Nursing Workflow Interrupted: The Shortcomings of Technology in Healthcare

Jonathan Dimas RN, BSN, CCRN 
PhD Student University of Utah College of Nursing 

The Good   

If you’ve ever listened to someone speak about emerging technology, at a symposium or in everyday conversation, there’s a pretty good chance you’ve heard about the countless benefits we now enjoy as a result of these technological advances.  “Look how fast…look how easy… look how much better… “, you get the idea.  Technology has already changed the world in so many ways it boggles the mind to consider what the future might bring.  The healthcare sector is no exception.  These advances are so numerous that to only list the most influential would take the length of an entire textbook, and still only scratch the surface. Healthcare breakthroughs such as the Human Genome Project, nanotechnology, and new insights into the human microbiome have brought about rapid changes, that are so profound we often don’t have the resources and infrastructure to manage the implications of new findings.  For the moment, however, let’s take a step back from the overwhelming and exciting technological leaps being made in pharmacogenomics, theranostics and tissue engineering. 

The Bad

If you’ve ever heard a nurse talking about charting in an electronic health record, or using a top of the line IV pump or using a barcode scanner when giving medications, there’s a pretty good chance you’ve heard about the countless headaches we now suffer as a result of these technological advances.  Unlike the incredible time and effort saving benefits that are usually seen with technological upgrades, the adoption of clinical technologies seems to move in the opposite direction.  A cursory search of PubMed, CINAHL and Google Scholar did not reveal any studies on the impact these technologies have on time, effort and workflow, but I’m confident that even a simple survey among nurses would reveal no small amount of unfavorable opinions. 

The (Ugly) Question

The question then becomes, why is it that with the phenomenal advances being made in healthcare science, the bedside is left to languish in subpar technologies?  Some of the self-explanatory concepts that helped form Vankatesh et al.’s Unified Theory of Acceptance and Use of Technology were: relative advantage, ease of use, job-fit, compatibility, and perceived usefulness (2003).  I’m not sure developers really had these in mind when creating the bedside technology we see in use today.  Nurses often bemoan the fact that they end up taking as much care of the computer as they do the patient.  It is one thing to complain, and another to come up with solutions… or at least to have a vision for the future. 

The Present

First, imagine a busy day as an ICU nurse.  You are caring for two, very sick patients that each require multiple dressing changes, near hourly medications (some IV drips, some liquid and some pills that need to be crushed and dissolved in solution), repositioning every 2 hours, oral care every 4 hours, bed baths, continual assessment and monitoring and, when necessary, communication with the interdisciplinary healthcare team.  Now imagine, as you go into the room to give your first medications, the patient’s barcode on their ID band has been inadvertently cut and is unusable.  You get a new one ordered, and when it finally arrives, another nurse has taken the scanner for use on another patient.  You get the scanner back, and you realize you accidentally threw away the packaging to the pills you had to crush, and you have to go back to the medication dispenser to get a new package that you have to scan and then return to the dispenser.  Your first round of medications is complete!  Now onto charting the assessment and interventions that you performed while you’re in the room.  You log on to the computer at the nurse’s station and receive an unexpected downtime warning.  Seems like a good opportunity to go get your second patient squared away, before returning to chart both patients’ assessments and interventions… but first to track down that barcode scanner again.  You finally sit down to chart, and you have to page through 6 different tabs and several different pages just to get a basic assessment complete.  I could go on, but I hope the frustration is evident. 

It may seem like an implausible story, intentionally filled with mishaps, but I assure you this is par for the course in many institutions.  And where in that scenario, did the nurse connect with the patient?  When did the family get spoken to and consoled?  These frustrations with technology aren’t just impediments to nurse workflow.  They take away from our ability to connect with our patients and their families.

The Future?

My hope for the future is that new technologies will be designed to make our jobs easier, and allow us to get back to the bedside where we belong.  I readily acknowledge the benefits of electronic healthcare records, for the management, access and storage of data.  Interface and usability need to become a priority to developers in the future.  Why haven’t Apple or Microsoft, companies known for their excellence in user interface and operability, dipped their toes in the electronic healthcare record market? (*Hint, hint*)

My vision of a perfect technological interface would look something like this.  I come to work and receive report on my patients.  I put on my work glasses, which contain an unobtrusive display screen, object recognition capability, location tracking and audio/video recording installed.  I walk into my patient’s room with the medications and supplies I will need.  The patient’s chart is automatically opened as I enter, since the device “knows” whose room I’m in.  I introduce myself and talk with patient about our plan for the day, and when I’m ready, I give the verbal prompt “assessment,” and begin verbalizing my findings into the recorder.  I’m now ready to give medications, and give the appropriate prompt.  The glasses recognize that I’m in the correct room and visually recognize the packaging and barcodes of each medication I’m giving to the patient and charts them as I go; I only give half a vial for one medication and let the recorder know.  I’m ready for the dressing change and again I give a prompt, and verbalize my assessment.  The wound is looking much better and I give a command to snap a photo for the physician, so the wound does not have to be undressed an hour later when they come for rounds.  I check the patient’s blood glucose and recognize the need to adjust the insulin drip.  My display screen shows me the blood glucose trend and any other labs I request, and lets me know the new rate to set the insulin pump.  I tell the IV pump the new rate, and it makes the changes after confirming the new settings are correct.  I perform the other routine tasks, verbalizing my actions as I go.  As I walk out of the room, my display screen reminds me to reposition the patient since it’s been 2 hours, and I neglected to tell the recorder I had done so.  I complete the task and walk out of the room without having to sit down and chart a thing.  The family approaches as I exit and I walk back into the room with them and sit down to answer their questions and soothe their distress. 

As far-fetched as it may sounds, the technological capabilities already exist (e.g. Google Glass, Bluetooth headsets, Dragon dictation, Natural Language Processing).  Now we need enterprising scientists and clinical practitioners to collaborate and make this fictional account into a reality.  The promise of technology can then, move nurses out of their computer chairs and bring them back to the bedside.

Reference

Vankatesh, V., Morris, M., Davis, G., & Davis, F., (2003) User acceptance of information technology: Toward a unified view. MIS Quarterly 27(3), 425–478.

This work is by Jonathan Dimas licensed under a Creative Commons Attribution 4.0 International License

Analysis of Shifting Paradigms: Provider-Centered to Patient-Centered Care & Research

Doctors Know Best, but Doctors Sometimes Do NOT Know Best

—THE NEW YORK TIMES, 2012

In current clinical practice, providers focus on assessing disease severity and evaluating drug and treatment effectiveness. There is less emphasis on patient involvement in decisions about care or on the specific needs of patients that affect their quality of life. Despite expensive, highly specialized, and technologically advanced care practices; this disease-centered approach to care has resulted in poor quality outcomes. In terms of research, knowledge gained from clinical research does not directly answer the primary clinical questions of what is best for the patient at hand.

Physician centered practice developed from a system that allowed mounting utilization of diagnostic testing, prescriptions, hospitalizations, and referrals without regard for specific patient needs or desires. It is considered “depersonalized medicine” or “illness- oriented care”, with the aim to treat the illness, not the patients with the illness. The long held assumption that “Dr. knows best” is now being challenged as payers and consumers demand better bang (better outcomes) for the buck.

Assumptions
Provider Centered Care	Patient Centered Care
Disease focused	Patient focused
Physicians know best:  the experts	Physicians collaborate: the enablers
Physician oriented outcomes: What is best for the disease or illness	Patient oriented outcomes: What is best for individual patient
The best intervention for the typical patient	The best intervention under what conditions works for which patient
Patients as passive: complying with physician’s orders	Patients as active: “Nothing About Me Without Me”
Patients voice is ignored	Patient voice guides clinical decision making
“What’s the matter” with patients	“What matters” to patients
Fee for service, Shorter, more frequent visits, less reimbursement	A variety of qualified primary care providers – including nurse practitioners
Consumers unaware what healthcare $$ buys	Consumer informed – demanding better deal
Provider Centered Research	Patients Centered Research
Absolute efficacy	Comparative effectiveness
Homogeneity	Heterogeneity
Generality	Individualizations
Statistical significance	“What matters” to patients

“Nothing About Me Without Me.”

--PATIENT'S VOICE

Consumers are demanding that the role of the healthcare professional should change “from experts who care for patients to enablers who support patients to make decisions.” Rapid advances in technology create a forum for improved health literacy and curiosity among the public. Health care consumers no longer are interested in playing passive roles, but rather expect to be listened to, respected and treated with dignity and earnestness. Published reports from regulatory agencies call out the health care industry to either improve morbidity and mortality or face consequences of limited reimbursement and penalties. Comparative effectiveness research (CER) moves scholarship in a direction that engages the population as partners, addressing diversity and creating personalized approaches. A consumer movement advocates that patient-centered care become a goal of most healthcare practitioners and researchers worldwide.

Effective partnership with patients has been reported being associated with a large variety of positive patient outcomes, such as adherence to treatment, improved health, and satisfaction. Today, patient-centered care is thus termed as one of six indicators of quality care. Patient-centered care requires more than a respectful attitude toward patients, it requires personalized clinical interventions.  It is not necessarily giving patients what they want regardless of values or costs, but rather requires knowing the patient as a person and engaging the patient as a partner in his or her own care. 

Similarly, patient-oriented research should not be based on the evaluation of medical interventions in the average patient, but “on the identification of the best intervention for every individual patient. Patient oriented research focuses on the study of heterogeneity and places greater value on observations and exceptions-especially as they occur in real life versus under experimental conditions”. The outcome measures should shift from what are most important to the doctors to what are most important to the patients.  “A difference, to be a difference, must make a difference”. The Patient Centered Outcomes Research Institute (PCORI) is a corporation authorized under the Affordable Care Act of 2010 that incorporates patient-centered principles in their goal.

Key drivers of this paradigm shift:

 

      Personalized medicine and tailored therapeutics;

      Advances in pharmacogenomics and technology;

      Medical costs forecasted to be 20% of GDP in 2020;

      Pressing shortage of primary care providers;

      Growing chronic conditions and increased medical complexity;

      Affordable Care Act- 16% of citizens uninsured

      

“Be Careful Not To Assume”  

  --Légaré et al., 2010

Determining what patients want does not require complex scales or sophisticated statistical tests.   Instead, providers must move from “what’s the matter” with our patients to “what matters” to our patients.  Often what the patient craves is a listening ear, compassionate interactions, access to information, and attention to their care.  Other factors such as level of adherence to medication, degree of tolerance to an adverse effect, past experience, and health objectives can have a decisive influence on the patient’s preferences. When more engaged with care, patients and families can help prevent drastic mistakes or oversights, such as identifying a wrong drug or dose they get from the pharmacy or notifying a doctor about a strange medication side effects.

Quality Equals Reduced Cost, Better Outcomes and Patient Satisfaction

The National Quality Strategy (NQS) promotes quality health care in which the needs of patients, families, and communities guide the actions of all those who deliver and pay for care; there are three broad aims: Better care; healthy people/healthy communities; and affordable care .  To advance these aims, they propose six priorities, of which “ensuring that each person and family is engaged as partners in their care” is one that pertains to patient centeredness. This priority is based on the latest research, input from a broad range of stakeholders, and examples from around the country and has great potential for rapidly improving health outcomes and increasing the effectiveness of care for all populations.

Healthcare Providers: "Nice, But Not Necessary"

Patients: "That's What I'm Paying You For"

--NURS 7106-001

It is important to explore tensions that lie between the margins of traditional medical models and stakeholder engagement models. As patients advocate for better care, providers may feel justified in taking a patriarchal stance given level of education and training. There has to be a change in how health care providers are educated in order to make this shift. Not only are schools of medicine and nursing going to need to teach how to recognize and treat diseases but also they are going to have to be innovative in their curriculum in order to teach their students how to enable their patients.

Some patients may expect the provider, who has the expertise, to take the lead in patient care. This expectation is summed up by the idea of "that's what I'm paying you for". If patients are to be taking charge of their own care, there needs to be a change in expectations. Responsibility should be shared in appropriate ways. The goals of the provider may be disparate from those of the patient when there is a misalignment in worldviews between provider and patient. A common challenge is one of respecting religious/cultural values. It is important to honor the patient's wishes as part of providing evidence based care.

There are myths about patient-centered care models - such as it is more expensive, takes more time, and really falls into that "nice but not necessary" category. As more evidence accumulates, these myths will be challenged. However, time constraints pose a real threat in the current environment. Patients or family members may be afraid to request something of the provider because they feel like they are rushed or the provider does not have time for them. Transparent communication about the time constraints and the need to schedule multiple appointments, using other team members as indicated, and prioritizing the patient's concerns can occur up front and mitigate this tension.

Fundamentally, a key challenge going forward will be the ability to demonstrate that positive patient-centered outcomes correlate with positive general health outcomes. One elephant in the room is reimbursement. Primary care provider (PCP) visits do not generate high levels of reimbursement so providers compensate by seeing as many patients as they can per day. Some would argue that to keep afloat until the major stakeholders - insurance and CMS gets behind this—patient centered care is not possible. New payment models are coming however –as soon as 2015 for patients with complex chronic conditions.

Patient-Centered Care is NOT Only the Job of Nurses,

But Will Transcend Across Disciplines.

--NURS 7106-001

Patient-centeredness must transcend across disciplines. Achieving this level of collaboration poses the greatest challenge. As care becomes more focused on populations, across the episodes of care and including prevention, interdisciplinary team care will become the norm and the entire team will need to partner with patients and families.  Not only will disciplines need to be able to communicate better, but also specialties will need to be able to communicate better with the primary care team. All will be challenged to communicate differently in a patient-centric model.

References

Boult, C., & Wieland, G. D. (2010). Comprehensive primary care for older patients with multiple chronic conditions:“nobody rushes you through”. JAMA, 304(17), 1936-1943.

Clayton, M. F., Latimer, S., Dunn, T. W., & Haas, L. (2011). Assessing patient-centered communication in a family practice setting: how do we measure it, and whose opinion matters? Patient Education and Counseling, 84(3), 294-302. doi: 10.1016/j.pec.2011.05.027

Epstein, Ronald M, Fiscella, Kevin, Lesser, Cara S, & Stange, Kurt C. (2010). Why the nation needs a policy push on patient-centered health care. Health Affairs, 29(8), 1489-1495.

Findley, L.J., & Baker, M.G. (2002). Treating neurodegenerative diseases. British Medical Journal, 324(7352), 1466-1467.

Godlee, Fiona. (2012). Outcomes that matter to patients. BMJ, 344.

Institute of Medicine Committee on Quality of Health Care in America. (2001) Crossing the quality chasm: a new health system for the 21st century. Washington (DC): National Academies Press (US).

Katon, W., Russo, J., Lin, E. H., Schmittdiel, J., Ciechanowski, P., Ludman, E., Von Korff, M. (2012). Cost-effectiveness of a multicondition collaborative care intervention: a randomized controlled trial. Archives of General Psychiatry, 69(5), 506-514. doi: 10.1001/archgenpsychiatry.2011.1548

Marshall, M., & Bibby, J. (2011). Supporting patients to make the best decisions. British Medical Journal, 342(d2117), 10.1136.

Picker Institute. (2008). About the patient-centered care improvement guide. Retrieved from http://www.patient-centeredcare.org/inside/abouttheguide.html

Rickert, J. (2012). Patient-centered care: what it means and how to get there. Retrieved from http://healthaffairs.org/blog/2012/01/24/patient-centered-care-what-it-means-and-how-to-get-there/

Sacristan, J. A. (2011). [Patient-centered medicine and comparative effectiveness research]. Medicina Clínica (Barc), 136(10), 438-440. doi: 10.1016/j.medcli.2010.11.014

Sacristan, J. A. (2013). Patient-centered medicine and patient-oriented research: improving health outcomes for individual patients. BMC Medical Informatics and Decision Making, 13, 6. doi: 10.1186/1472-6947-13-6

The National Quality Strategy. (n.d.). The national quality strategy overview. Retrived from http://www.ahrq.gov/workingforquality/toolkit.htm

Van der Eijk, M., Nijhuis, F. A., Faber, M. J., & Bloem, B. R. (2013). Moving from physician-centered care towards patient-centered care for Parkinson's disease patients. Parkinsonism & Related Disorders, 19(11), 923-927. doi: 10.1016/j.parkreldis.2013.04.022

Wynia, M., & Matiasek, J. (2006). Promising practices for patient-centered communication with vulnerable populations: examples from eight hospitals. The Commonwealth Fund, 1-94.

Key Links and Resources

1.        Agency for Healthcare Research and Quality. (n.d.). Working for quality. Retrieved from http://www.ahrq.gov/workingforquality/index.html

2.        Agency for Healthcare Research and Quality. Retrieved from http://www.ahrq.gov/research/findings/factsheets/patient-centered/ria-issue5/index.html

3.        Patient-Centered Outcomes Research Institute. Retrieved from http://www.pcori.org/

4.        Wen, L. (2012). From doctor-centered to patient-centered care. Psychology Today. Retrieved from http://www.psychologytoday.com/blog/the-doctor-is-listening/201211/doctor-centered-patient-centered-care

5.        Zickmund, S. (n.d). Incorporating stakeholder engagement into VA research: What can we learn from the patient-centered outcomes research institute (PCORI)? Retrieved from http://www.hsrd.research.va.gov/for_researchers/cyber_seminars/archives/777-notes.pdf

6.        Institute of patient-and family centered care center at http://www.ipfcc.org/advance/topics/videos.html

7.        The National Quality Strategy (NQS): six priorities at http://www.ahrq.gov/workingforquality/toolkit.htm

8.        The Doctor is Listening by Leana Wen. (2012, November).  Psychology Today at http://www.psychologytoday.com/blog/the-doctor-is-listening/201211/doctor-centered-patient-centered-care

9.        Patient- and Family-Centered Care: Why it Matters and How to Practice It. At https://www.youtube.com/watch?v=7g-5I7DO1rQ&feature=related   

10.    Patient-Centered Care: What It Means And How To Get There at http://healthaffairs.org/blog/2012/01/24/patient-centered-care-what-it-means-and-how-to-get-there/

11.    The Values and Value of Patient-Centered Care. At http://www.annfammed.org/content/9/2/100

12.    The Ideal Medical Practice Model: Improving Efficiency, Quality and the Doctor-Patient Relationship at http://www.aafp.org/fpm/2007/0900/p20.html

13.    About the patient-centered care improvement guide at http://www.patient-centeredcare.org/inside/abouttheguide.html

14.    The Trouble With ‘Doctor Knows Best’ at http://www.nytimes.com/2012/06/05/health/views/essay-urging-doctors-to-do-less-may-fall-on-deaf-ears.html?_r=0

15.    Patient-Centered Care Improvement Guide at http://planetree.org/wp-content/uploads/2012/01/Patient-Centered-Care-Improvement-Guide-10-28-09-Final.pdf

Created by Participants in Nursing 7106 Context for Advancing Science (and Improving Health)

University of Utah College of Nursing PhD Program Summer 2014 

Submitted by: By Sara Hawkins RN MSN & Rumei Yang RN MS

(Lead Authors)