Hardly a single aspect of health care has gone untouched by technology. Yet health care lags behind other industries in collecting and sharing data in standardized ways that ensure the security, privacy, and integrity of that data. In a sense, health care is still emerging from its roots as a cottage industry that traditionally has promoted individualism, shunned standardization, and perpetuated proprietary approaches to handling data.
This situation is changing rapidly, though, and the key to transforming health care and improving outcomes lies in harnessing the power of health information technology (IT). The Office of the National Coordinator for Health Information Technology (ONC) at the Department of Health and Human Services (HHS) is charged with improving healthcare quality and safety by leveraging health IT. All nurses should have working knowledge of how health IT can improve outcomes and provide opportunities for them to participate in the national health IT agenda. What’s more, nurses’ insights can help propel change.
To figure out how nurses fit into the grand scheme of healthcare transformation, American Nurse Today Editor-in-Chief Pam Cipriano interviewed Farzad Mostashari, MD, ScM, National Coordinator for Health Information Technology within the ONC. With a passion for transforming health care, Dr. Mostashari leads an aggressive agenda to coordinate programs that foster the implementation and use of advanced health IT and the electronic exchange of health information to improve healthcare quality and reduce costs. He talks comfortably with staff, students, consumers, and federal officials about the promise of health IT in delivering better and more cost-effective health care. His capacity to think forward, enthusiasm for innovative solutions, and keen understanding of how people connect with technology help him keep pace with the rapid-fire developments in the evolving health IT world.
PC: What should nurses know about health IT and adoption of the electronic health record?
In their daily practice, nurses are seeing the beginnings of a broad-based transformation of healthcare delivery. If they haven’t already implemented an electronic health record (EHR), they’re probably either in the midst of doing this or are planning for it. The time really is now for being a part of this transformation, helping it succeed, and making sure it reflects the priorities we’ve always counted on nursing to support.
PC: What’s your vision for ONC to transform care under your leadership?
I see EHRs as the best servants they can be in the pursuit of safer, higher quality, well-coordinated and, most importantly, patient-centered care. For decades, benchmark institutions have shown positive outcome results, and now communities are showing them. I’d like to see similar results in everyday healthcare storefronts, small practices, community health centers, and critical-access hospitals. We call on EHRs to be tools in service of quality improvement to create the kind of care our patients deserve and we want to deliver.
PC: How do you see nurses working with other team members to advance EHR use, address
improved care transitions, and reduce harmful acquired conditions?
Throughout my career [as an internal medicine physician], I’ve found nurses have an orientation that prioritizes certain factors that will prove critical to using EHRs and other new technologies. The first is implementation—nurses get it done. I don’t know of a successful EHR implementation that hasn’t been led by “boots on the ground” nurses or in which they weren’t deeply involved. Why? Because nurses understand workflow.
The second factor is team-based care. Nurses know how important that is to care today. Care isn’t just about the great diagnostician and figuring out the treatment. It demands we work together and coordinate care in teams. When EHRs are implemented correctly, they can dramatically improve the efficiency of team members working together.
Third—nurses understand and appreciate protocols and standardization of best-care practices, checklists, and the other ways that can help turn medicine from an "artisanal" cottage industry into one that uses an array of quality-improvement tools, such as Six Sigma [a measurement-based approach to continuous improvement that aims to eliminate product defects], and protocolized, evidenced-based best practices to deliver care.
The fourth factor nurses bring to the table is patient centeredness. Nurses look at the impact of care transformation on the most important person—the patient. They ask how a treatment feels to or works for the patient. How will it affect that person on a real basis?
PC: Do you think we’re starting to see a change in how physicians interact with patients—perhaps encouraging them to be more interactive with their data and EHRs?
The trend over the last decade has been going in that direction. Traditional assumptions about provider-patient relationships have changed. Students today are taught very different relationships that call for them to work with patients to improve their health and functioning. No longer is the provider the only one with a protected body of knowledge. We’ve seen an enormous democratization of information, with consumers having access to more health information. This changes the provider-patient relationship. People now can manage various aspects of their life through the Internet and online services—banking, investments, and travel, for instance. When they come up against healthcare barriers or inefficiencies that make it less customer friendly, they’re increasingly asking providers for a better experience.
PC: An unintended consequence of hospital EHRs relates to the desire to make RNs’ documentation as "quick as possible," with a proliferation of drop-down boxes to document care. Entries that describe the patient context are diminishing and may be optional, which makes it hard for other providers to tell what’s going on. How would you suggest we preserve the valuable aspects we’ve used in the past to tell our patients’ stories?
Education about EHR design options is part of the answer. It’s important to make informed decisions about design, determining what should be in drop-down boxes or free text, and understanding why certain elements must be structured in certain ways. We haven’t been trained to understand how structured data elements, such as blood pressure or smoking status, are used by the EHR to derive a decision support alert or prompt, or the reporting of a quality measure.
Part of the process also may be to guide the market based on the priorities of patient care—letting vendors know that products that allow nurses to minimize drop-downs while offering other ways to preserve the context of care are more desirable and will do better in the market. Educating both vendors and systems users will help vendors move in that direction.
PC: We still have the compartmentalized aspect of EHRs. To fully achieve team-based care, do we need to change the structure of the electronic record itself? Or is it more about the culture of how teams come together to use the EHR?
I believe in the saying, "Culture eats strategy for lunch." It definitely starts with culture. Inculcating the right culture can be helped through payment systems that reward team-based and integrated care. We’re seeing movement in that direction from both the private and public sectors. Once we have payment systems that reward team-based care, together with the desire to deliver care differently, technology can be a real enabler. But the culture and payment system have to be aligned.
As the interview neared an end, Dr. Mostashari reflected on some of the most intellectually rewarding work he has ever done. While employed by Urban Health Plan, a network of federal qualified community health centers serving the South Bronx and Queens in New York City, he worked with Allison Connelly-Flores, a nurse practitioner and clinical system administrator. At their weekly Monday meetings, they brainstormed ways to improve the design of their EHR to provide higher-quality care. On Fridays, they would see the revised prototypes and iterate more rapid-cycle changes as needed. Dr. Mostashari said, "The insights she brought as the lead for implementation in her community health center, plus delivering care and being in charge of workflows that needed to be changed, contributed amazing things to the success of the primary care initiative in New York. Allison taught me so much about patient care and technology, and how they work together. I’d like to extend my appreciation to her and the many other nurses like her who are doing this hard but incredibly important work."