visits should be commensurate with the cost and benefit of providing the service. Otherwise, institutions may favor physical visits over telehealth for reimbursement purposes." Ricardo Munoz, MD, Chief, Division of Cardiac Critical Care Medicine & Executive Director, Telemedicine, Children's National Health System
Finally, debate will continue over appropriate telehealth payment amounts, but key principles can help focus these discussions. Telehealth should be seen as neither inherently driving nor reducing costs. Similarly, payers should have flexibility in rates and sites based on different markets and different situations and should retain the ability to innovate with product offerings that reward value-based providers. It is in everyone's interest to ensure that telehealth services are reimbursed at a rate that reflects the cost of providing these services and the value that they bring as part of the overall care experience. Appropriate reimbursement and access to telehealth services will allow patients to utilize these services where they and their care team feel it is both clinically appropriate and the best possible way of receiving care.

1. Telehealth services should be reimbursed based on a thoughtful consideration of the value provided and the cost of delivery-as is done with in-person care. Flexibility on the use and reimbursement of these services is essential to maximizing the benefit to patients and the system at large.

2. When analyzing and discussing telehealth costs, policymakers should take a wider view and incorporate costs to patients and family caregivers, clinicians and other providers, and payers. These costs could-and should-include avoided transportation costs, time spent scheduling, preparing for or waiting for a visit, missed work, child/elder care, missed appointments, and technology/infrastructure costs. Although a change in care modality may create new costs, policymakers should not examine these costs without considering "baked in" in-person costs.
"Value-based arrangements with providers and plans at risk create the flexibility to design models that utilize telehealth where and when it can help improve care and outcomes." Margaret E. O'Kane, President, NCQA

3. Accurately assessing the true value - including the cost and quality - of telehealth utilization will require that policymakers focus on evidence of its effectiveness and its ability to meaningfully increase access to care, not previously-held assumptions. Data from the current public health emergency are a first look at the effect on Medicare costs of lifting telehealth restrictions and it does not, at this writing, reflect excessive or unnecessary utilization. However, long-term conclusions and policies based on costs and outcomes in Medicare can only be drawn from data derived during the relatively normal conditions that follow the pandemic. Increased behavioral health utilization during the pandemic may provide a good example of meaningful increased access that has potential to improve outcomes and avoid future unnecessary and costly utilization. This will require further investigation.

Cost Recommendations

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Taskforce on Telehealth Policy Findings and Recommendations - Telehealth Effect on Total Cost of Care - NCQA

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Among the greatest barriers to broader telehealth adoption are assumptions among policymakers that allowing greater telehealth access will lead to higher utilization and costs. This opinion is especially prevalent for FFS Medicare. Recent data provided to the TTP challenge some of these assumptions. A small silver lining of the pandemic has been the generation of [...]

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As the Covid pandemic swept across the U.S., providers nationwide switched one third or more of their in-person care to telephone and video encounters. While the volume of telemedicine visits has declined in recent months, it's clear that the technology is here to stay - though there's work to be done. A national Press Ganey survey that returned 1.3 million completed patient questionnaires found that while patients appreciate the convenience and, perhaps surprisingly, intimacy of virtual encounters, there is enormous room for improvement in the processes of telemedicine.

Across the 154 medical practices surveying both in-person and telemedicine visits between January and August 2020, telemedicine visits peaked at an estimated 37% of all encounters in early May, decreased to 22% in early July, and then leveled out around 15% by mid-August - still far above the pre-pandemic baseline of less than 1%. Overall adoption ranged between 18% to 22% across all age groups up to age 79, falling slightly (to 13%) among those 80 and older.

Even though most clinicians and patients were new to virtual visits at the start of the pandemic, patients have clearly come to appreciate them. In fact, in our survey patients were just as likely - or even slightly more likely - to give high ratings to their care providers after telemedicine visits compared with in-person care. This finding held true across specialties and for all measures of providers' concern, ability to establish a connection, and trust-building. Among the reasons the telehealth connection seems to resonate with patients is that providers can actually seem more attentive on-screen. One patient commented that while her doctor always seemed distracted by a computer screen during in-person visits, during video visits the doctor looked directly at her. Some providers have also suggested that simply scheduling a televisit can signal a doctor's attentiveness. As Jon Slotkin and colleagues at Geisinger wrote in HBR, "A shift in patients' perception of telehealth has perhaps been the most important in increasing adoption, with attitudes moving from, This provider must not think my problem is important since they are seeing me via telehealth, to This provider cares about me and therefore is seeing me via telehealth. "

That's the good news. The bad news is that patients clearly feel that the process of telemedicine (logistical things like ease of scheduling and making audio/video connections) falls short: while 89% of patients would recommend their provider after having had a telemedicine visit, only 76% of patients would recommend a video visit following a telemedicine visit.

What's needed?

The wide gap between patients' ratings of the processes of telemedicine and in-person care did not narrow over the six-month period - indicating that improvement cannot be expected to happen organically. From observing how telemedicine is being used around the country, three recommendations can be made about how to accelerate improvement.

First, organizations should develop a central resource team to efficiently scale up telemedicine operations for all specialties and effectively support patient, provider and clinic-workflow needs. This will require redesigning care delivery to support the office flow and staff allocation for telemedicine, just as is done in the in-person setting. To this end, the central resource team should focus on optimizing the technology for video visits, integrating visits into providers' workflow (e.g., launching from the EMR), and arranging for telephone visits if patients or providers are unable, or reluctant, to use video. ( Yale Medicine's approach to some of these issues provides a useful model.)

Second, aided by the central team, specialties should develop telemedicine capability to support organizational efforts to deliver a virtual patient experience across specialties. While not every visit can be done virtually, providing this option when possible should become the standard approach (one academic medical center found that at least half of care could be provided virtually). Each specialty should develop protocols for triaging patients to in-person or virtual care, opting for virtual visits when possible to reduce patients' hassle-factor and free up in-person visits for those requiring them. Specialists should benchmark their telemedicine rates against others in the same specialty, looking for untapped opportunities to provide virtual visits.

Third, providers and office staff should be trained in virtual-care operational and communication practices to support the goal of delivering a consistent, cross-specialty patient experience. For example, patients should encounter a similar telemedicine "rooming" process (where they wait for their clinician to virtually arrive) across the organization. With fewer real-world sources of patient stress to contend with (traffic, parking, and crowded waiting rooms), even organizations in disseminated campus settings have a real opportunity to create a seamless, branded virtual patient care experience.

Using what we have learned from the initial six months of telemedicine during the Covid pandemic, we have an opportunity to accelerate the strategic use and operational efficiency of this tool in ways that can greatly benefit patients, providers, and organizations. Doing so in a strategic and comprehensive way might even accelerate efforts to transform patient experience in ways we have yet to do in our traditional in-person environments.

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What Patients Like - and Dislike - About Telemedicine

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As the Covid pandemic swept across the U.S., providers nationwide switched one third or more of their in-person care to telephone and video encounters. While the volume of telemedicine visits has declined in recent months, it's clear that the technology is here to stay - though there's work to be done.

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No, King's Move is completely free! The platform was created purely to help motivate the King's community to stay active during their busy schedules.

The Moves+ app currently tracks, steps walked, miles run, miles cycled, metres swum.

Moves+ does not collect data associated with any other activities so, if your tracker/wearable allows you to log different types of activity (eg weights or rowing), then any steps recorded during this activity will not be collected by Moves.

You can directly connect with the following trackers and wearable devices:

Apple Health (iOS devices only)* - no wearable device required.

Fitbit - you will need to purchase a Fitbit wearable device, we recommend the Fitbit Charge 3 or above. This tracker is recommended for swimmers.

Garmin

Google Fit - no wearable device required.

Strava - no wearable device required. App is recommended for cyclists and runners.

Withings (Health Mate app) - you will need to purchase a Withings wearable device.

There are more details within the app about the benefits of each of these tracking apps so you can choose the right connection for you. Visit the 'My tracker' section within the profile page.

You can only connect one tracker at a time! If you have two trackers or apps downloaded on your phone, e.g. a Fitbit wearable and Google Fit app, we recommend that use one tracker/wearable with Moves+; there is no need to attach Fitbit to Google Fit and Google Fit to Moves+, for example.

Remember that you will need to connect one of the above trackers to your Moves account to earn points.

We have an array of rewards you can redeem from King's including Kings Sport & Wellness merchandise and activity, Kings Food and Drink and Kings Move clothing.

The rewards available to redeem will be shown in the 'Rewards' page of on the Moves+.
The app will display rewards as:

Available - you can redeem this reward.

Coming soon - the reward will become available on a set date in the future.

Not enough points - you cannot redeem until you collect more Moves+ points.

There's two ways to claim a reward:

Merchant Claim
Follow the instructions, you will be prompted on pressing claim to hand your device to the salesperson you are redeeming the reward. They will confirm receipt of the claim on your device.

Code Claim
On claiming the reward, a unique code will be revealed. Instructions will be given on how to use the code to claim your reward.

Details about 'how to redeem' your reward will be written in the Reward Description of each listing. Additional information and any Terms will be listed in the Terms of Service of each listing.

It is important to read the Reward Description and Terms of Service in full for each reward before redeeming, so that you are aware of all of the information and any action that may be required by you, the user.

Please note: points will not be refunded for rewards redeemed by accident, or for not following the instructions provided.

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King’s Move | King’s Sport & Wellness | King’s College London

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Sync your fitness tracker app or wearable and earn points for rewards across King’s.

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Alarm Fatigue - Consequences, and Solutions

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Alarm Fatigue - Consequences, and Solutions

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Constant beeping - medication pumps, monitors, beds, ventilators, vital sign machines, and feeding pumps - are alarms that are all too familiar to nurses, especially in the intensive care unit. Research indicates that 72% to 99% of all alarms are false which has led to alarm fatigue. Unfortunately, due to the high number of false alarms, alarms that are meant to alert clinicians of problems with patients are sometimes being ignored. Assuming that an alarm is false puts patients in harm's way and could lead to medical mistakes.

The American Association of Critical Care Nurses defines alarm fatigue as a sensory overload that occurs when clinicians are exposed to an excessive number of alarms, which can result in desensitization to alarm sounds and an increased rate of missed alarms.

The Joint Commission (TJC) has been trying to combat alarm fatigue since 2013. In 2013, there were numerous reported sentinel events, which led the TJC to issue an alert on alarms and then made alarm management a National Patient Safety Goal starting in 2014. Each year since, it has continued to be a National Patient Safety Goal because there continue to be sentinel events related to alarm management and fatigue.
>>Listen to this episode on the Ask Nurse Alice podcast, "I'm experiencing alarm fatigue as a nurse, what advice do you have?"
Alarm fatigue is one of the most troubling and highly researched issues in nursing. Over the last decade, research has found the following staggering statistics related to alarm fatigue and false alarms:

The Food and Drug Administration reported more than 560 alarm-related deaths in the United States between 2005 and 2008.

Between January 2009 and June 2012, hospitals in the United States reported 80 deaths and 13 severe injuries.

One study showed that more than 85 percent of all alarms in a particular unit were false.

A hospital reported an average of one million alarms going off in a single week.

A children's hospital reported 5,300 alarms in a day - 95% of them false.

A hospital reported at least 350 alarms per patient per day in the intensive care unit.

Reducing the harm associated with clinical alarm systems continues to be a national patient safety goal. The Joint Commission continues to encourage healthcare systems to put policies in place to decrease the burden of unnecessary alarms on staff. The Joint Commission issues the following safety guidelines for all hospitals in their annual report:

Leaders establish alarm system safety as a hospital priority

Identify the most important alarm signals to manage based on the following

Input from the medical staff and clinical departments

Risk to patients if the alarm signal is not attended to or if it malfunctions

Published best practices and guidelines

Establish policies and procedures for managing the alarms identified and address the following:

When alarms can be disabled or changed

Monitoring and responding to alarm signals

Checking individual alarm signals for accurate settings, proper operation, and detectability

Who can set alarm parameters

Who can change alarm parameters

Who can turn alarm settings to "off"

Educate staff about the purpose and proper operation of alarm systems

In the original sentinel event alert, The Joint Commission identified numerous factors that they believed contributed to alarm fatigue in the hospital setting. These included:

Alarm parameter thresholds were set too tight

Alarm settings not adjusted to the individual patient's needs

Poor EKG electrode practices resulting in frequent false alarms

Inability of staff to hear alarms or detect where an alarm is coming from

Inadequate staff training on monitors and alarms

Inadequate staff response to alarms

Alarm Malfunction

Recommendations and Solutions

While there is no universal solution to alarm fatigue, hospitals are taking individual approaches to combat it. The Joint Commission stresses in the 2019 National Patient Safety Goals that there needs to be standardization but can be customized for specific clinical units, groups of patients, or individual patients.

The Association for the Advancement of Medical Instrumentation released recommendations to combat alarm fatigue including:

Have an alarm-management process in place.

Review and adjust default parameter settings and ensure appropriate settings for different clinical areas.

Determine where and when alarms are not clinically significant and may not be needed.

Create procedures that allow staff to customize alarms based on the individual patient's condition.

Make sure all equipment is maintained properly.

Nursing associations have also released recommendations to combat alarm fatigue. The most striking and was the recommendations released by the American Association of Critical Care Nurses in May 2018. The Practice Alert outlined evidence-based recommendations to reduce alarm fatigue and false clinical alarms. Recommendations released for nurse leaders included:

Organize an interprofessional alarm management team.

Develop policies/procedures for monitoring only those patients with clinical indications for monitoring.

Develop unit-specific default parameters and alarm management policies.

Provide ongoing education on monitoring systems and alarm management for unit staff.

While recommendations for bedside clinicians included:

Providing proper skin preparation for and placement of ECG electrodes.

Using proper oxygen saturation probes and placement.

Checking alarm settings at the beginning of each shift.

Customizing alarm parameter settings for individual patients in accordance with unit or hospital policy.

Electronic charting systems, such as EPIC, have the ability for providers to place an order for alarm limits for each individual patient based on age and diagnosis. It also allows nurses to document each alarm limit every shift and if it is outside of the ordered parameters. It will also trigger a computer warning to the staff as a reminder to have the orders changed if the alarms are not set correctly. Some hospitals have tagged this as meaningful use so that it is a requirement for staff for each patient during every shift.

A contributing factor to alarm fatigue is the amount of noise the alarms produce. Constant beeping and alarms throughout the unit can cause nurses to miss their own alarms or change the settings to improper parameters in order to avoid the noise. The World Health Organization recommends noise levels of 35 decibels (dB) during the day and 30 dB during the night.

Advances in technology have increased the use of visual and/or vibrating alarms to help reduce alarm noise. Hospitals can implement functions on their monitors to pause alarms for short periods when providing patient care, turning a patient, and/or suctioning. These may all trigger patient alarms but if a trained healthcare professional were at the patient's bedside pausing alarms would help reduce the alarm noise.

Boston Medical Center switched cardiac monitor thresholds from "warning" to "crisis" and as a result reduced the noise levels from 92 dB to 70 dB. In doing so, nurses had quicker reaction times to alarms and patients were less disturbed.

Hospitals throughout the country have been able to successfully combat alarm fatigue. The Cincinnati Children's Hospital Medical Center in Cincinnati, Ohio specifically focused on reducing the number of alarms in the bone marrow transplantation unit. A multi-disciplinary team including nurses, physicians, nursing assistants, medical engineers, and family representatives met to devise a plan to reduce the number of alarms in the unit on a daily basis.

After making a variety of changes, the unit was able to drastically reduce the number of alarms from 180 to 40 per patient per day, and the number of false alarms fell from 95% to 50%.

Boston Medical Center was able to reduce the number of alarms by 60% by altering the default heart rate settings based on each patient's condition. They also implemented the following mnemonic to help prevent alarm fatigue and increase patient satisfaction and outcomes:

Alarm sensitivity

Sounding notification

Significant need to monitor

Evaluate the situation

Timely response/technology training

Alarm fatigue is a serious concern in hospitals around the country and The Joint Commission will continue to address this in their annual national safety goals. Until the number of false alarms decreases and there are no patient safety events, focus needs to remain on alarm fatigue.

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Alarm Fatigue is Way Too Real (and Scary) For Nurses

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False alarms are nothing new, but with the majority of all alarms being false, nurses struggle with "alarm fatigue" and have difficulty reacting properly when a real emergency happens.

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Should Patients Have Access to Their Medical Records?

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If you've been to any type of health care provider for a check-up since 1996, you will likely recall signing a document that either denies access or gives certain people (e.g., a family member or friend) permission to accept phone calls or receive other medical information about you. That's a HIPAA release form.

Here, we'll explain what HIPAA is, how it applies to non-medical businesses, and how your company (even if it's not a healthcare facility) can stay on the right side of the law.

What is HIPAA?

The Health and Insurance Portability and Accountability Act (HIP AA... not HI PPA) is a law enacted in 1996 to, in part, prevent patients' protected health information (PHI) from being released without their permission or knowledge. Compliance is required by covered entities such as healthcare providers and health insurers (commercial and employer sponsored), as well as those entities' business associates such as transcriptionists and health care clearinghouses that standardize information into usable data for the Department of Health & Human Services (HHS).

Of course, most people equate HIPAA violations with medical offices and facilities. While these providers are the most widely reported violators, business associates that have absolutely nothing to do with medicine can also be fined.

What is a Business Associate?

Business associates are companies that perform diverse types of services on behalf of HIPAA covered entities, including:

Accounting

Actuarial services

Medical benefits management

Data aggregating, analysis, and transmission

Insurance utilization review

Medical billing

Medical practice management

Electronic medical records (EMR) management

Processing insurance claims

What HIPAA Obligations Do Business Associates Have?

Business associates are held to the same rigorous HIPAA compliance standards as covered entities. Covered entities are required to maintain contracts outlining HIPAA standards with their business associates to help ensure patient data is safeguarded. In turn, business associates must also have written contracts with any subcontractors that they hire.

What Are Hybrid Entities?

A hybrid entity performs both non-HIPAA-related and HIPAA-related tasks. For example, a professional services company that provides an onsite medical office for the benefit of its employees would be considered a hybrid entity. The physician and staff might be employed by the company, but the medical office itself remains separate and is the only covered entity. Another example is a grocery store that has a pharmacy inside. With hybrid entities, only the part of the company that is considered a covered entity is required to comply with HIPAA regulations.

Does HIPAA Apply to Employers?

Medical records that are frequently found in a workplace include:

While these documents often contain personal health information, under HIPAA guidelines, they're considered employment records and not medical records.

HIPAA also doesn't prohibit an employer from:

Requesting a doctor's note for an absence

Requesting information relating to healthcare coverage or wellness programs

Asking for proof of COVID-19 vaccine or test results

Examples of HIPAA Violations by Employers

Any company that wants to steer clear of potential workplace HIPAA violations needs to properly guard the PHI they're responsible for.

A HIPAA violation occurs when a person's PHI at a covered entity or business associate has fallen into the wrong hands, whether willfully or inadvertently, without that person's consent. The major challenge for non-medical business associates is twofold:

1. They may not be aware that HIPAA applies to them; and

2. If they are aware, their employees may not be well-trained in the ins and outs of the law, leaving them vulnerable to infringing on patients' privacy rights.

In 2020, the U.S. experienced 1.76 data breaches of 500+ healthcare records every day, netting more than 29 million exposed records (HIPAA Journal). These are the three most typical HIPAA workplace violations that are found in healthcare organizations:

Lost or Stolen Devices

At most businesses, losing a work phone or laptop is somewhat of a big deal, but not as huge a deal as it is for businesses that are covered by HIPAA. Covered entities are more frequently using mobile devices to communicate about patients, so PHI data breaches resulting from loss and theft are more common than you may think. Fortunately, the increased use of encryption and cloud services for data storage have helped reduce the number of loss and theft incidents.

Unsecured Patient Information

Employees who handle sensitive patient data need to know where records are stored at all times. For instance, if an employee has patient records open on their desktop computer and leaves for lunch without locking their screen, someone could easily access them, which is enough to violate HIPAA rules. And even if employees are diligent about locking their workstations, strong password protection is just as critical.

Inadequate Employee Training

If you're a covered entity or business associate, your employees can unintentionally leak PHI and result in your business being fined. Consider these situations:

An employee discusses something unusual they read in a patient's medical record with another employee in a break room full of other staff members

A new employee in your billing department sends a detailed medical bill to the wrong mailing address

An employee posts a story about a patient to their Facebook page

What Happens if a Business Violates HIPAA?

The Office for Civil Rights (OCR) is the investigating arm within the U. S. Department of Health and Human Services (HHS) that manages HIPAA violation complaints. The penalty for a HIPAA violation depends on its severity. In something of a departure from its federal department counterparts, the OCR would rather not punish violators with fines, instead preferring to offer guidance and education. But if a violation is severe enough, financial penalties will be imposed.

OCR has four categories of penalties, and the financial amounts are adjusted annually for inflation:

Tier 1: The covered entity or business associate was unaware of and couldn't have avoided a violation. Minimum fine of $100/violation up to a maximum $50,000.

Tier 2: The covered entity or business associate should have been aware of but couldn't have avoided a violation. Minimum fine of $1,000/violation up to a maximum $50,000.

Tier 3: The covered entity or business associate willfully neglected HIPAA rules and attempted to correct the violation. Minimum fine of $10,000/violation up to a maximum $50,000.

Tier 4: The covered entity or business associate willfully neglected HIPAA rules but did not attempt to correct the violation. Minimum fine of $50,000/violation.

What are examples of HIPAA violations?

Some examples of HIPAA violations include:

An emergency department employee posting a photo to social media without obscuring the faces of the people in the photo.

A nurse sharing a hospitalized patient's medical history with an unauthorized family member.

Disposing of sensitive medical documentation without appropriately shredding it first.

What happens if an employer violates HIPAA?

If an employer is a covered entity or business associate and they violate HIPAA rules, they can be fined depending on the level of violation listed above.

Can an employee violate HIPAA?

Yes. If an employee works for a covered entity or business associate, it's possible for them to violate HIPAA rules.

Can an employer be sued for a HIPAA violation?

No, an individual cannot sue their employer for violating HIPAA, as any medical information stored is considered part of the employment record and not protected health information. If the employer is a covered entity or business associate, and an individual feels a violation has occurred, the individual should file a complaint with the Department of Health and Human Service's Office of Civil Rights.

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What is a HIPAA Violation in the Workplace? Avoid Penalties

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If you've been to any type of health care provider for a check-up since 1996, you will likely recall signing a document that either denies access or gives certain people (e.g., a family member or friend) permission to accept phone calls or receive other medical information about you.

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Does asking vaccination status violate HIPAA? Are mask mandates a HIPAA violation? Is it a HIPAA violation for employers to require vaccines?

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When someone hears a story, multiple parts of the brain are engaged, including:

Wernicke’s area, which controls language comprehension

The amygdala, which processes emotional response

Mirror neurons, which play a role in empathizing with others

When multiple areas of the brain are engaged, the hippocampus—which stores short-term memories—is more likely to convert the experience of hearing a story into a long-term memory.

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When you hear the term "data analysis," what do you think of? Your mind may jump to scouring spreadsheets, implementing algorithms, and making mathematical calculations-all "hard skills" of data analysis. Yet, hard skills are useless without their soft skill counterparts. It's not enough to just analyze data; you need to know how to communicate the story it tells in a clear, compelling manner-a skill called data storytelling.

According to the Bureau of Labor Statistics, the demand for research analysts is expected to grow 25 percent between 2020 and 2030, much faster than the average across all industries. Many companies have begun including data storytelling as a required skill in analyst job descriptions, while others have opted to hire for data storyteller positions to supplement their existing analytics teams' abilities. Possessing the skills to both analyze data and communicate its insights can help you stand out as a well-rounded candidate.

Here's a primer on the key components of data storytelling, why storytelling is an impactful communication tool, and how to craft a compelling narrative of your own.

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What Is Data Storytelling?

Data storytelling is the ability to effectively communicate insights from a dataset using narratives and visualizations. It can be used to put data insights into context for and inspire action from your audience.

There are three key components to data storytelling:

1. Data: Thorough analysis of accurate, complete data serves as the foundation of your data story. Analyzing data using descriptive, diagnostic, predictive, and prescriptive analysis can enable you to understand its full picture.

2. Narrative: A verbal or written narrative, also called a storyline, is used to communicate insights gleaned from data, the context surrounding it, and actions you recommend and aim to inspire in your audience.

3. Visualizations: Visual representations of your data and narrative can be useful for communicating its story clearly and memorably. These can be charts, graphs, diagrams, pictures, or videos.

Data storytelling can be used internally (for instance, to communicate the need for product improvements based on user data) or externally (for instance, to create a compelling case for buying your product to potential customers).

The Advantages of Data-Driven Decision-Making

The Psychological Power of Storytelling

Humans have told stories since the Cro-Magnon era to communicate with others for survival and record accounts of daily life. While storytelling methods have come a long way since the days of cave paintings, its psychological power holds true tens of thousands of years later.

The brain's preference for stories over pure data stems from the fact that it takes in so much information every day and needs to determine what's important to process and remember and what can be discarded.

When someone hears a story, multiple parts of the brain are engaged, including:

Wernicke's area, which controls language comprehension

The amygdala, which processes emotional response

Mirror neurons, which play a role in empathizing with others

When multiple areas of the brain are engaged, the hippocampus-which stores short-term memories-is more likely to convert the experience of hearing a story into a long-term memory.

Rather than presenting your team with a spreadsheet of data and rattling off numbers, consider how you can engage multiple parts of their brains. Using data storytelling, you can evoke an emotional response on a neural level that can help your points be remembered and acted upon.

How to Craft a Compelling Data Narrative

Data storytelling uses the same narrative elements as any story you've read or heard before: characters, setting, conflict, and resolution.

To help illustrate this, imagine you're a data analyst and just discovered your company's recent decline in sales has been driven by customers of all genders between the ages of 14 and 23. You find that the drop was caused by a viral social media post highlighting your company's negative impact on the environment, and craft a narrative using the four key story elements:

1. Characters: The players and stakeholders include customers between the ages of 14 and 23, environmentally conscious consumers, and your internal team. This doesn't need to be part of your presentation, but you should define the key players for yourself beforehand.

2. Setting: Set the scene by explaining there's been a recent drop in sales driven by customers of all genders ages 14 to 23. Use a data visualization to show the decline across audience types and highlight the largest drop in young users.

3. Conflict: Describe the root issue: A viral social media post highlighted your company's negative impact on the environment and caused tens of thousands of young customers to stop using your product. Incorporate research (such as this article in the Harvard Business Review) about how consumers are more environmentally conscious than ever and how sustainably-marketed products can potentially drive more revenue than their unsustainable counterparts. Remind the team of your company's current unsustainable manufacturing practices to clarify why customers stopped purchasing your product. Use visualizations here, too.

4. Resolution: Propose your solution. Based on this data, you present a long-term goal to pivot to sustainable manufacturing practices. You also center marketing and public relations efforts on making this pivot visible across all audience segments. Use visualizations that show the investment required for sustainable manufacturing practices can pay off in the form of earning customers from the growing environmentally conscious market segment.

If there isn't a conflict in your data story-for instance, if the data showed your current marketing campaign was driving traffic and exceeding your goal-you can skip that element and go straight to recommending that the current course of action be maintained.

Whatever story the data tells, you can communicate it effectively by formatting your narrative with these elements and walking your audience through each piece with the help of visualizations.

Communicating the Need for Action

Data storytelling can help turn data insights into action. Without effective communication, insights can go unnoticed or unremembered by your audience; both hard and soft skills are crucial for leveraging data to its fullest potential.

Harvard Business School Professor Jan Hammond speaks to this in the online course Business Analytics, one of three courses that make up the Credential of Readiness (CORe) program.

"Always remember that applying analytical techniques to managerial problems requires both art and science," Hammond says. "Over my career, I've learned that it's the soft skills that are the hardest to master, but they're critically important."
Do you want to become a data-driven professional? Explore our eight-week Business Analytics course and our three-course Credential of Readiness (CORe) program to deepen your analytical skills and apply them to real-world business problems.

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Data Storytelling: How to Tell a Story with Data

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Data storytelling is the ability to communicate insights from data using narratives and visualizations. Here's how to effectively tell a story with data.

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Animated match-burning video shows how social distancing can stop the spread of Covid-19

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Former nurse found guilty in accidental injection death of 75-year-old patient

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RaDonda Vaught’s conviction could lead to years in prison. It’s a rare case of a medical mistake being deemed a crime, and many worry it will have a chilling effect on the entire nursing profession.

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Should I retain ventilatory support for a critical patient who is unlikely to survive or use the ventilator for a less critical patient with better prognosis?

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Ethical dilemmas faced by health care workers during COVID-19 pandemic: Issues, implications and suggestions

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Standards of care do not, in fact, change during periods of resource scarcity. The legal standard is that you cannot be held accountable for doing something that is not possible to do, an idea also captured in medical ethics. In other words, you’re not obligated to do something impossible.

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The responsibility to show up for patients-often called the duty to treat-is an ethical obligation in medicine. But amid a pandemic, it may be difficult to satisfy because of the added obligation to protect oneself and one's patients from infection during shortages of personal protective equipment (PPE).

A webinar, "Ethics and Equity in Crisis Standards of Care," produced by Project Firstline-the Centers for Disease Control and Prevention's national training collaborative for infection prevention and control-featured a presentation by Matthew Wynia, MD, MPH, professor of medicine and public health and director of the Center for Bioethics and Humanities at the University of Colorado.

Dr. Wynia, an AMA member, placed the topic of infection control in the larger context of crisis standards of care and outlined the core ethical issues that should be top of mind for physicians during disaster response. The presentation was followed by a discussion of infection control guidance under crisis standards with a specific focus on staffing and PPE shortages.

Unless you do no clinical work, you almost certainly have operated under crisis standards of care at some point during the COVID-19 pandemic, Dr. Wynia noted. Early in the pandemic, for example, physicians had to adopt standards of care for PPE.

"Reusing N95 or surgical masks is clearly not normal care," he said. "Prior to this pandemic, that would've been essentially unthinkable-and now we do it all the time."

This points to four realities that underscore how complicated-and imperfect-medical ethics can be during disaster response:

Standards of care do not, in fact, change during periods of resource scarcity. The legal standard is that you cannot be held accountable for doing something that is not possible to do, an idea also captured in medical ethics. In other words, you're not obligated to do something impossible.

Ethical principles won't always provide answers about rationing. "We can't just make decisions based on a utilitarian calculus," Dr. Wynia said, noting that physicians are taught to look to ethical principlism for guidance.

Its four components are autonomy, beneficence, lack of maleficence and justice. The challenge is that ethical principlism rarely provides a clear-cut answer. The reason is that its principles often come into conflict with each other.

"This is why ethical dilemmas arise-because you have a circumstance in which you cannot optimize all of your key ethical principles," Dr. Wynia said. "You have to pick some that are going to exceed the value of others."

Equity is important-even when trying to maximize the number of lives saved. In the rollout of vaccines, public health authorities sometimes prioritized older populations over people who have been historically marginalized.

"The efficient, rapid rollout of vaccinations might warrant that, knowing that we are going to exacerbate inequity." Dr. Wynia said. "But it's going to be short term, and this is the easiest way to get vaccines into the arms of the highest risk individuals."

Making local decisions requires processes, not just rules. "What we are trying to do here is really hard. We are drawing lines about who gets what in a very granular world," Dr. Wynia said. "There are very few decisions we've made that we haven't had to revisit."

Read more about how the COVID-19 pandemic has served up new questions of medical right and wrong.

Project Firstline is a collaborative of dozens of national, state and local health care and public health organizations-including the AMA-that have come together to provide infection control training for millions of front-line U.S. health care workers and members of the public health workforce.

Its include educational videos, a training facilitator toolkit, web buttons and social media graphics, print materials and online events. There are also a number of partner resources, which include additional helpful videos, webinars and podcasts.

Additionally, Project Firstline has several modules on the ™, covering everything from infection control and virus basics to injection safety and hand hygiene.

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Why COVID-19 has provided a timeless lesson in ethics

# data[].attributes.attachment_link.description
The responsibility to show up for patients-often called the duty to treat-is an ethical obligation in medicine. But amid a pandemic, it may be difficult to satisfy because of the added obligation to protect oneself and one's patients from infection during shortages of personal protective equipment (PPE).