
Ashlyn Johnson
 w036amj@pilot.wright.edu
Amy Vanbuskirk

 w015amv@pilot.wright.edu
Amy Wiley w064amw@pilot.wright.edu
Bethany HanenKrat
 w137bmb@pilot.wright.edu
Jessica Akemon w106jkp@pilot.wright.edu

Kathleen Owens

 w005kao@pilot.wright.edu
Shawn Kise w025sek@pilot.wright.edu
Shelley Thiebeau
 w023skt@pilot.wright.edu
Whitney Dunbar w105wld@pilot.wright.edu

1. Understand the background of how the Tiger
Initiative got started.
2. Know the 9 collaborative teams of the Tiger
Initiative.
3. Be able to state goals of the Tiger Initiative.
4. Know where to access information on the Tiger
Initiative.


Focused awareness with nursing stakeholders in three areas

Develop a U.S. nursing workforce capable of using electronic health records to improve the delivery of healthcare

Engage more nurses in the development of a national healthcare information technology (NHIT) infrastructure

Accelerate adoption of smart, standards-based, interoperable technology that will make healthcare delivery safer, more efficient, timely, accessible, and patient-centered


2004: President Bush supported adoption of electronic health records

2005: Small group of nursing leaders and advocates met and resolved to strengthen the voice of the nursing profession in the transformation of healthcare for 21 st century

Organized TIGER Initiative (2005)

TIGER: BACKGROUND- NURSING ENGAGEMENT

2006: Interactive summit, “Evidence and
Informatics Transforming Nursing”

Created a vision for the future of nursing that bridges the quality chasm with information technology, enabling nurses to use informatics in practice and education to provide safer, higher quality patient care





Focus on nursing, however recommendations apply to interdisciplinary health professions
Aim to develop a nursing workforce in the US capable of using electronic health records (EHRs) with hope to improve care delivery
2009 Obama signs American Recovery and
Reinvestment Act- $19 billion for health information technology (HIT)
Funding by Dept of Labor and Dept of Education to increase HIT workforce


Capital, technology, resources, and people needed to create an informatics-aware healthcare workforce

Healthcare provider competency with EHRs
(requires basic computer skills, information literacy, and understanding of informatics and information management)

Education reform- ≈3 million currently practicing nurses may not be competent with HIT

“Our vision is to enable nurses to use informatics tools, principles, theories, and practices to make health care safer, more effective, efficient, patient-centered, timely, and equitable by interweaving enabling technologies transparently into nursing practice and education, making information technology the stethoscope for the 21st century”.

TIGER EXPECTED OUTCOMES

Publish a Summit report, including Summit findings and exemplars of excellence.

Establish guidelines for organizations to follow as they integrate informatics knowledge, skills, and abilities into academic and practice settings.

Set an agenda whereby the nursing organizations specify what they plan to do to bridge the quality chasm via information technology strategies.

1.) Communication
2.) Education
3.) Informatics Design
4.) Information Technology
5.) Culture
6.) Management and Leadership
7.) Policy


Provides executive summary of activities through 2008

Synopsis of findings and recommendations of the nine teams

Available at

1.) Standards & Interoperability
2.) National Health Information Technology Agenda
3.) Informatics Competencies
4.) Education & Faculty Development
5.) Staff Development
6.) Usability & Clinical Application Design
7.) Virtual Demonstration Center
8.) Leadership Development
9.) Consumer Empowerment & Personal Health Records


Standard-A definition or format that has been approved by a recognized standards organization or is accepted as a de facto standard by the industry. A standard specifies a well-defined approach that supports a business process and is:
1. Derived by a group of experts
2. Examined and evaluated
3. Provides rules, guidelines, or characteristics
4. Helps to ensure that materials, products, processes, and services are fit for their intended purpose
5. Ensures that it is in an accessible format
6. Is in a continuous review and revision process

Interoperability-the ability to communicate and exchange data accurately, effectively, securely, and consistently with different information technology systems, software applications, and networks in various settings, and exchange data such that clinical or operational purpose and meaning of the data are preserved and unaltered


Integrate industry standards for health IT interoperability with clinical standards for practice and education.

Educate practice and education communities on health IT standards.

Establish use of standards and set hard deadlines for adoption.

Why Do We Need Reform?
National Health IT Organizations that Need Nursing Participation

Decrease healthcare costs

Reduce medical errors

National disasters

Threat of terrorism




National eHealth
Collaborative
Healthcare Information
Technology Standards
Panel
Certification Commission for Healthcare
Information Technology
HIT Policy Committee and
HIT Standards Committee

3.TIGER INFORMATICS COMPETENCIES MODEL
Model

Basic Computer
Competencies

Informatics Literacy

Information Manage ment
Standard/Source

European Computer Driving
License/European Computer Driving
License Foundation

Information Literacy Competency
Standards/American Library
Association

Electronic Health record Functional
Model-Clinical Care
Components/Health Level
Seven(HL7)
International Computer Driving
License-Health/European Computer
Driving License Foundation

4. EDUCATION AND FACULTY DEVELOPMENT

Recommendations for

Associate Degree Programs

State Boards of Nursing

State Initiatives

Human Resource Services Administration

Curriculum Development


National League for Nursing (NLN) and
American Association of Colleges of Nursing
(AACN) support TIGER Initiatives

Changes to curriculum to include HIT and EHRs



NLN

23 recommendations for nursing schools

Nursing School Administrators



Infrastructure, faculty development, student access to HIT in clinical experience, inclusion of informatics in curriculum
Faculty

Informatics education, a champion in every nursing school, provide hands on experience to students
NLN

Funding for think tank, minimal informatics competency for all nurses, create faculty development programs
AACN

Include informatics in Baccalaureate and Doctor of
Nursing Practice education





Official TIGER Staff Development Collaborative
Team report not yet available
Staff Development Collaborative Team

Aim to help staff communicate and manage information effectively
Research suggests that HIT can improve patient safety

If used improperly HIT may be detrimental to patient safety
Healthcare Organizations

Educate practicing nurses

Adopt new technologies to improve patient safety


Staff Development Collaborative – 3 Goals

Education/programs in practice settings for IT

Continuing education/training in informatics

Collaborate with industry, service, and academia to promote HIT education and improve use of HIT in practice



Workforce Readiness-

Prepare nurses already in the workforce

Nurses are the most frequent users of clinical information systems
Organizational Readiness

Knowledge readiness





Technical readiness
Operation readiness
Functional readiness
Resource readiness
Internal environmental readiness


Technology can improve patient safety

Healthcare Settings (implementing HIT)

Staff preparation and training

Process changes

Continuity of patient care

IT administrative support

THE INFORMATICS FOR ADVANCED ARIAL BOLD
PROGRAM AT COLUMBIA

Informatics

Competency development

Patient safety

Evidence-based care

THE INFORMATICS FOR ADVANCED ARIAL BOLD
PROGRAM AT COLUMBIA

Applications to support nurses in various roles

Student use of handheld devices for clinical documentation

Clinical practice guidelines for depression, obesity, and tobacco cessation

A patient safety website for reporting hazards

Access to National Cancer Institute information for tobacco cessation

6.USABILITY AND CLINICAL APPLICATION DESIGN

Current information systems may not meet workflow demands

Current technology was not designed with nursing workflow or thought process in mind

Systems with designs appropriate for daily nursing practice are needed

USABILITY AND CLINICAL APPLICATION DESIGN

Recommendations provided for HIT vendors as well as practitioners

Improve HIT products




Efficiency
Effectiveness
Satisfaction
Better HIT designs




Greater productivity
Reduction of errors
Fitting to workflow
Improvement of accuracy


Easy to learn
Increased satisfaction of healthcare providers


Usability Principles

Focus on the product users

Match designs to users, tasks, and environments

Evaluate products (users and metrics)

Usability Goals

Evidence-based

Patient-centered

Allow interdisciplinary collaboration at point-of-care

USABILITY & CLINICAL APPLICATION DESIGN



Human Factors


Usability
Ergonomics

Human-computer interaction
Clinical application design




Usability
EBP interdisciplinary collaboration knowledge discovery
Systems thinking





Individual competency
EBP
Scope of practice
Knowledge discovery
Integrated competency



Usability Goals

Nursing informed and helpful for nursing workflow


Known principles and processes drive systems design
Improve system effectiveness by working with developers
Clinical Application Design Goals

Support EBP




Collaborative and interdisciplinary care
Provide access to literature and knowledge
Support knowledge-discovery
Enable research to practice translation


Define user needs

Understand nursing role and appropriate system actions

Provides recommendations to both health care practitioners and vendors


Recommendations for Vendors

Clinician representation

Clear requirements for developers (non-clinicians) who hard-code designs

Requirements of different skill levels (nurses choose level of system support)

Work with organizations analysts and users to validate requirements during development/customization of the product

Partner with customers to meet the needs of end-users


Recommendations for Health Care Practitioners

Select the team (interdisciplinary team to define clinical requirements)

Analyze the systems impact on workflow of each dept

Use standardized terminology for organization (allow free text, support EBP, end-users to review)

Customization of system

Legal considerations (electronic signature, audit trail)

Tools (system setup and maintenance)

USABILITY AND CLINICAL APPLICATION AND
DESIGN RECOMMENDATIONS



Safety and usability recommendations

 for vendors
For healthcare practitioners
Usability Evaluations

Design prototype then evaluate



Product design
User
Environment
Human Factors recommendations

Understand human capability and limitation




Human errors
Technical errors
Judgmental errors
Monitoring and vigilance failures


Case studies have identified key factors for success

User and key stakeholder involvement

Involved early on

Involved with requirements development and selection

Clinicians + developers

Create design which fits workflow

Vendors understand workflow of end users

7: VIRTUAL DEMONSTRATION CENTER (VDC)


Created to develop a dynamic Internet
Create a physical destination to demonstrate high effective and efficient, technologyenabled, solutions of exemplary health care delivery systems


Goal: Encourage innovative and disruptive approaches to improving health care delivery with the use of technology

Allow access to the Center from anywhere

Expand current thinking about healthcare


Held two virtual conferences in 2008

Provided “Gallery Walk” to nurses

Provided exemplars of best practice for technology utilization, contact resources, and virtual networking

Interactive experience


Provided visibility to the vision of IT

Demonstrated future IT resources

Demonstrated collaboration between industry, healthcare organizations, academic institutions, and professional organization

Provided universal accessibility to this demonstration for all nursing stakeholders


Used practice exemplars from different practice environments

Demonstrated how integrated IT systems impact nurses and the quality and safety of patient care


Nurses who can visualize the benefits of an Itenabled future will be more likely to use EHR in their practice setting

Most exposure to IT capabilities are sitespecific, except nursing informatics resources

Provided a vision of how to partner with colleagues to widen the availability of resources due to limited accessibility


Provided an example of how education can be made more widely available

Universal adoption of informatics competencies for all nurses


Develop a virtual environment- Second Life

3D interactive “avatars” that allows interaction with the program

Social networks and virtual technology

Goal: secure funding to help build out a virtual island that will support the TIGER mission

Improve patient care and outcomes


Transform organization’s values, beliefs, and behaviors

Technology changing but adoption of technology will not happen without leadership

Requires vision, influence, risk taking, clinical knowledge, and a strong expertise related to professional nursing practice


Leaders:

Model the Way

Inspire a Shared Vision

Challenge the Process

Enable Others to Act

Encourage the Heart


Develop revolutionary leadership that drives, empowers, and executes the transformation of health care

Requires nursing leadership to understand, promote, own, and measure the success of health IT

Ensure development of informatics competencies at the beginning management role or the charge nurse


Informatics competencies should focus on: budgetary, regulatory, safety, security, and privacy policies

Expected to fully understand and articulate goals and benefits of technology implementation

Remain engaged throughout the lifecycle of system selection, implementation, and optimization


Responsible for developing a culture that is innovative and ready to embrace change

The Magnet Program

TIGER – collected examples of how organizations used HIT to demonstrate aspects of their Magnet journey


Develop programs for nurse executive and faculty that emphasizes the value of IT and empowers those to use HIT

Expand and integrate informatics competencies into Nursing Leadership Development
Programs


Promote sharing of best practices using HIT effectively to improve the delivery of nursing care

Promote alignment with the Magnet
Recognition Program as a mechanism to demonstrate nursing excellence in using


Maintain knowledge of cutting edge practice and for management of clinical teams

Areas of focus:

Evidence

Content

Technology

Standards

9: CONSUMER EMPOWERMENT & PERSONAL
HEALTH RECORDS

33% of adults are confident in their physicians an other HC providers having a complete and accurate picture of their medical history

Need for consumers to take a more active role in their health care

Personal Health Record (PHR)- internet based

CONSUMER EMPOWERMENT & PERSONAL
HEALTH RECORDS

PHR: promotes patient empowerment and supports the patient’s engagement in their own health care

Nurses obligated to become families with the technology

Objective of TIGER: make information available to nurses about PHRs and to encourage inclusion of this content to nursing curricula

CONSUMER EMPOWERMENT & PERSONAL
HEALTH RECORDS

Ways nurses can impact the adoption and use of consumer empowerment strategies

PHRs: easy to use and accessible to consumers

Developed an inventory of usability principles for patient-focused applications

Barrier of PHRs: lack of interoperability with other systems

National Health IT activities have focused on identifying and supporting the adoption of standards for PHRs

CONSUMER EMPOWERMENT & PERSONAL
HEALTH RECORDS

President Obama supports greater use of technology in healthcare

Included significant funds in the economic stimulus package to increase adoption of PHRs

High prospect of achieving PHRs that are complete, accessible, interoperable, and secure

Reducing Medication Errors with Electronic Medical
Records and Bar Coding Technology
Bar Coding Video

While caring for a premature neonate the nurse administers many intravenous medications throughout her shift, including heparin 10 units/mL. The adult dose of heparin 10,000 units/mL is in similar packaging and labeling. The two very different doses of medication are easily confused due to similar labeling and packaging. To prevent medication errors we observes the 5 Rights of Medication administration: checking:
Right Patient
Right Medication
Right Dose
Right Route
Right Time

But, to err is human. We increase patient safety and lessen the risk of medication error with preventative strategies, such as electronic medical records, medication bar coding, unit dose labeling and smart (programmed pumps).

Discussion Points
Informatics Competencies
Review
The Informatics
Competencies as outlined in the TIGER initiatives is a plan for “all practicing nurse and students to have the necessary skills to practice nursing in the hightechnology environment emerging in all avenues of healthcare.” (Hebda and
Calderone, 2010)

For All Nurses
Entry and retrieval of data in electronic medical records
Analyze and interpret information as part of care plan
Use informatics applications designed for nursing practice
Implement policies relevant to best practice

For Students and Beginning
Nurses
Basic computer literacy and desktop applications such as e-mail
Access data and document using computerized patient records
Access and apply evidenced based practice
Support patient safety using information technology

For Experienced Nurses
Build upon informatics knowledge gained
Become content expert in system designs
Appreciate relationships among data patterns
Exercise clinical judgment based on observed data trends
Safeguard access to patient data
Work toward improving information management and communication

As a student seeking degree and certification as an Advanced Practice Nurse
What are some of the ways we support patient safety initiatives while integrating informatics technology? In what ways do nurses or physicians resist change in patient care?
How can we work toward safeguarding patient data and health information in electronic medical records? What challenges does this present in your nursing practice?
References
Hebda, T. Calderone, T. (2010) What Nurse Educators Need to Know About the
TIGER Intiative. Nurse Educator , (35) 2, 56-0
Saba, K. & McCormick, K. (2006) Essentials of Nursing Informatics , McGraw Hill


Structured as program

Relied on the participating organizations to distribute information

Collaborative approach

Organizations and nine collaborative teams

Nursing Informatics Community

Presentations and meetings at several national, regional, and international conferences


Practice Specialty Community: ANA & STTI

Presented on TIGER at regional and national conferences, & conferences within organization

Published articles in member newsletters or journals

Nursing Leadership Community

Enhanced visibility and access to nursing executives

Executives contributed articles and presentations r/t technology and the TIGER effort




Educational Community


¼ of leaders and participants came from the academic community
Academic partnerships proliferating
State-Wide Collaboration


Minnesota developed a state approach: bringing together stakeholders in an annual Minnesota TIGER conference
Other states have brought together the key organizations to discuss issues r/t technology adoption
Vendor Community:
GE Healthcare, Mckennson, Cerner, CPM Resource
Center & others


Developed an interactive “Gallery Walk”
Presented TIGER at their user group conferences or via webinars






Kouzes, J.M., & Posner, B.Z. (2007). The leadership challenge (4 th ed.). San
Francisco: Jossey-Bass.
McCormick, K. A, & Saba, V.K. (2006). Essentials of nursing informatics (4 th ed.). New York, New York: McGraw-Hill
The T.I.G.E.R. Initiative . (2011). Retrieved July 6, 2011, from Tiger Summit: http://www.tigersummit.com/Home_Page.php
The TIGER Initiative. (2007-2011). Designing usable clinical systems:
Recommendations from the TIGER usability and clinical application design collaborative team . Retrieved from http://www.tigersummit.com/uploads/Tiger_usability_Report.pdf
The TIGER Initiative. (2007-2011). Staff development and continuing education programs that support technology adoption . Retrieved from http://tigerstaffdev.pbworks.com/w/page/22250544/FrontPage



The TIGER Initiative. (2007-2011). Transforming education for an informatics agenda: TIGER education and faculty development collaborative . Retrieved from http://www.tigersummit.com/uploads/Educ.Tiger.Report_final4.pdf
You Tube. Computerized Health Records Reduce Medical Errors (2008).
Retrieved from http://www.youtube.com/watch?v=fjnyDNZE3RY&feature=relmfu .