After using an “all hands on deck approach,” the White House Rural Council was able to produce a package of new job initiatives that were announced at the White House Rural Economic Forum. The Council’s recommendations, which leverage existing programs and funding, include making HHS loans available to help more than 1,300 Critical Access Hospitals recruit additional staff, and helping rural hospitals purchase software and hardware to implement health IT. The specifics are below:

Increasing Rural Access to Health Care Workers and Technology

Increasing Physician Recruitment at Critical Access Hospitals: HHS will issue guidance to expand eligibility for the National Health Service Corps loan repayment program so that Critical Access Hospitals (those with 25 beds or fewer) can use these loans to recruit new physicians. This program will help more than 1,300 CAHs across the country recruit needed staff.  The addition of one primary care physician in a rural community generates approximately $1.5 million in annual revenue and creates 23 jobs annually.  The average CAH creates 107 jobs and generates $4.8 million in payroll annually.

Expanding Health Information Technology (IT) in Rural America: USDA and HHS will sign an agreement linking rural hospitals and clinicians to existing capital loan programs that enable them to purchase software and hardware needed to implement health information technology (HIT). Under current conditions, rural health care providers face challenges in harnessing the benefits of HIT due to limited access to capital and workforce challenges.  Rural hospitals tend to have lower financial operating margins and limited capital to make the investments needed to purchase hardware, software and other equipment.

The health status of rural residents are intertwined with geography, economy, individual habits and genetics as well as access to care. The result of the dynamic interplay between these factors is a population that tends to experience a higher rate of: accidents, suicides, people with low income, public health insurance eligibility and uninsured than their metropolitan counter-parts.

Policy solutions for rural health have taken many forms including: loan repayment programs (Federal and State); construction of schools, hospitals and clinics; National Health Service Corps; J1 visas (non-US trained physicians); and telemedicine. While each of the policy solutions have its merits and effected rural health disparities to varying degrees, the basic mismatch of providers to residents still exist and create a very real access to care problem.

Hopefully this latest package combined with those provided by ACA will increase access to health care in rural areas.

Helpful Rural Health Terms to Know

Rural Health Clinics (RHCs): Clinics in official “rural designated” areas that provide a “safety net” for health care delivery.  There are approximately 3,800 Rural Health Clinics nationwide that provide access to primary care services in rural areas[i].

Federally Qualified Health Centers (FQHCs): “Safety net” providers such as community health centers, public housing centers, outpatient health programs funded by the Indian Health Service, and programs serving migrants and the homeless that meet the Centers for Medicare and Medicaid Services (CMS) criteria for FQHC designation. The main purpose of the FQHC Program is to enhance the provision of primary care services in underserved urban and rural communities[ii].

Health Professional Shortage Areas (HPSAs): These areas, designated by Health Resources and Services Administration (HRSA), have shortages of primary medical care, dental or mental health providers and may be geographic (a county or service area), demographic (low income population) or institutional (comprehensive health center, federally qualified health center or other public facility). [iii]

Medically Underserved Areas (MUA): Areas that are designated by HRSA in which residents have a shortage of personal health services.  They may be a whole county; a group of contiguous counties, a group of county or civil divisions; or a group of urban census tracts. [iv]

Medically Underserved Populations (MUPs): Groups of people who face economic, cultural or linguistic barriers to health care as defined by HRSA.[v]

Criteria for Rural and Urban Designation

Rural definitions are typically based on the following three concepts; administrative, land-use, or economic[vi]. Each definition provides considerable variation in socio-economic characteristics and well-being of the measured population[vii]. This process becomes more confusing when more than one definition is used during policy creation and evaluation.

However, one of the major criteria for Rural Health Clinics is to meet the Census Bureau’s standard of rural. The standard is straightforward- is a definition based on exclusion. Simply put, in order to meet the definition of rural an area cannot meet the Census Bureau’s definition of urban (see below)[viii].

The Census Bureau does not define suburban[ix].

Urban: All territory, population, and housing units located within an urbanized area (UA) or an urban cluster (UC). UA and UC boundaries encompass densely settled territory, which consist of: 1) core census block groups or blocks that have a population density of at least 1,000 people per square mile and 2) surrounding census blocks that have an overall density of at least 500 people per square mile[x].

Rural: The Census Bureau's classification of "rural" consists of all territory, population, and housing units located outside of urban areas (UAs and UCs). The rural component contains both place and non-place territories. Geographic entities, such as census tracts, counties, metropolitan areas, and the territory outside metropolitan areas, often are "split" between urban and rural territory, and the population and housing units they contain often are partly classified as urban and partly classified as rural[xi].

[i] Centers for Medicaid and Medicare Rural Health Clinic Fact Sheet (April 2009), available at http://www.cms.gov/MLNProducts/downloads/RuralHlthClinfctsht.pdf (last accessed August 2010)

[ii] Centers for Medicaid and Medicare Rural Health Clinic Fact Sheet (April 2009), available at  http://www.cms.gov/MLNProducts/downloads/fqhcfactsheet.pdf (last accessed August 2010)

[iii] U.S. Department of Health and Human Services, Health Resources and Services Administration Shortage Designation: HPSAs, MUAs & MUPs (May 28, 2010) http://bhpr.hrsa.gov/shortage/ (last accessed July 2010)

[iv] Ibid

[v] Ibid

[vi] Cormartie,J.; Bucholtz S.(Economic Research Service) Defining “Rural” in Rural America (2008) Volume 6 Issue 3 available at http://www.ers.usda.gov/AmberWaves/June08/Features/RuralAmerica.htm (last accessed August 2010)

[vii] Ibid

[viii] U.S. Census Bureau Census 2000 Urban and Rural Classification (2009)

http://www.census.gov/geo/www/ua/ua_2k.html last accessed August 2010

[ix] U.S. Census Bureau Census 2000 Urban and Rural Classification: Question and Answer (2009)

https://ask.census.gov/cgi-bin/askcensus.cfg/php/enduser/std_adp.php?p_faqid=623&p_sid=CSWjaK5k&p_created=1092150238&p_sp=cF9zcmNoPSZwX3NvcnRfYnk9JnBfZ3JpZHNvcnQ9JnBfcm93X2NudD0mcF9wcm9kcz0mcF9jYXRzPSZwX3B2PSZwX2N2PSZwX3BhZ2U9MQ!!&p_search_text=rural%20definition last accessed August 2010

[x] U.S. Census Bureau Census 2000 Urban and Rural Classification (2009)

http://www.census.gov/geo/www/ua/ua_2k.html (last accessed August 2010)

[xi] Ibid

This is the third day of the week long exploration of care transitions and medication errors. Knowing the importance and vulnerability surrounding care transitions I will present findings from the literature regarding medication reconciliation and safety culture/teamwork that will illuminate their “true” impact in reducing medication errors. For another look at how Hope Street Group conceives to improve the quality and cost of transitions between acute and other types of care, click here: http://www.hopestreetgroup.org/docs/DOC-2479 .

Medication Reconciliation

Medication reconciliation is a comparison of the patient’s current medication regimen against the admission, transfer and/or discharge orders for the purpose of identifying and fixing discrepancies (Northwest Memorial Hospital, 2011). Medication reconciliation is needed during every transition of care in order to clearly identify what medication changes are permanent, temporary and that duplicate or conflicting medications are not being prescribed. AHRQ projects that 14%

of patients upon being discharged from the hospital have some sort of medication inconsistency due to a lack of medication reconciliation (Agency for Healthcare Research and Qulaity).  Regardless, to date, evidenced based methods for medication reconciliation are lacking

despite the need for it to occur. As a result, the Joint Commission

announced in 2009 that they would no longer score medication reconciliation during on-site accreditation surveys, thereby reversing their 2005 stance (Agency for Healthcare Research and Qulaity).

Safety Culture/Teamwork

The concept of safety culture came from high reliability organizations. Agencies or groups such as air traffic control systems

that operate in hazardous conditions but have few adverse events were evaluated for common traits. Common features of high reliability organizations include

(Agency for Healthcare Research and Quality):

• “Preoccupation with failure—the acknowledgment of the high-risk, error-prone nature of an organization’s activities and the determination to achieve consistently safe operations.
• Commitment to resilience—the development of capacities to detect unexpected threats and contain them before they cause harm, or bounce back when they do.
• Sensitivity to operations—an attentiveness to the issues facing workers at the frontline. This feature comes into play when conducting analyses of specific events (e.g., frontline workers play a crucial role in root cause analyses by bringing up unrecognized latent threats in current operating procedures), but also in connection with organizational decision making, which is somewhat decentralized. Management units at the frontline are given some autonomy in identifying and responding to threats, rather than adopting a rigid top-down approach.
• A culture of safety, in which individuals feel comfortable drawing attention to potential hazards or actual failures without fear of censure from management.”

Even though safety can be defined and measured by survey and providers at all levels, creating sustainable cultures of safety has proven difficult

(Agency for Healthcare Research and Quality, 2011). Poor perceived safety culture has been linked to increased error rates (Agency for Healthcare Research and Quality, 2011).  Team training is a proven intervention to improve an organization culture regarding safety by raising situational awareness (Agency for Healthcare Research and Quality, 2011). Teamwork training also emphasizes the role of human factors such as fatigue, management styles, organizational cultures and perceptual errors such as mishearing instructions. This can be addressed using simulations or classroom/lecture style sessions.

Tomorrow, I’ll cover shovel ready interventions such as TeamSTEPPS and provide a research-based comparison of each intervention discussed this week in a handy chart for you to use.

I know there are dedicated supporters of each intervention. Let us hear what you have to say! Log in and share below.

Agency for Healthcare Research and Quality. (2011 February). Nursing Home Survey on Patient Safety Culture. Retrieved 2011 10-August from Agency for Healthcare Research and Qulaity: http://www.ahrq.org.gov/qual/patientsafetyculture/nhsurvindex.htm

Agency for Healthcare Research and Qulaity. (n.d.). PSNET, Patient Safety Primer, Medication Reconciliation. Retrieved 2011 10-August from Agency for Healthcare Research and Qulaity: http://psnet.ahrq.gov/primer.aspx?primerID=1

Agency for Healthcare Research and Quality. (n.d.). PSNet, Glossary, High Reliabiltiy Organizations. Retrieved 2011 10-August from Agency for Healthcare Research and Quality: http://psnet.ahrq.gov/popup_glossary.aspx?name=highreliabilityorganizations

National Priorities Partnership. (2011 10 August). National Quality Forum, Overuse. Retrieved 2011 10-August from National Quality Forum: http://www.qualityforum.org/Topics/Overuse.aspx

Northwest Memorial Hospital. (2011). MATCH Medicatin Reconciliation Toolkit. Retrieved 2011 14-March from Northwest Memorial Hospital: http://www.nmh.org/nm/making+the++case

I will explore some key causes and solutions to medication errors associated with care transitions using components of Hope Street Group’s analytical model: “Amplify” our productivity- Improve the quality and cost of transitions between acute and other types of care.

Care transitions have been identified as points in the health care continuum that can increase risk of medication errors due to poor coordination (California HealthCare Foundation, 2007). Approaches to improving medication errors during care transitions include: checklists, computerized order entry, medication reconciliation, improving the “safety culture” and teamwork (Agency for Healthcare Research and Quality).  This post will discuss the overall impact of post-hospital adverse events. Subsequent posts this week, will discuss the feasibility, appropriateness and evidence for the leading potential solutions/interventions based upon a review of the literature.

The overall incidence of post-hospital adverse events has been reported to be 20% within 3 weeks of discharge(Forster, Murff, Peterson, Ganhi, & Bates, 2003). Moreover, the same researchers stated that nearly 75% of those adverse events could have been prevented or ameliorated (Forster, Murff, Peterson, Ganhi, & Bates, 2003).   It has also been argued that care transitions are especially important for elderly patients and other high-risk patients who have multiple medications and comorbidities (Halasyamani, et al., 2006).  Despite the lack of official numbers, researchers agree that the risk for post-hospital adverse events continues to mount as the elderly and other high-risk patients make the transition to a nursing home(Halasyamani, et al., 2006).

However, a combination of individual, team and organizational issues contribute to the challenges of lowering the risk of medication errors during care transitions to nursing homes and long-term care facilities from hospitals (Table 1).

While the research focus here is between hospitals and nursing homes, lessons can be applied to any situation where there is a transition of care in the health eco-system.

As we look to see if these approaches to improving medication errors during care transitions really help this week, please tell us about your experiences with:

• checklists,
• computerized order entry,
• medication reconciliation,
• improving the “safety culture”/teamwork  and;
• shovel ready interventions (i.e. TeamSTEPPS)

California HealthCare Foundation. (2007). Fast Facts: Coordinating Care Transitions. Oakland: California HealthCare Foundation.

Agency for Healthcare Research and Quality. (2011 February). Nursing Home Survey on Patient Safety Culture. Retrieved 2011 14-March from Agency for Healthcare Research and Qulaity: http://www.ahrq.org.gov/qual/patientsafetyculture/nhsurvindex.htm

Forster, A., Murff, H., Peterson, J., Ganhi, T., & Bates, D. (2003). The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital. Annals of Internal Medicine , 138 (3), 161-167.

Halasyamani, L., Kripalani, S., Coleman, E., Schnipper, J., vanWalraven, C., Nagamine, J., et al. (2006). Transition of Care for Hospitalized Elderly Patients: Development of a Discharge Checklist for Hospitalists. Journal fo Hospital Medicine , 1 (6), 354-360.

Walmart changed the pharmaceutical retail industry forever by creating the $4 Prescription Program. In one fell swoop, a gargantuan company disrupted part of the health care ecosystem. Today it looks like they are taking a new angle on how to manage in store health clinics. In the past, Walmart utilized a separate company that ran health clinics within the store but these closed in 2008 after about 3 years in operation. By partnering with St. Dominic in Mississippi, Walmart has made a deliberate choice to support local health care professionals ability to provide care to their community.

This type of movement directly ties with Hope Street Group’s belief that using new places to deliver primary care can achieve greater capacity at lower cost.

You can read more about this here: Walmart to open clinics in stores , The Clinic at Walmart and Recommendation 3: Use new people, places, and tools to achieve greater capacity at lower cost.

In its 2001 seminal report “Crossing the Quality Chasm:  A New Health System for the 21rst Century”, the Institute of Medicine (IOM) described the current state of health care delivery.  The report described a health care system that was fragmented, poorly designed and most importantly not delivering quality care. It also outlined a plan with very specific performance objectives designed to close the quality gap and support the patient-provider relationship. These objectives called for a radical redesign of the health system to achieve six aims—safe, effective, patient-centered, timely, efficient, and equitable care.  A new phase in health care improvement is now emerging: one that focuses on value. Value considers providing safe, effective, and efficient care at the right cost. The Institute for Healthcare Improvement (IHI) has developed a model for optimizing health, care experience, and costs for populations -- The Triple Aim. This is a structure in which we know and care about:

1. Patient and Family experience,
   
2. The quality of care delivered, and
   
3. How our efforts impact the cost of care.
   

I would add from my own perspective that we care about our community and providing care for all.

My career started working as a nurse in a hospital system before I moved to the ambulatory care setting. As a nurse there are moments in my career that haunt me. These tragic events had catastrophic impact on patients and families. It was not the failure of caring and competent staff which led to these haunting memories--it was the lack of systems and process to support evidence based care. These experiences drive my passion for a healthier health care delivery system.

In my current position with Colorado Beacon Consortium as Director, Community Collaboratives and Practice Transformation, I have the pleasure of helping primary care practices in transformation and learning from their amazing efforts. In my 15 years working with primary care practices, I have never met a staff member clinical or non-clinical who came to work hoping not to deliver the best possible care. Practices need support for these transformational changes.  Having a “small test of change” fail has meaning for clinical staff because of our educational experience. Failure in the clinical training means that a patient is harmed. Clinical staff need to understand that failures in the quality improvement process mean that the team will not be wasting their time on processes that do not bring value to their patients or to the practice.

In an era of incentive programs such as Meaningful Use and system designs such as Accountable Care Organizations, now more than ever strong Primary Care delivery systems is necessary for creating a healthier health care system. Primary Care transformation is integral is achieving the goals articulated in Crossing the Quality Chasm.

Now more than ever Primary Care needs support to transform systems and processes to make their best better. Redesign efforts started with the development of the Chronic Care Model by Dr. Edward Wagner and the MacColl Institute. The Chronic Care Model serves as a structure to organize care delivery for patients with chronic disease by maximizing proactive team based care, implementing processes which deliver evidence based care, utilizing health information technology (HIT) and delivering proactive care. Through several national organizations such as Health Resources and Services Administration (HRSA) Health Disparities Collaboratives, the Institute for Healthcare Improvement (IHI), the MacColl Institute and more recent initiatives such as National Demonstration Project and Improving Performance in Practice (IPIP) best practices in primary care transformation have been developed.

The Patient-Centered Medical Home (PCMH) has been recognized as a catalyst to support Primary Care transformation that delivers on the expectations described in Crossing the Quality Chasm. Agency for Healthcare Research and Quality (AHRQ) describes PCMH as:

• Patient-Centered
  
• Comprehensive  & Coordinated care
  
• Superb access to care
  
• A systems-based approach to quality and safety
  

These attributes must be supported by a foundation of Health Information Technology and rich data which provides knowledge to drive outcomes.  The other structural change must come in the form of a payment structure that supports primary care and the attributes that will drive the value primary care delivery will bring to healthcare.

A comprehensive program to recognize practices who implement the attributes of PCMH has been developed by the National Committee for Quality Assurance (NCQA) Physician Practice Connections- Patient-Centered Medical Home (PPC-PCMH). NCQA has recently updated the recognition program.

The 2011 program includes the core components of primary care:

• PCMH 1: Enhance Access and Continuity
  
• PCMH 2: Identify and Manage Patient Populations
  
• PCMH 3: Plan and Manage Care
  
• PCMH 4: Provide Self-Care and Community Support
  
• PCMH 5: Track and Coordinate Care
  
• PCMH 6: Measure and Improve Performance
  

The transformation process for primary care is more than tinkering around the edges. This process of change requires a foundation of culture and leadership that is supportive of the efforts within the practice. This can be either through the leadership structure of a broader organization or within a small independent primary care practice. The Primary Care Practice team members are being asked to reconsider the hierarchical nature of medicine for a team based approach to patient-centered care. All members of the team to participate in the redesign process and in evidence based care delivery. Practices establish structures to make “small tests of change” that are reviewed to understand if the impact is positive in delivering safe, effective, evidence based care.  Implementing self-management support with primary care builds on the most intimate of relationships between patient & families and the care team. Self-management techniques utilized in the care setting build on patient activation and engagement in their care. Technology is a tool to be maximized and utilized meaningfully.

Clearly, we understand the role of Primary Care in supporting our current sick health care system to become healthier. This transformation takes time and requires support. As we establish principles, goals, care models and incentive programs to create a healthy health care system, it is important not to lose sight of the need to also transform the current payment model with is perfectly designed to assure that our fragmented, ineffective, dysfunctional and harmful health care system continues.

Crossing the Quality Chasm

http://www.iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx

Institute for Healthcare Improvement

http://www.ihi.org/IHI/Programs/StrategicInitiatives/IHITripleAim.htm

Improving Chronic Illness Care

http://www.improvingchroniccare.org/

HRSA Healthcare Communities

http://www.healthcarecommunities.org/

Agency for Healthcare Research and Quality

http://www.pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483/what_is_pcmh_

National Committee for Quality Assurance

http://www.ncqa.org/tabid/631/default.aspx

Office of the National Coordinator for HIT (ONC)

http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__home/1204

Colorado Beacon Consortium

http://www.coloradobeaconconsortium.org/

Center for Medicare and Medicaid (CMS)

https://www.cms.gov/EHRIncentivePrograms/30_Meaningful_Use.asp

Partnership with Patients

http://www.healthcare.gov/center/programs/partnership/index.html

Where does the healthcare continuum really begin?

With prevention?

In the home?

With the Primary Care Provider?

In the Emergency Department?

Although an argument can certainly be made for any of the four choices above, I’d like to challenge your opinion and perspective with a different answer…the continuum for many begins with Emergency Medical Services (EMS).

This past year I had the privilege to be included in two standard setting and forward thinking discussion forums-- AHRQ’s 2010 Annual Conference and HCIE Innovators Event as well as Hope Street Group’s Policy 2.0: Using Open Innovation to Reinvent Primary Care Project. Both of these events offered diverse perspectives from diverse participants in academia, corporations and all levels of government and localities who gathered to discuss and make recommendations to improve the health care system. Interestingly, the first responder perspective of EMS was only a footnote in these discussions. I believe that policy makers and leaders within healthcare all too often fail to look outside their sphere of influence and familiarity for answers or more importantly the critical questions. That said, I know this minimalization was not intended or planned, but a result of historical processes and comfort levels.

The numbers…

EMS contributes 15% or 17.25 million patients to the nations 123.8 million annual Emergency Department (ED) visits (CDC, 2008), yet Fire, EMS or Law Enforcement respond to over 240 million 911 calls per year (NENA, 2009). It’s difficult to accurately breakdown the national percentages of 911 call types, but upwards of 60% of EMS calls are generally considered low-acuity or non-emergent. To put this into a local perspective, the City of Tucson AZ with a population of approximately 530,000 (2005) generates approx. 79,000 Fire and EMS 911 calls per year, 84% or ~67,000 of these are medical in nature and 60% of those, ~46,000 require only Basic Life Support (BLS) care (TFD, 2009).

So what does that really mean? It means that the 911 system provides a substantial safety net for the Nation’s healthcare system. While this should come as no surprise, the volume of patients utilizing EMS, Emergency Departments and the 911 system continues to grow. Over 15 years ago, the National Highway Traffic Safety Administration and the Health Resources and Services Administration joined with leaders from the EMS community to put forth an EMS plan that would require significant collaboration with acute care, primary care and public health. This provided one of the earliest, nationwide, use of the scale-up-and spread model and was published as the1996 EMS Agenda for the Future (NHTSA, 1996).

The past…

To implement that vision and professional template, EMS has continued to grow it’s service provision model from one that was historically created for stabilization and transport of the acutely ill and injured; one that was set-up to intervene only when patients needed emergent support; one that operated in relative isolation from other health care and community resources; one that was not involved in the business of ensuring social service follow-up and one that did not have a working knowledge of community health care providers and regional health care organizations (NHTSA, 1996).

The present…

Today, EMS is integrated with other health care providers, public health and public safety agencies to provide community-based healthcare and management. EMS agencies and providers are involved in activities related to prevention education, illness and injury risk, acute illness and injury care, follow-up, treatment of chronic conditions and community health monitoring. This vision is also shared by the Injury Response Division of the National Center for Injury Prevention and Control/Centers for Disease Control and Prevention (NCIPC/CDC) and the American College of Emergency Physicians (ACEP) who have called for a better understanding of roles and collaboration between Public Health and EMS through their Appleseed Project initiative (CDC, 2004).

The reality …

As you can see, EMS has developed into more than a group of fire departments, rescue services and ambulance companies. While providing these additional and collaborative services, EMS remains the public’s emergency medical safety net.  Looking back to those 240 million 911 calls and the 17.25 million EMS-to-ED admissions, it’s clear that a significant amount of health assessment, care and triage occurs outside the hospital walls. In fact, there are no other healthcare providers that see patients in their own home or living environment quite like EMS. The “scene assessment” which is a fundamental EMS skill reveals more information about a person, their living conditions, their health, their support system and their coping mechanisms than any other assessment tool.  How many Primary Care providers, case managers or health plan administrators have this perspective into their own patient’s lives?

From where I sit with over 30 years of experience as an RN in Maternal-Child Health and EMS, I see several important questions that need further discussion and clarification before we can begin to understand how to move forward in improving the healthcare of our Nation.

• How can we better educate individuals to utilize the 911 system for acuity appropriate reasons?
  
• How do we encourage the use of Primary Care practitioners for non-emergent and urgent medical and injury complaints instead of defaulting to the approach of “if this is a medical emergency, please hang up and dial 911?
  
• How do we share the burden of after-hours and weekend low-acuity patient needs?
  
• How do we facilitate better communication and collaboration between EMS, public health, acute and chronic care case management, behavioral health and community services?
  
• How do we move patients calling 911 for non-emergent or non-healthcare reasons into a public or human services system that will better meet their needs?
  

Communication, collaboration, connectivity, consistency and caring are all functions of healthcare, yet as the patient numbers and range of patient complaints increase, we all need to utilize each others skills, knowledge and expertise to meet the needs of our patient population. Reaching out to our colleagues may be the first step toward improvement, integration and understanding of our healthcare system.

http://www.911dispatch.com/info/fact_figures.html

http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/nhamcsed2008.pdf

http://cms3.tucsonaz.gov/sites/default/files/imported/data/demographic/eecpop00_05.pdf

http://www.nena.org/911-statistics

http://www.cdc.gov/injury/publications/index.html

http://www.nremt.org/nremt/about/emsAgendaFuture.asp

http://www.tucsonaz.gov/fire/AnnualReport.pdf

The promise of telemedicine has been around for years, with robotic surgeries, remote monitoring of patients and big city doctors able to care for rural patients over computer networks. But not until Apple IOS devices like iPhone and iPad as well as Android OS phones and tablets have been introduced, have we seen the true promise and convenience of what telemedicine can really be. Not on an emergency, expensive basis, but in a day-to-day, real-world kind of way.

Widespread use of remote monitoring over broadband networks, located in both institutions and homes, to track vital signs and metrics of patients with chronic diseases such as congestive heart failure and diabetes is a critical and urgent development. Remote monitoring can spot health problems sooner, reduce hospitalization, improve life quality and save money. Adoption of remote monitoring technologies will be slowed and benefits reduced unless the United States does a better job of reimbursing health care organizations for remote care and encouraging continued investment in broadband infrastructure that can be tailored to meet privacy, security and reliability requirements for telemedicine applications.

Telemedicine can help those with chronic illnesses to lead normal work and personal lives and enable older Americans to remain in their own homes instead of moving to institutional settings. Remote monitoring technologies can transmit data on a regular, real time basis and prevent hospitalizations by identifying and treating problems by triggering adjustments in care before negative trends reach crisis stage. As a result, increase access to care is achived and hospitalizations can be averted.

However, success in translating potential savings into real savings depends in part on public policy decisions that speed the acceptance and penetration of remote monitoring. The realignment of reimbursement policy for telemedicine is among the most critical policy decisions that need to be made. Right now, like other preventive care, telemedicine is only covered to a limited extent and reimbursement is low. For example, remote consultations with physicians are reimbursed if they are conducted over two-way video. However, physicians are not reimbursed for examining remote monitoring data as a preventive measure. Right now, patients and insurers are capturing many of the quality improvements and cost savings from telemedicine, but paying for few of them. The costs are largely incurred by health care providers, but not fully reimbursed. This leaves little incentive to encourage optimal levels of investment and commitment to the provision of telemedicine infrastructure and services.

As someone interested in innovation in health care, I’m very much excited about technologies like Apple’s Facetime, a video calling protocol that can be used by iPhone 4 users. I see FaceTime as a catalyst for renewed interest in telehealth. This type of technology lowers the cultural barrier to telemedicine as well as increasing its use by the general public.

What makes FaceTime different from existing telemedicine applications? The first thing is that it is simple to use. All you need is a phone number/email address and an Internet connection. Dedicated hardware or need to go to a specialized room is bypassed. Privacy can be secured in a variety of locations instead one sanctioned spot in a facility.

Recently, I was privy to an FDA-cleared platform which allows patient information - including waveforms and other critical data from EMRs, bedside monitors and devices, pharmacy, lab, and other clinical information systems - to be securely and natively accessed by physicians and nurses on their smart phones or tablets…anytime, and anywhere. Airstrip Technologies has launched an exciting set of enterprise-wide solution that delivers waveforms (cardiac, SPO2, ventilator, arterial line, etc.), vital signs, medications, I&Os, lab results, allergy lists, and EMR data for patients in areas such as ICUs, CCUs, PACUs, Ors and EDs. Users can refer to current or historical results through the patient medical file by simply selecting the required results view.

Quite simply, we need integrated technology policies. We need policy incentives that ensure institutions and practitioners who invest in telemedicine are sufficiently compensated for the resulting improvements in both care and costs. Policies that bring broadband technologies into more homes will also help bring in remote monitoring, video visits with providers, and self-care education. Policies and advances in products that increase the public’s fluency with advanced communications technology will make telemedicine more effective and easier to implement. In addition to policies we needs investments in networks to increase capacity for live video and continuous monitoring. Smart communications policy also can expedite the adoption of remote monitoring and other telemedicine technologies.

Nursing  Modernizes to Reflect Modern Times

As health care evolves, so has the nursing profession.  Advanced Practice Registered Nursing (APRN),  an umbrella term to include the 4 roles of advanced practice nurses, have been expanding at a rapid rate.    There are over 250,500 APRNs in the country, according to the recently released HRSA report on the nation’s nursing workforce, in 2008, there were:

1) 174,300 Nurse Practitioners

2) 18,500 Nurse Midwives

3) 35,000 Nurse Anesthetists

4) 59,000 Clinical Nurse Specialists.

Landmark reports including the IOM’s Crossing the Quality Chasm and it’s follow up, Health Professions Education: A Bridge to Quality, emphatically recommended that a modern well-functioning health care workforce must be prepared to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement innovation, outcomes results and informatics.

Advanced Practice Nurses Evolve to the Doctoral Level

The American Association of Colleges of Nursing developed a consensus process to address the nursing profession’s current practice of preparing advanced practice nurses in master’s degree programs as no longer adequate to meet modern complexity and demands.   A roadmap to adopt the position that all advanced practice nursing programs will move  to the doctorate of nursing practice (DNP) by 2015.  This curriculum is intended to propel nursing practice forward and keep it grounded in the practice domain.  Historically, nurses were often earning PhDs with a focus on generating new knowledge.  What was missing was an expert clinician to provide leadership and could translate and infuse evidence into care delivery systems.    A clinical doctorate would address the growing complexity of health care,  compounded by an escalating demand for services, burgeoning growth in scientific knowledge, and the increasing sophistication in technology. The nursing profession recognizes that in order to transform health care delivery, we must recognize the critical need for clinicians to lead, design, evaluate, and continually improve the context within which care is delivered.   Picture an expert nurse practitioner who can also lead quality improvement efforts,  build programs to help all providers practicing within the context of an evidence-base,  effect cultural change, and engage in executive level decision-making in large, complex health care institutions.  A DNP will create a highly qualified APRN to meet evolving models of care delivery that focus on outcomes, a nurse practitioner on steroids, if you will.

National  APRN Standards are Established. 

The National Council of State Boards of Nursing has internally modernized their standards across a range of issues by creating an advanced practice nursing regulatory model.  It requires all APRN programs follow clear, consistent curriculum guidelines with rigorous accreditation standards, that state licensing boards develop standard requirements for APRN licensure, and that educational programs are standard across the 4 APRN roles.  It boldly states that the hodge-podge of nurse practice  acts across  the nation, over half of which are restrictive, must be removed.  It recommends that solely boards of  nursing regulate advanced practice nurses – which is not the norm in some states.   For example, some states require boards of medicine to regulate or co-regulate advanced nursing practice.   The profession has set new standards and many states are not in compliance with them.  Some states, such as Virginia, have a restrictive practice act, which had not been modernized since the 1970s,  creating unnecessary practice restrictions in a time of dire need and workforce shortages.   [The report, APRN Consensus, is found below]

IOM Focuses on Nursing’s Future

Last fall the IOM released, The Future of Nursing, which makes several bold recommendations.  The report is based on 4 key principles: 1) Nurses should practice to the full extent of their education and training; 2) Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. 3) Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States; and 4) Effective workforce planning and policy making require better data collection and an improved information infrastructure.  The report recommends that the number of nurses with a doctorate be doubled by 2020 so that nurses are prepared to lead and improve collaborative health care improvement efforts. In order to do this, the report strongly urges all levels of government to remove regulatory barriers to practice.   One strategy  the IOM recommends is to have Congress limit federal funding for nursing education to states that have not adopted the model rules and regulations described above.

All to say, the times they are a changing.  Modern nursing practice has adapted to the surge in chronicity,  the broad mandate to make threshold improvements in patient safety, care transitions and quality of care.  Advanced practice nurses with doctorates in nursing practice are prepared to lead the way.   In this time of transformation, if the health  professions stay fixed, immutable, and non-adaptive to the changing landscape, we can expect more of the same bleak health care outcomes, unsafe practices, and out of control health care inflation.  

Dr. Eileen O’Grady is a Certified Nurse Practitioner and Wellness Coach and teaches health policy at Pace University’s DNP program.   She earned a PhD and wishes she had a DNP degree.    www.eileenogrady.net

Sources:

American Association of Colleges of Nursing. DNP Roadmap Taskforce Report.  http://www.aacn.nche.edu/dnp/pdf/DNProadmapreport.pd

The National Council of State Boards of Nursing: Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education  http://www.nonpf.com/associations/10789/files/APRNConsensusModelFinal09.pdf

IOM: The Future Of Nursing Report    http://thefutureofnursing.org/recommendations

The National Sample Survey of Registered Nurses (2008)   http://bhpr.hrsa.gov/healthworkforce/rnsurvey/2008/nssrn2008.pdf