FINDING THE WAY
FORWARD FOR EHEALTH AND
NURSING
Nancy Staggers, PhD, RN, FAAN
University of Maryland
YOUR PRESENTER
Nancy Staggers
 Professor, Informatics, University of Maryland
 Former IT executive, led enterprise Electronic Health Record (EHR)
projects
 Foundational work in nursing informatics
 NI definition, Scope & Standards for NI, NI competencies
 25 years in the Army, primarily working on HIT
 Research program in the user experience (usability, human factors) for
clinical products
 Clinical nursing on medical-surgical units
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GREETINGS FROM UTAH, USA
TO YOUR BEAUTIFUL COUNTRY
TODAY’S PRESENTATION
 Discuss
two possible visions to organize
our thinking about e-Health
 Outline three contemporary informatics
topics that all nurses need to know
 Analyze implications for e-Health
competencies
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WHY SHOULD YOU CARE?

e-Health is critical to the practice
of nursing

Slow infusion of e-health in the past
 Disparate efforts world-wide

Formal, organized efforts needed

Education
 Practice

Must think futuristically

Current collection of NI competencies
based upon the past
 Current trends must be incorporated
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E-HEALTH VISIONS
LEARNING HEALTH SYSTEM
Connects care quality, knowledge, costs using
Health IT
 Converts data about care and operations into
knowledge


Translates into evidence-based clinical practice and
health system transformation (Health Affairs, 2013)
New knowledge captured as a by-product of
care (Institute of Medicine, 2012)
 Continuous improvement and innovation
 Includes best practices

LEARNING HEALTH SYSTEM – UNITED KINGDOM
https://www.gov.uk/government/publications/thehealth-and-care-system-explained/the-healthand-care-system-explained
COMMONALITIES, UNDERSTANDINGS

Patient-centered
 Engaged
patients, consumers
Assumes interconnectivity (interoperability)
across agencies, entities, persons
 Only possible with robust Health IT
 Mandates good data quality
 Requires specific competencies for providers

 Ability
to evaluate information sources
 Advanced analytic skills
 New levels of decision making
PERSON-CENTERED CARE
Patientcentered
care
Personcentered
care
Patient-Centered Information
Primary
Care Clinic
ED
Home
OR
Specialty
Clinic
PACU
Med-surg/
Acute care
SICU
IMC Stepdown
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Person-Centered Information
Home
Primary
Care Clinic
ED
OR
Specialty
Clinic
PACU
Person-Centered Care
Med-surg/
Acute care
SICU
IMC Stepdown
14
PERSON-CENTERED CARE


“Keep-you-well” care delivery system
Care wherever the person is


With whatever device




Mobile device, telehealth
Integrated care team


Work, school, home
Community worker, nurse, health coach
Health care technology assistant
Information at the point of care
Hospital at home (for common diagnoses)
Cortese, 2013, JAMA
PERSON-CENTERED CARE
Information owned by the person
 Implies engagement, self-efficacy
 E-patients


E-patient Dave (Bronkhart)


TED talk – at
http://www.ted.com/talks/dave_debronkart_meet_e_patient_dave.html
Dave Riley
 His own EEG, home laboratory
 Engaged in his own healthcare, partner to his
provider
 Tailored his biochemistry to improve his own diabetes
care
PATIENTS LIKE ME
CONTEMPORARY
INFORMATICS
TOPICS
CONTEMPORARY INFORMATICS TOPICS
 mHealth
 Nanotechnology,
nanomaterials
(emerging technologies)
 User experience, usability
MHEALTH
mHealth = mobile health
 “There is an app for that.”
 400 health-related apps being developed each
month1


Healthy eating (Ruder-Finn, 2012 survey)
 Fitness, knowledge (West et al., 2012)
 Calorie counting
 Pain management
 Asthma management (32 apps not supported by
evidence or contrary, Huckvale, et al., 2012)
 Smoking cessation (little adherence to guidelines,
Abroms, et al., 2011)
1. House Energy and Commerce Subcommittee, Health IT, 2013
MHEALTH

mHealth Summit

mHealth community (HIMSS)
Wedded to the phone

CONTEMPORARY INFORMATICS TOPICS
 mHealth
 Nanotechnology,
nanomaterials
 User experience, usability
NANOMATERIALS
 What?
 The
design and use of tools and devices in the
range of 1-100 nanometers
 Who?
 Engineering,
chemistry, pharmacy, biology,
biomedical, electronics
 Where?
Nearly everywhere
 Lotions,
sunscreens, tennis rackets
 Titanium dioxide in sunscreen
 iPod Nano
UNIQUE ASPECTS OF NANOMATERIALS
 Increased
strength
 Adhere tightly with cell membranes in vivo
 Increased resilience
 Increased electrical conductivity
 Changed light refraction
 Enter cells in vivo and in vitro
 Cross the blood-brain barrier
 Increased surface area to interact
UNIQUE ASPECTS

Interact differently in living systems than
current products and materials
 Due

to their small size and higher surface area
More easily absorbed
 Lotions,
sunscreens penetrate the top layer of
cells more readily
Xudong Wang, Ph.D.,
Z. L. Wang, Ph.D.
NANO-APPLICATIONS IN HEALTH

Treating infections

Nanoviricides (Hogle, 2009)
 Wound dressings with silver nanoparticles
 Textiles with nanoparticles (Thompson, 2011)

Surgical procedures (Janin, 2008, Huang, 2010)

Nanoneedles, molecular machines
 Nanosurgical forceps to extract DNA bits
 Self-assembling gels to stop intraoperative bleeding
NANO-APPLICATIONS IN HEALTH

Regenerative science




Nanorobots


Propelling systems (Kostarelos, 2010)
Nephrology (Saini et al., 2012)



Skin, bone, cartilage (European Technology Platform, 2008)
Structure and mechanics at the nanoscale (Guo, 2008)
Nanoceramics (Simchi et al., 2011)
Human nephron filter developed by researchers
Could lead to a wearable artificial kidney
Theranostics (Puri & Blumenthal, 2011)


Combined nanoimaging, sensors, treatment delivery
Sensors and insulin release
CONTEMPORARY INFORMATICS TOPICS
 mHealth
 Nanotechnology,
nanomaterials
 User experience, usability
CAUTIONS

With new technologies, come unintended
consequences and new issues

Nanotoxicity
 Ethics
 Regulation
 Workplace safety
 Nursing issues?
CONTEMPORARY INFORMATICS TOPICS
 mHealth
 Nanotechnology,
nanomaterials
 User experience, usability
USER EXPERIENCE
All aspects of users’ interactions with product,
system, service
 Includes perceptions, responses (ISO 9231-11)
 Multiple disciplines involved


Psychology
 Engineering
 Graphical design
 Industrial design
 Informatics
 Interface design
 Domain experts
ROLE OF USABILITY
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Copyright © 2010 Lisa Battle, Jasmin Phua & Duane
Degler
VALUE OF USABILITY TO ORGANIZATIONS
HIMSS, 2011
IMRI OR INTRAOPERATIVE


MRI
Operating room configuration that allows imaging
during surgery
Useful for neurosurgery
USABILITY ISSUES AND PATIENT SAFETY



Ignoring the magnet proximity alarm during patient
positioning. This could potentially injure the patient
by crushing their arms
Surgical instruments left behind when the iMRI
magnet comes out. The instruments will become a
projectile and fly to the center of the magnet (which
is where the head of patient is positioned).
Delayed patient resuscitation in the event of a code
while the patient is the iMRI chamber.

The iMRI OR doors are on lock down during the iMRI
procedure. There is a 2 minute delay before the iMRI
magnet can go back to the cage and staff can
open the OR doors.
JUST GO MOBILE! MHEALTH IS THE ANSWER
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CONTEXT AND TASKS MATTER MORE!
39
USABILITY = PATIENT SAFETY
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Brick, 2012
USABILITY = PATIENT SAFETY
Nancy to get electronic
example of growth chart
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Brick, 2012
USABILITY = PATIENT SAFETY
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Guo, et al., 2011
NURSING SUMMARY REPORT
Staggers, Clark, Blaz
& Kapsandoy, 2012
NURSING SUMMARY REPORT
No visual trend
Staggers, Clark, Blaz
& Kapsandoy, 2011
NURSING SUMMARY REPORT
No visual trend
Orders
truncated
Staggers et al., 2011
NURSING SUMMARY REPORT
No visual trend
Orders
truncated
Hand-written grid
for medications
due across patients
Staggers et al., 2011
NURSING SUMMARY REPORT
No visual trend
Orders
truncated
Missing
information
Hand-written grid
for medications
due across patients
Staggers et al., 2011
NURSING SUMMARY REPORT
No visual trend
Orders
truncated
Hand-written grid
for medications
due across patients
Missing
information
Static information
Staggers et al., 2011
Preferred Tool
OBSERVE USERS TO UNDERSTAND WORKFLOW AND TASKS
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SET USABILITY GOALS & BENCHMARKS
User Groups: Physicians | Nurses | Administrative
Usability Measurement Relative to Goals
Task
Schedule a new
patient
Enter patient
vitals
Enter patient
visit notes
Effectiveness
Efficiency
Satisfaction
Goal: 100%
Goal: 2 mins
Goal: 4
EMR A: 80%
EMR B: 95%
EMR A: 4 mins
EMR B: 1.5 mins
EMR A: 3.0
EMR B: 4.5
Goal: 100%
Goal: 30 secs
Goal: 4
EMR A: 95%
EMR B: 100%
EMR A: 1 min
EMR B: 45 secs
EMR A: 4.0
EMR B: 5.0
Goal: 100%
Goal: 5 mins
Goal: 4
EMR A: 85%
EMR B: 100%
EMR A: 7 mins
EMR B: 6 mins
EMR A: 3.25
EMR B: 4.75
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IMPROVE ORGANIZATIONS WITH THE HIMSS USABILITY
MATURITY MODEL
Focus on
Users
Management
Process &
Infrastructure
Resources
Education
Phase 5Strategic
Phase 4Integrated
Phase 3Implemented
Free!!
Just browse
using “HIMSS
usability
maturity”
Phase 2Preliminary
Phase 1Unrecognized
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IMPLICATIONS
IMPLICATIONS

Systematic consideration of emerging
technologies
 Safety
for consumers, workers
 Integration into work and workflow
 Impact on productivity
 Evaluation for user experience issues, goals
Efficiency
 Effectiveness
 Workflow
 Satisfaction

IMPLICATIONS – E-CARE SYSTEMS

Information capture relayed from sensors,
personal data, genomics, nanomaterials


Input/output standardization
Inventive architecture
 Sense
and transfer data automatically to systems
Individually tailored data and information
 Massive storage capability
 Current systems (electronic orders,
documentation) do not accommodate this type of
individualized data


New methods to accommodate intentional variability in
patient-centered data and individualized orders
IMPLICATIONS – E-HEALTH SYSTEMS
No longer electronic health records as we
know them
 Distributed information
 Vast networks of networks?


Trust
 Data quality
 Data transfer
Who owns the data?
 Who assures accuracy, security?

IMPLICATIONS – DATA ANALYTICS

“Big data”



Large amounts of available data (2.5 quintillion bytes every day
by an IBM estimate)
Inexpensive storage makes this possible
Example for molecular biology, experimental data, published
literature


Developing interactive, integrated, modeling technologies now
Data analytics



Making sense of large data stores
Developing models, insights
Data visualization


At the intersection of computing, human perception, design
Special tools, techniques, issues
Fowlkes et al. 201153
Fowlkes, et al, 2011
IMPLICATIONS - PUBLIC HEALTH
 Could change the whole structure and
functioning of Public Health (Hogle, 2009)
 Vaccines versus nanotreatment of actual disease
 Big data analyses of worldwide, chronic conditions
 Surveillance and reporting systems
 Personal data, sensor data, nanotoxicity reporting?
 Who will monitor?
 Informatics support
 Communication & integration of information
 Public health decision support
IMPLICATIONS - CONSUMERS

Patient monitoring for sensors, nanomaterials
 Diagnosing faster


Finding familial diseases
Treatment and monitoring for specific needs

Chronic diseases


Treatment at the microscopic level
Personalized medicine



Treating diseases explicitly and precisely to individual
consumers
Beyond genomics
Implications for provider-patient communication
technology
IMPLICATIONS - CONSUMERS

Person-centered monitoring






Crosses traditional boundaries
Data access by patients first
Interpretation perhaps by patients first
Change in the “first responder” to data
Change in power base from provider to consumer
Consumer education


Have consumers heard of nanotechnology, sensors?
Products not yet labeled as having nanomaterials embedded
Consumer policy
 Health insurance for some countries

IMPLICATIONS - CONSUMERS

Cognitive support and interface design for
consumers as “first responders”
 Likely
a role change for patients
Increased responsibilities for patients,
caregivers and clinicians
 What about patients who are unable or
unwilling to accept these new
responsibilities?

IMPLICATIONS - CLINICIANS
Today’s concepts of routine care may no
longer exist
 Absolute individualized care, disease
management exquisitely customized
 No longer a standard approach for a given
health condition
 Demands even greater information synthesis
 New interdisciplinary teams with new
members and different functions

Staggers et al., 2008
IMPLICATIONS - CLINICIANS

A patient presents with mysterious symptoms
or a new disease directly related to the
embedded technology
How will we diagnose and treat it?
 How do we differentiate it?
 Consider interactions between nanoparticles, devices


Consider “bugs” in software or a circuit


New safety considerations


How will we troubleshoot it?
How will we provide protection for the clinicians delivering
the therapy to avoid accidental or inadvertent ingestion or
absorption?
Impact on clinicians productivity?
IMPLICATIONS - CLINICIANS
 Increasing
power of patients, social media,
e-patients

Expands a role change that began with consumers
accessing information on the internet and bringing it to
their appointments – questioning and challenging the
clinicians
 Health care providers may have a role change from
expert to participant, coordinator, or coach
IMPLICATIONS - CLINICIANS

Critical thinking and decision making
 More, perhaps better targeted data, information,
and knowledge about patients and disease
processes
 Sheer amount of data could create information
overload and issues of data synthesis
 Could there be an over-reliance on devices?
 Assumption all data is received when it may not be
 Inaccuracies with monitoring devices may be hard
to detect and require different problem solving
techniques
IMPLICATIONS - DECISIONS

Monitoring individuals’ decision making

Consequences of poor decision making
 Clinician responsibility in consumers’ choices?

Insurance company decisions

Will they monitor your health at a cellular level and
deny care or coverage based on poor genetics or
poor lifestyle choices…
IMPLICATIONS - EDUCATION
Devices will need to be understood by both
caregivers, patients, and those in their
immediate care circle
 Curricular design and clinical education
changes
 Differing capabilities and limitations of care
providers and the consumers
 How to collate, correlate and interpret the data


In essence, how will we teach information synthesis
at this level?
CONCLUSIONS



The future of e-health will be interesting
Technology may develop faster than we can respond
with policy and health IT
Competencies need to move beyond the basics to
include

Emerging technologies and safety (genomics, nanomaterials)
 Usability
 Big data and critical thinking
 Person-centered health, mHealth
TAKK!
Contact information:
staggers@son.umaryland.edu
THANK YOU!
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