Future advancement of health care through standardized nursing terminologies: reflections from a Friends of the National Library of Medicine workshop honoring Virginia K. Saba.

OBJECTIVE: To honor the legacy of nursing informatics pioneer and visionary, Dr. Virginia Saba, the Friends of the National Library of Medicine convened a group of international experts to reflect on Dr. Saba's contributions to nursing standardized nursing terminologies. PROCESS: Experts led a day-and-a-half virtual update on nursing's sustained and rigorous efforts to develop and use valid, reliable, and computable standardized nursing terminologies over the past 5 decades. Over the course of the workshop, policymakers, industry leaders, and scholars discussed the successful use of standardized nursing terminologies, the potential for expanded use of these vetted tools to advance healthcare, and future needs and opportunities. In this article, we elaborate on this vision and key recommendations for continued and expanded adoption and use of standardized nursing terminologies across settings and systems with the goal of generating new knowledge that improves health. CONCLUSION: Much of the promise that the original creators of standardized nursing terminologies envisioned has been achieved. Secondary analysis of clinical data using these terminologies has repeatedly demonstrated the value of nursing and nursing's data. With increased and widespread adoption, these achievements can be replicated across settings and systems.

Analyzing Hospital Transfers Using INTERACT Acute Care Transfer Tools: Lessons from MOQI.

OBJECTIVES: We explored the differences in potentially avoidable/unavoidable hospital transfers in a retrospective analysis of Interventions to Reduce Acute Care Transfers (INTERACT) Acute Transfer Tools (ACTs) completed by advanced practice registered nurses (APRNs) working in the Missouri Quality Improvement (QI) Initiative (MOQI). DESIGN: Cross-sectional descriptive study of 3996 ACTs for 32.5 calendar months from 2014 to 2016. Univariate analyses examined differences between potentially avoidable vs unavoidable transfers. Multivariate logistic regression analysis of candidate factors identified those contributing to avoidable transfers. SETTING: Sixteen nursing homes (NHs), ranging from 120 to 321 beds, in urban, metro, and rural communities within 80 miles of a large midwestern city. PARTICIPANTS: A total of 5168 residents with a median age of 82 years. MEASUREMENTS: Data from 3946 MOQI-adapted ACTs. RESULTS: A total of 54% of hospital transfers were identified as avoidable. QI opportunities related to avoidable transfers were earlier detection of new signs/symptoms (odds ratio [OR] = 2.35; 95% confidence interval [CI] = 1.61-3.42; P < .001); discussions of resident/family preference (OR = 2.12; 95% CI = 1.38-3.25; P < .001); advance directive/hospice care (OR = 2.25; 95% CI = 1.33-3.82; P = .003); better communication about condition (OR = 4.93; 95% CI = 3.17-7.68; P < .001); and condition could have been managed in the NH (OR = 16.63; 95% CI = 10.9-25.37; P < .001). Three factors related to unavoidable transfers were bleeding (OR = .59; 95% CI = .46-.77; P < .001), nausea/vomiting (OR = .7; 95% CI = .54-.91; P = .007), and resident/family preference for hospitalization (OR = .79; 95% CI = .68-.93; P = .003). CONCLUSION: Reducing avoidable hospital transfers in NHs requires challenging assumptions about what is avoidable so QI efforts can be directed to improving NH capacity to manage ill residents. The APRNs served as the onsite coaches in the use and adoption of INTERACT. Changes in health policy would provide a revenue stream to support APRN presence in NH, a role that is critical to improving resident outcomes by increasing staff capacity to identify illness and guide system change. J Am Geriatr Soc 67:1953-1959, 2019.

Impact of Advanced Practice Registered Nurses on Quality Measures: The Missouri Quality Initiative Experience.

PURPOSE: The purpose of this article is to review the impact of advanced practice registered nurses (APRNs) on the quality measure (QM) scores of the 16 participating nursing homes of the Missouri Quality Initiative (MOQI) intervention. The MOQI was one of 7 program sites in the US, with specific interventions unique to each site tested for the Centers for Medicaid and Medicare Services Innovations Center. While the goals of the MOQI for long-stay nursing home residents did not specifically include improvement of the QM scores, it was anticipated that improvement most likely would occur. Primary goals of the MOQI were to reduce the frequency of avoidable hospital admissions and readmissions; improve resident health outcomes; improve the process of transitioning between inpatient hospitals and nursing facilities; and reduce overall healthcare spending without restricting access to care or choice of providers. METHODS: A 2-group comparison analysis was conducted using statewide QMs; a matched comparison group was selected from facilities in the same counties as the intervention homes, similar baseline QM scores, similar size and ownership. MOQI nursing homes each had an APRN embedded full-time to improve care and help the facility achieve MOQI goals. Part of their clinical work with residents and staff was to focus on quality improvement strategies with potential to influence healthcare outcomes. Trajectories of QM scores for the MOQI intervention nursing homes and matched comparison group homes were tested with nonparametric tests to examine for change in the desired direction between the 2 groups from baseline to 36 months. A composite QM score for each facility was constructed, and baseline to 36-month average change scores were examined using nonparametric tests. Then, adjusting for baseline, a repeated measures analysis using analysis of covariance as conducted. RESULTS: Composite QM scores of the APRN intervention group were significantly better (P = .025) than the comparison group. The repeated measures analysis identified statistically significant group by time interaction (P = .012). Then group comparisons were made at each of the 6-month intervals and statistically significant differences were found at 24 months (P = .042) and 36 months (P = .002), and nearly significant at 30 months (P = .11). IMPLICATIONS: APRNs working full time in nursing homes can positively influence quality of care, and their impact can be measured on improving QMs. As more emphasis is placed on quality and outcomes for nursing home services, providers need to find successful strategies to improve their QMs. Results of these analyses reveal the positive impact on QM outcomes for the majority of the MOQI nursing homes, indicating budgeting for APRN services can be a successful strategy.

APRN-Conducted Medication Reviews for Long-Stay Nursing Home Residents.

OBJECTIVE: As part of the Missouri Quality Initiative (MOQI) to reduce hospitalizations for long-stay nursing home residents, this article describes reasons MOQI advanced practice registered nurses (APRNs) recommended medication order changes as part of their medication review process as well as the outcomes of their recommendations. DESIGN: Cross-sectional descriptive study of MOQI APRN-conducted medication reviews. SETTING: Long-stay nursing homes participating in the MOQI project. PARTICIPANTS: Seventeen MOQI APRNs recorded medication reviews for 3314 long-stay residents residing in 16 Midwestern nursing homes over a 2-year period. INTERVENTION: APRNs conducted medication reviews and made recommendations for medication order changes to residents' medical providers. MEASUREMENTS: The MOQI medication review database was used to abstract data. RESULTS: There were 19,629 medication reviews recorded for 3314 residents during the 2-year period. Of the 19,629 reviews, 50% (n = 9841) resulted in recommended order changes of which 82% (n = 8037) of order changes occurred. More than two-thirds of recommendations were because of changes in the residents' plans of care. Other recommendations included adjusting and/or discontinuing medications that had the potential for harm. CONCLUSION: Resident care needs are dynamic, resulting in the need for frequent medication order changes. MOQI APRNs, because of their advanced pharmacological education and daily presence in the nursing home, are uniquely positioned to ensure residents' medications aligned with their overall goals of care while minimizing risk of harm.

Successfully Reducing Hospitalizations of Nursing Home Residents: Results of the Missouri Quality Initiative.

PURPOSE: The goals of the Missouri Quality Initiative (MOQI) for long-stay nursing home residents were to reduce the frequency of avoidable hospital admissions and readmissions, improve resident health outcomes, improve the process of transitioning between inpatient hospitals and nursing facilities, and reduce overall healthcare spending without restricting access to care or choice of providers. The MOQI was one of 7 program sites in the United States, with specific interventions unique to each site tested for the Centers for Medicaid and Medicare Services (CMS) Innovations Center. DESIGN AND METHODS: A prospective, single group intervention design, the MOQI included an advanced practice registered nurse (APRN) embedded full-time within each nursing home (NH) to influence resident care outcomes. Data were collected continuously for more than 3 years from an average of 1750 long-stay Medicare, Medicaid, and private pay residents living each day in 16 participating nursing homes in urban, metro, and rural communities within 80 miles of a major Midwestern city in Missouri. Performance feedback reports were provided to each facility summarizing their all-cause hospitalizations and potentially avoidable hospitalizations as well as a support team of social work, health information technology, and INTERACT/Quality Improvement Coaches. RESULTS: The MOQI achieved a 30% reduction in all-cause hospitalizations and statistically significant reductions in 4 single quarters of the 2.75 years of full implementation of the intervention for long-stay nursing home residents. IMPLICATIONS: As the population of older people explodes in upcoming decades, it is critical to find good solutions to deal with increasing costs of health care. APRNs, working with multidisciplinary support teams, are a good solution to improving care and reducing costs if all nursing home residents have access to APRNs nationwide.

Patient-centered care, collaboration, communication, and coordination: a report from AMIA's 2013 Policy Meeting.

In alignment with a major shift toward patient-centered care as the model for improving care in our health system, informatics is transforming patient-provider relationships and overall care delivery. AMIA's 2013 Health Policy Invitational was focused on examining existing challenges surrounding full engagement of the patient and crafting a research agenda and policy framework encouraging the use of informatics solutions to achieve this goal. The group tackled this challenge from educational, technical, and research perspectives. Recommendations include the need for consumer education regarding rights to data access, the need for consumers to access their health information in real time, and further research on effective methods to engage patients. This paper summarizes the meeting as well as the research agenda and policy recommendations prioritized among the invited experts and stakeholders.

Evaluation of health alerts from an early illness warning system in independent living.

Passive sensor networks were deployed in independent living apartments to monitor older adults in their home environments to detect signs of impending illness and alert clinicians so they can intervene and prevent or delay significant changes in health or functional status. A retrospective qualitative deductive content analysis was undertaken to refine health alerts to improve clinical relevance to clinicians as they use alerts in their normal workflow of routine care delivery to older adults. Clinicians completed written free-text boxes to describe actions taken (or not) as a result of each alert; they also rated the clinical significance (relevance) of each health alert on a scale of 1 to 5. Two samples of the clinician's written responses to the health alerts were analyzed after alert algorithms had been adjusted based on results of a pilot study using health alerts to enhance clinical decision-making. In the first sample, a total of 663 comments were generated by seven clinicians in response to 385 unique alerts; there are more comments than alerts because more than one clinician rated the same alert. The second sample had a total of 142 comments produced by three clinicians in response to 88 distinct alerts. The overall clinical relevance of the alerts, as judged by the content of the qualitative comments by clinicians for each alert, improved from 33.3% of the alerts in the first sample classified as clinically relevant to 43.2% in the second. The goal is to produce clinically relevant alerts that clinicians find useful in daily practice. The evaluation methods used are described to assist others as they consider building and iteratively refining health alerts to enhance clinical decision making.

Sensor technology to support Aging in Place.

Older adults want to age in place at home. Sensor technology has the potential to help by monitoring individuals' health status, detecting emergency situations, and notifying health care providers. Researchers at the University of Missouri are investigating the impact of registered nurse care coordination and technology on the ability of older adults to age in place. Technology coupled with care coordination has improved clinical outcomes. This article presents an overview of the Aging in Place research, TigerPlace as a Missouri-sponsored Aging in Place facility, and the sensor technology developed to support Aging in Place.

The use of bedside electronic medical record to improve quality of care in nursing facilities: a qualitative analysis.

It appears that the implementation and use of a bedside electronic medical record in nursing homes can be a strategy to improve quality of care. Staff like using the bedside electronic medical record and believe it is beneficial. Information gleaned from this qualitative evaluation of four nursing homes that implemented complete electronic medical records and participated in a larger evaluation of the use of an electronic medical record will be useful to other nursing homes as they consider implementing bedside computing technology. Nursing home owners and administrators must be prepared to undertake a major change requiring many months of planning to successfully implement. Direct care staff will need support as they learn to use the equipment, especially for the first 6 to 12 months after implementation. There should be a careful plan for continuing education opportunities so that staff learn to properly use the software and can benefit from the technology. After 12 to 24 months, almost no one wants to return to the era of paper charting.

Improving nurse care coordination with technology.

Technology offers potential solutions to the pending crisis of healthcare for older adults, while healthcare workers are in short supply. Technology can enable remote monitoring of individuals and early detection of potential problems, so that early interventions can help older adults remain as healthy and independent as possible. Research is under way with passive monitoring technology in senior housing that is finding patterns in the data that can enhance nurse care coordination through early illness detection. With early detection, interventions can be more effective and reduce hospitalization and other healthcare expenses. Case studies are presented, and implications are discussed.

Cost, staffing and quality impact of bedside electronic medical record (EMR) in nursing homes.

OBJECTIVE: There is growing political pressure for nursing homes to implement the electronic medical record (EMR) but there is little evidence of its impact on resident care. The purpose of this study was to test the unique and combined contributions of EMR at the bedside and on-site clinical consultation by gerontological expert nurses on cost, staffing, and quality of care in nursing homes. METHODS: Eighteen nursing facilities in 3 states participated in a 4-group 24-month comparison: Group 1 implemented bedside EMR, used nurse consultation; Group 2 implemented bedside EMR only; Group 3 used nurse consultation only; Group 4 neither. Intervention sites (Groups 1 and 2) received substantial, partial financial support from CMS to implement EMR. Costs and staffing were measured from Medicaid cost reports, and staff retention from primary data collection; resident outcomes were measured by MDS-based quality indicators and quality measures. RESULTS: Total costs increased in both intervention groups that implemented technology; staffing and staff retention remained constant. Improvement trends were detected in resident outcomes of ADLs, range of motion, and high-risk pressure sores for both intervention groups but not in comparison groups. DISCUSSION: Implementation of bedside EMR is not cost neutral. There were increased total costs for all intervention facilities. These costs were not a result of increased direct care staffing or increased staff turnover. CONCLUSIONS: Nursing home leaders and policy makers need to be aware of on-going hardware and software costs as well as costs of continual technical support for the EMR and constant staff orientation to use the system. EMR can contribute to the quality of nursing home care and can be enhanced by on-site consultation by nurses with graduate education in nursing and expertise in gerontology.

Developing a comprehensive electronic health record to enhance nursing care coordination, use of technology, and research.

As in acute care, use of health information technology in long-term care holds promise for increased efficiency, better accuracy, reduced costs, and improved outcomes. A comprehensive electronic health record (EHR), which encompasses all health care measures that clinicians want to use-both standard health care assessments and those acquired through emerging technology-is the key to improved, efficient clinical decision making. New technologies using sensors to passively monitor older adults at home are being developed and are commercially available. However, integrating the clinical information systems with passive monitoring data so that clinical decision making is enhanced and patient records are complete is challenging. Researchers at the University of Missouri (MU) are developing a comprehensive EHR to: (a) enhance nursing care coordination at TigerPlace, independent senior housing that helps residents age in place; (b) integrate clinical data and data from new technology; and (c) advance technology and clinical research.

Helping nursing homes "at risk" for quality problems: a statewide evaluation.

The Quality Improvement Program for Missouri (QIPMO), a state school of nursing project to improve quality of care and resident outcomes in nursing homes, has a special focus to help nursing homes identified as "at risk" for quality concerns. In fiscal year 2006, 92 of 492 Medicaid-certified facilities were identified as "at risk" using quality indicators (QIs) derived from Minimum Data Set (MDS) data. Sixty of the 92 facilities accepted offered on-site clinical consultations by gerontological expert nurses with graduate nursing education. Content of consultations include quality improvement, MDS, care planning, evidence-based practice, and effective teamwork. The 60 "at-risk" facilities improved scores 4%-41% for 5 QIs: pressure ulcers (overall and high risk), weight loss, bedfast residents, and falls; other facilities in the state did not. Estimated cost savings (based on prior cost research) for 444 residents who avoided developing these clinical problems in participating "at-risk" facilities was more than $1.5 million for fiscal year 2006. These are similar to estimated savings of $1.6 million for fiscal year 2005 when 439 residents in "at-risk" facilities avoided clinical problems. Estimated savings exceed the total program cost by more than $1 million annually. QI improvements demonstrate the clinical effectiveness of on-site clinical consultation by gerontological expert nurses with graduate nursing education.

A systematic review of the designs of clinical technology: findings and recommendations for future research.

Human factors (HF) studies are increasingly important as technology infuses into clinical settings. No nursing research reviews exist in this area. The authors conducted a systematic review on designs of clinical technology, 34 articles with 50 studies met inclusion criteria. Findings were classified into 3 categories on the basis of HF research goals. The majority of studies evaluated effectiveness of clinical design; efficiency was fewest. Current research ranges across many interface types examined with no apparent pattern or obvious rationale. Future research should expand types, settings, and participants; integrate displays; and expand outcome variables.