Dean's Blog: Catherine Gilliss, PhD, RN, FAAN

Electronic Health Records and Nursing Care

April 2013
David Vlahov

A few months back, when interviewed in this publication, I said: “Our role in technology adoption has to be that of supportive skeptics. We have to evaluate and mold technology-related tools and interventions so that we optimize the benefits and avoid unintended consequences.”

My feelings on this have only deepened in the wake of recent reports that question the ability of electronic health records (EHRs) to achieve their promised clinical and efficiency gains. As our UCSF colleague Robert Wachter writes in The Health Care Blog, EHRs are an absolutely necessary step in improving what clinicians do every day in both hospital and ambulatory settings; I don’t believe we can significantly enhance health care quality while making it more efficient and less expensive without them.

But again as Wachter points out, anyone who believes that EHRs are a panacea, that widespread implementation can be easy or smooth or – as a recent article in the New York Times pointed out – that hard-core capitalism will not play a role has to be living in a world other than the one I live in. So it’s not surprising that there have been a series of reports, both academic and anecdotal, that have pointed out flaws ranging from clunky and time-consuming implementations and distractions from face-to-face time to fraudulent “upcoding” of procedures. Nor have the projections of billions of dollars in annual savings materialized – or at least not yet.

The question for me is: What do we do about it? If we all agree that EHRs are a necessary tool in achieving what has come to be known as the “Triple Aim” – a term coined by former CMS Administrator Donald Berwick, referring to “improving the experience of care, improving the health of populations, and reducing per capita costs of health care” – then how can we ensure that we get the best out of EHRs and avoid as many pitfalls as possible?

I believe the answer is simple and stark: While we have multiple anecdotal reports about lessons learned – Science of Caring ran an extensive piece on this issue for nurses last year – we need more scientific research on the impact of EHR diffusion and adoption for both health care professionals and patients. Such research needs to study the design, implementation, clinician training, and impact on patient care quality, safety and costs. The good news is there are already multiple models for how to successfully approach such research.

  • Michael Harrison and colleagues published a conceptual piece in 2007 on the unintended consequences of information technologies in health care using an interactive sociotechnical analysis.
  • Erin Sparnon and William Marella from the Pennsylvania Patient Safety Authority found 933 reports from 2004 to 2012 in which electronic medical records (EMRs) caused problems due to categories that include human factors (e.g., wrong input, using default values, failure to update data, failure to alert, failure to carry out duty, wrong record retrieved) and technical factors (e.g., output display error, record unavailable, output device down, data loss, access network down).
  • For nurses, there is the work of Tom Clancy and Connie Delaney from the University of Minnesota School of Nursing on predicting the impact of an EHR on practice patterns using computational modeling and simulation.
  • Joanne Spetz from our own School of Nursing reported in 2010 on the impact of health information technology on nurses and nursing care.

These and other studies provide a powerful framework for the next generation of research that can help us better understand and improve our design and practice, so EHRs can achieve the goal of safe, efficient and high-quality patient care. The potential is there, but without supportive skeptics rigorously molding the tools and processes, we risk allowing the doubters and cynics to win the day.

 

Don’t Disrupt Health Care’s Vital Supply of Providers

March 2013
David Vlahov

As health care reform takes effect and the population ages, the demand for health services increases; many have raised alarms about critical shortages in the health care workforce. Primary care is usually front and center, and while much of the attention has focused on physicians, we have repeatedly commented that any response to shortages should consider the contribution that advanced practice nurses, especially nurse practitioners, can make. In nursing, we also need more doctorally prepared nurses to serve as faculty. Physicians and other health care colleagues have their own very legitimate concerns about their pipelines.

Thus it is especially distressing that inaction and political jockeying in Washington is stymieing efforts to address critical workforce issues. Without a robust supply of providers, health care services become anemic and real people pay a real price.

It’s not just the sequester. An article in the New York Times on Sunday, February 24, began this way:

“One of the biggest threats to the success of President Obama’s health care law comes from shortages of doctors, nurses and other health care professionals. But a 15-member commission created to investigate the problem has never met in two and a half years because it has no money from Congress or the administration.”

The article goes on to outline how Congress refuses to fund the commission in any way and how appointed individuals have been warned against even having conversations on the topic they were appointed to help solve.

As to the sequester, while there are supposed protections in the legislation for the most vulnerable among us, some speculate that cuts to federally funded community clinics will seriously impair their ability to serve hundreds of thousands of individuals and families across the country who cannot otherwise afford health care services. The Association of American Medical Colleges projects that cuts to Title VII and Title VIII programs – which help educate providers committed to meeting the needs of the underserved – will seriously deplete the supply of those providers. Billions of dollars in Medicare cuts means hospitals will have to make hard choices about how to spend their resources on patient care. Guess which segment of the population is most likely to feel those cuts.

Yet while there has been a lot of headshaking and disgust at the way politicians in Washington have failed to achieve even the most basic responsibilities of governance, the reaction seems more resigned than outraged. The politicians continue to bicker, and the media cover it as though it is just another sporting event.

Here’s the problem: Cuts in care and in training for health professionals mean, bluntly, that perhaps thousands of people will suffer unnecessarily; some will die. There is no difference between this and when those of us in the health professions engage in self-serving turf wars rather than keeping top of mind the people we are paid to care for.

It’s time for all of us – those in the health professions and politicians in Washington – to make sure the touchstone for all of our actions is the needs of the people we have sworn to serve.

Stop Ignoring the Science

February 2013
David Vlahov

When the Institute of Medicine (IOM) of the National Academy of Sciences issues a report, the IOM panels and review process ensure that conclusions and recommendations are based on solid science. This is a profound principle, one that those of us in health care have long held dear.

It’s especially important as we prepare to expand care to 32 million more Americans, because it is scientific evidence that will be central to ensuring the safest, highest-quality care. So why is it that as numerous articles raise alarms about a physician shortage, they ignore or minimize scientific evidence from the IOM and others that there are alternative and, perhaps, more efficient and lower-cost ways to fill some of the gaps?

Exhibit A: The authors of a 2010 IOM report entitled The Future of Nursing: Leading Change, Advancing Health amassed and reviewed evidence about the role of advanced practice nurses (APNs). Multiple studies – including randomized controlled studies – over several decades had shown that APNs provide high-quality and safe patient care in multiple clinical settings. This led to the recommendation that APNs should be able to practice to the level of their education. Evidence and advocacy efforts continue to grow in support of this recommendation, but in some places it remains an uphill battle.

Moreover, some studies also show that APNs can be trained in less time and for less expense than physicians, and are lower cost in practice even as patients remain satisfied with the care they receive from APNs. These are all relevant metrics for the accountable care organizations springing up around the country in response to the Affordable Care Act.

Exhibit B: Diana Taylor, professor emerita at UCSF School of Nursing, and Tracy Weitz, associate professor, Department of Obstetrics, Gynecology & Reproductive Sciences at UCSF School of Medicine, recently published a report in the American Journal of Public Health. The researchers – who work out of Advancing New Standards in Reproductive Health (ANSIRH) and the UCSF Bixby Center for Global Reproductive Health – completed an observational prospective study that evaluated the outcomes of aspiration abortions completed by 5,812 physicians and by 5,675 newly trained nurse practitioners (NPs), certified nurse-midwives (CNMs) and physician assistants (PAs). The study found that abortion complications were clinically equivalent between the physicians and the combination of NPs, CNMs and PAs.

Policy advocates intent on changing California law to expand access to abortion care have latched onto the study. On the 40th anniversary of Roe v. Wade (1973), advocates held a press conference on the capitol steps in Sacramento to mark the occasion and introduce legislation based on Weitz and Taylor’s study. Authored by Assembly member Toni Atkins, Assembly Bill 154 seeks to allow NPs, CNMs and PAs to provide aspiration abortions.

While health care providers and the general populace will differ on their positions about reproductive health choice, the study from the UCSF schools of medicine and nursing is important for several reasons.

First, it is a potent example of health professions working together to generate new data to inform practice. Second, the study findings – the evidence – are being used beyond academia to spur policy debate and action – always an encouraging development.

Finally, the study joins the IOM’s The Future of Nursing report in the continually expanding literature on the competence of APNs to provide high-quality and safe patient care. Thus these highly and specifically trained professionals – often working closely with physician partners – can mitigate the effects of projected physician shortages and help meet the growing health care, disease prevention and wellness needs of the US population.

The evidence is clear.

 

Senseless

December 2012
David Vlahov

As I write this, the country is reeling from the senseless mass murders at an elementary school in Newtown, Connecticut. This most recent gun-related horror is especially shocking as the primary victims were young children. Even for those of us who did not know these children, when we see their pictures we feel nearly incomprehensible sadness. Our hearts reach out to the grieving families and communities.

In a profession dedicated to helping others, it is a shock to suddenly feel a collective helplessness. Many nurses have seen wounded individuals on the street or coming though the door, and have worked to save lives and comfort families, but the human devastation in the Connecticut shooting – and the one this past summer at a movie theater in Aurora, Colorado – is on a completely different scale. Perhaps it is my training, perhaps why I became a nurse in the first place, but after mourning, I can’t help fighting the helplessness by wondering what I can do to make sure nurses prepare for, respond to and help prevent these tragedies.

At one level, there’s the training we can offer nurses in acute care, including trauma care, where the science has advanced tremendously in the past few decades. Nurse clinical specialists who work in acute and trauma care are often among the teams that minister to the victims when they make it through the door, and we must do everything we can to ensure their training is equal to the task.

Other nurses choose to return to school to train as nurse practitioners in community health, including school health. Increasingly, clinics at middle schools and high schools fill an important gap in health care for otherwise underserved communities. Nurses in this setting can be an important resource, working with teachers to raise awareness – and working with police and school officials to train and drill on responses to school emergencies. Here, too, we must see to it that nurses are prepared to fill that role.

But of course, in reality all nurses are frontline community resources. We are more than one-on-one clinicians in outpatient or acute care settings. Nurses bring perceptive and sensible eyes and ears on the ground; we bring our training in communication skills, primary care, mental health and leadership and so can become credible leaders in our various communities, from work to worship and the broader community. Communities are strengthened when leaders and experts work with members to knit a social fabric that helps move individuals and the group toward physical, mental, emotional and spiritual health.

Finally, nurses can be strong policy advocates – and those so inclined should not shrink from that role. We are witnesses, we are credible, we can step forward and, with others, we can frame and change policy to reduce and maybe someday stop this senseless killing.

What a Disaster

December 2012
David Vlahov

Two weeks ago, Hurricane Sandy arrived on the East Coast of the United States, slamming into the New Jersey coast, Long Island and New York City. We at the UCSF School of Nursing send our best wishes to those affected directly and indirectly by this catastrophic storm. We have seen footage and spoken with relatives and colleagues, but only those of you experiencing it know what is happening beyond what the pictures show and the voices tell.

As I write this, the week before Thanksgiving, I am in Manhattan, seeing the devastation firsthand. Uptown is mostly unaffected, but yesterday I went to Hunter-Bellevue School of Nursing and Bellevue Hospital. Hunter-Bellevue faculty member David Keepnews had reported that the school sustained serious damage, with boilers and the electrical system destroyed and dormitories evacuated. The administration has relocated classes to a big open floor in the library so that education can continue.

My daughter, Ali, is a nurse at NYU Langone Medical Center, which is a few blocks up from Hunter-Bellevue Hospital. She was among those helping with the evacuation, her patients sent to hospitals throughout the city. The damage at the medical center is so extensive that portions of it will likely be closed until January. Ali herself lives in downtown Brooklyn, and she and her neighbors are still feeling the effects of the storm.

Eileen Sullivan-Marx, the new dean at NYU College of Nursing, reports that the outer boroughs are in terrible shape and that shelters are starting to feel the burden as the power is still out in parts of Long Island and Queens. Hospitals are discharging people who have nowhere to go. Some shelters have reported norovirus outbreaks. Folks are tired.

People outside of New York City often think of it as a dense, pulsating, anonymous mass. Live there, as I have, and you learn that it is a series of nearly discrete, closely knit neighborhoods where people know and care about each other. Today I hear them talking in their buildings and on their streets, as they’ve done during past disasters. As I walked down First Avenue toward NYU, I heard more conversations than when I made the same walk soon after the terrorist attacks on September 11th – and this gives me hope. People will recover well before the damage to property is repaired in this resilient city.

But as I look at my daughter and my colleagues scrambling to begin rebuilding – and I consider the concepts of healing and prevention – I can’t help wondering about the role of nursing schools and nurses in a world that seems to include more frequent adverse weather events.

Our first priority, of course, is to protect our students and faculty, making sure they are safe and cared for. But more broadly, we need to plan. We need disaster drills that understand these new and frightening threats of rising waters and wind damage along the coasts (where most people live), tornados across the plains, and earthquakes along and near faults. We need community assessments that can become longitudinal in nature to learn about creating more effective responses. And, because nurses may often be among the first or second responders – NYU is checking on its neighbors, as did advanced practice nurses from Southern University School of Nursing after Katrina – we must bear witness and provide testimony on the need for policy changes that affect the conditions that lead to these events. We know this firsthand because UCSF School of Nursing graduate Hiroko Minami lived through the Kobe earthquake in 1995, which led to her work with us and others in disaster preparedness.

We talk often about the value of our holistic training – our understanding that the health and well-being of our patients is dependent on a universe outside of their individual bodies. The hurricane and our colleagues in New York have sent an unmistakable signal about just how widely that universe extends. We should pay attention and we should act.

The Future Is Here: Citizen Health and the Role of Nurses

October 2012
David Vlahov

“Citizen Health” is a movement that envisions patients becoming more engaged in their own health through growing access to health information on the Internet. Fostering engaged and informed patients is a good thing, but with the quality of information uneven and many citizens ill-equipped to sort through it to make an informed decision, there is cause for concern.

Today many patients arrive in clinical settings with information that has shaped their thinking about diagnosis and treatment. A few even have full online access to their medical records – and those numbers will increase dramatically – as well as online access to many different ideas about best practices for managing their condition. This alters clinical interactions in ways for which few clinicians have been prepared – and which can lead to an unsatisfactory rapport between patient and clinician that erodes the clinician’s credibility.

The risks of credibility erosion can deepen as access to information increases. In February 2011, IBM’s Watson computer appeared on “Jeopardy!” and defeated two of the show’s most successful human contestants. Now IBM and Nuance Communications are developing Watson as a clinical decision-making tool. Once it becomes available to physicians, how long before it becomes accessible to patients as well, especially given the speed of development and democratization of health informatics?

What is the future of nursing in this brave new world of Citizen Health? First, we must stay abreast of technological changes, no matter how rapidly they occur. Second, we must lead in providing insight into the unintended consequences of technology: When and how is information counterproductive? Third, we must explore the myriad ways that true health literacy can enable citizens to more effectively participate in health promotion and disease prevention.

All of this should lead us to a hybrid approach in which the patient’s access to intelligently vetted health information can supplement the human touch, training and experience of the nurse and physician. Nurses will still need to coordinate care, identify gaps, direct patients and families to resources, and advocate for the preventive and therapeutic care that drives people to information in the first place. To shape and participate in this hybrid approach, we need to be prepared for both the present and the future.

As numerous articles in Science of Caring have illustrated, that is precisely what we are doing at UCSF School of Nursing. We were the first school of nursing in the country to upload content on Coursera, which provides free access to high-quality courses on health information; our two courses combined already have over 20,000 registrants from around the globe. Faculty here develop new theories and validate protocol-based products for self-assessment and management. At scientific meetings and product exhibitions, they present their work on the use of apps, computer avatars and gaming platforms to improve diagnosis, treatment and care.

And as highlighted in this issue’s feature story, UCSF nursing faculty had the first of what we hope to be many meetings with GE Healthcare to describe clinical problems that may be addressed with technological solutions. Partnerships of this type provide the opportunity to create a shared vocabulary and processes for collaboration. They enable nurses to become more adept at understanding where technology fits in the framework of identifying clinical problems – and to better understand technology’s potential to bring together the citizen patient, his or her family and the clinician in meaningful ways to improve health.

David Vlahov, PhD, RN, FAAN
Professor and Dean, UCSF School of Nursing

 

Walking the Talk for a More Diverse Nursing Workforce

September 2012
David Vlahov

Recently, UCSF School of Nursing co-hosted an event with the Jonas Center for Nursing Excellence on caring for veterans returning from wars in Iraq and Afghanistan. Discussions focused on improving nursing care to this population and recruiting and retaining veterans as students and faculty. The latest of many efforts to acknowledge and improve diversity in nursing, the event was an acute reminder that for reasons both practical and principled, diversity and inclusiveness must be core values in schools of nursing.

In most cases, I’m proud to say, they are. But there’s a difference between professing values and successfully living up to them, and for all of us in this profession, living up to these values demands a hard look in the mirror.

That look begins with definitions, because too often the terms diversity and inclusiveness are used loosely and vaguely.

Diversity refers to human qualities that are different from our own and those of groups to which we belong, but that are manifested in other individuals and groups. Dimensions of diversity include but are not limited to age, ethnicity, gender, physical abilities/qualities, race, sexual orientation, educational background, geographic location, income, marital status, military experience, parental status, religious beliefs, work experience and job classification. Inclusion is a sense of belonging: feeling respected and valued for who you are – even more than that, feeling a level of supportive energy and commitment from others so that you can do your best work.

Diversity is important because we need a nursing workforce that mirrors the population. Consider that disparities in health exist across almost all diseases and conditions. For example, African American adults, Hispanics, American Indians and Native Alaskans and Hawaiians receive a diagnosis of diabetes – one of our country’s most significant public health problems – about twice as often as non-Hispanic whites. Numerous studies have shown that a more diverse health care workforce holds enormous potential to reduce disparities, in part by enhancing the cultural understanding and creativity of the work environment. And it is inclusiveness that enables us to tap that potential, first by fostering diversity in recruitment and retention and then by creating an environment where honest exchanges can occur.

Over the past 30 years, the nursing workforce has become more diverse, but even today over 83 percent of the 3 million registered nurses in our country are non-Hispanic white, a group that makes up only 66 percent of the general population. The proportions of registered nurses who are African American, Asian and Hispanic are 5, 5 and 3 percent, respectively; by contrast, the proportions of the US population that are African American, Asian and Hispanic are 13, 5 and 15 percent, respectively. And men account for only 6.6 percent of the US nursing population today.

So working on the numbers is one important goal. When we recruit students, we need to be sensitive that the language and images we use are inclusive. We should highlight ways in which we have achieved greater diversity and provide information about the support systems in place at the school and the surrounding community, about scholarships and awards. Wherever possible, we should also demonstrate that we have a committed minority faculty committee, an environment that is supportive at all levels, and mentors in place who can provide guidance and support in a new and different environment. If those things aren’t in place, they should be.

Increasing faculty diversity is equally important, because just as more diverse providers offer something uniquely important to patients, more diverse faculty are essential for achieving a learning environment where nurses of all backgrounds can be prepared to provide the best care in an increasingly diverse society.

But improving the numbers is only a beginning. At UCSF School of Nursing, a cadre of faculty formed a group called DIVA (Diversity in Action) in 1994. Since that time, DIVA has led the way in helping us confront some of the more difficult issues that arise on a multicultural campus – and create and share tools to nurture diversity. The DIVA group has forced us to consider how we can ensure that our entire student population feels fully part of every classroom, to revamp our curriculum and to do the hard work of honestly confronting and resolving incidents of insensitivity or unconscious bias.

For example, back in 2006 DIVA initiated a process that rigorously examined every course in the school to discern how effectively, if at all, it addressed issues of bias or inclusiveness. DIVA looked at student evaluations to understand student experience and held meetings with various groups. That process led to creation of a faculty development program for diversity and inclusiveness that has six modules. In essence, the modules are a series of six training sessions that help faculty:

1.   Facilitate inclusive discussions within the classroom

2.   Design syllabi and courses to engage issues of diversity

3.   Create a respectful and inclusive classroom management approach

4.   Encourage a culturally humble approach in the clinical setting and encourage students to be culturally humble

5.   Teach future faculty to engage in issues of diversity

6.   Form more diverse research teams, incorporate issues of difference into research projects and comply with NIH mandates

The modules are rooted in the concept of cultural humility, which, rather than focusing on particular answers to these difficult challenges, suggests that the way to deal with bias and create an environment that leads to a more diverse and more effective nursing workforce is to recognize, understand and address power imbalances with respect and humility.

We are justifiably proud of such efforts, but that hard look in the mirror tells us we still have a tremendous amount of work to do. I suspect we are not alone.

New Roles for Advanced Practice Nurses

September 2012
David Vlahov

As the country gears up for the 2014 implementation of the Affordable Care Act, which will open up access to care for 32 million currently uninsured people, advanced practice nurses (APNs) will play an important role.

Working with other health care providers in a variety of settings, APNs can meet many essential needs of a modern health care system, including health promotion, disease prevention and primary and specialty care. In addition, nurse practitioners are a significant part of the solution for improving access to underserved populations.

Perhaps most importantly given the urgency of the situation, evidence exists that APNs take less time to train, provide less expensive care and in the many areas for which they are trained deliver equal or better quality of care and patient satisfaction than physicians. 

The catch is that there is a shortage of expert teachers to prepare the next generation of APNs. At the moment, there are 1,200 vacant APN faculty jobs nationwide, and this year we are seeing a rash of retirements in among nursing faculty across the country. Looking ahead five years, between one-third and one-half of APN faculty at our school alone will be eligible to retire. Replacing them will not be easy.

Returning to school for a doctorate requires a special dedication, especially for nurses who have practiced and taken on financial and family responsibilities. Tuition has increased as federal and state funding for advanced education has eroded, making higher-paid clinical positions like nurse practitioner more appealing. Those who choose to teach make personal sacrifices so that we can have a new and more responsive health care system.

Some of those who remain in clinical positions do serve as volunteer faculty and preceptors. Often alumni, they too do a remarkable job of training the next generation of nurses. Yet here again, their role demands sacrifice, and we do not have the numbers to meet the need.

To fill the gaps, most schools are experimenting with new strategies, including advanced simulation labs, online education, and partnerships with other professionals in nutrition and pharmacology as well as among formerly competitive nursing schools.

All of these strategies are important, but none can fully replace the human interaction – the nurse educators who have made personal sacrifices to nurture and guide the clinician who will provide outstanding frontline care, the administrator who will supervise the positive patient experience, and the educator and scholar who will advance knowledge in the university setting.

These individuals deserve more than our thanks. They need concrete support in the form of better wages – not just to show our appreciation, but also to entice others to fill these crucial roles. Schools need more endowed chairs to recognize faculty excellence. And we must maintain and strengthen our relationships with volunteer alumni and other community clinicians who teach students in real-world clinical settings.  

Because the flattened economy has caused some nurses to put off retirement or return to work, job vacancies are low in some areas, causing some debate about whether a nursing shortage actually exists. But when the economy recovers, many nurses will again leave the clinical and academic settings, depleting our ranks at a time when the aging of the population will demand more nursing care than ever before. We need nurse educators now to be prepared for the future that is already upon us.

David Vlahov, PhD, RN, FAAN
Professor and Dean, UCSF School of Nursing

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