1. THE POWER OF INFORMATICS Adoption – Analytics - Outcomes Mari Tietze, PhD, RN-BC, FHIMSS, Texas Woman’s University Susan McBride, PhD, RN-BC, CPHIMS Texas Tech Health Sciences Center DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

2. Conflict of Interest Disclosure Mari Tietze and Susan McBride have no real or apparent conflicts of interest to report. 2

3.  1. Review preliminary online survey quantitative and qualitative results for 1,000+ responses from Texas nurses on the experience using their electronic health record (EHR) systems.  2. Explore relationship between factors reflective of user satisfaction with their EHRs, maturity of the EHR and user demographics.  3. Provide knowledge-driven recommendations for improving the experiences of nurses and other health professionals using their EHRs. © Texas Nurses Association, 2015 3

4.  History  Charges  Survey Results © Texas Nurses Association, 2015 4

5.  Charge: Determine implications of health care informatics for nursing practice and education in Texas  Include nationally-based Technology Informatics Guiding Education Reform (TIGER) initiative TNA = Texas Nurses Association TONE = Texas Organization of Nurse Executives Vision: To enable nurses and interprofessional colleagues to use informatics and emerging technologies to make healthcare safer, more effective, efficient, patient- centered, timely and equitable by interweaving evidence and technology seamlessly into practice, education and research fostering a learning healthcare system. http://www.thetigerinitiative.org/ © Texas Nurses Association, 2015 5

6. Advisory Committee: Practice, Administration, Education and Vendors/Suppliers Nursing HIT Curriculum Development CNE for Practicing Nurses Awareness Campaign Educational Content Dissemination Embrace the Technology Preserve the Art Environmental Forces: Health Care Reform/ARRA Advanced Practice Nurse Roles EHR Incentives IOM/RWJF Report Advancing Health Care Informatics Nurse Standards by ANA Benchmark Reports on Progress Nursing Leaders HIT Orgs. and For 400,000 Texas Nurses

7. Task Force Members − Julie Brixey − Nancy Crider (co-chair) − Mary Anne Hanley − Linda Harrington − Susan McBride (PI) − Elizabeth Sjoberg − Laura Thomas − Mari Tietze (co-chair) TNA − Cindy Zolnierek [pres./co-PI] − Laura Lerma [educ.] − Kat Hinson [comm.] − Collene Lewis [admin.] Composed of TNA and TONE Member from practice and academia © Texas Nurses Association, 2015 7

8. http://texasnurses.site-ym.com/?page=HIT © Texas Nurses Association, 2015 8

9. Clinical Information Systems Implementation Evaluation Scale (CISIES) Survey* 1. Launched September 23, 2014, statewide 2. Over sampled rural hospitals in an effort to insure representation 3. To date over 1,000 responses received − Included a newly-developed** EHR “maturity-index” 4. Preliminary results to follow © Texas Nurses Association, 2015 * = Gugerty, B. ** = McBride, S. & Tietze, M. 9

10. Supports the tool kit content/survey 1. Establish/support local nursing informatics chapters – − DFW ANIA − Gulf Coast ANIA − Houston ANIA [in process] 2. Coordinate publication schedule with TNA communications staff 3. Contributed to Ebola Outbreak awareness campaign © Texas Nurses Association, 2015 10

11. Content for toolkit  Use CISIES survey responses to guide toolkit content  Create and place on TNA and TONE Web sites  Three CNE Webinars are being proposed based on trends in the industry: − “Workflow versus Work-Arounds to Optimize EHR Patient Safety and Quality.” − “Interoperability of Electronic Health Records.” − Best Practices for Using EHRs in Nursing Practice within Interprofessional Teams © Texas Nurses Association, 2015 11

12. Renew the 2010 resolution and add the following content: 1. Interoperability 2. Meaningful Use of EHRs (for Nursing) 3. Interprofessional Education/Collaboration 4. TIGER competencies initiative 5. Defining Best Practices for Using an EHR within the Clinical Workflow © Texas Nurses Association, 2015 12

13. THE POWER OF INFORMATICS Adoption – Analytics - Outcomes Pre-publication

14.  What are key issues with the current deployment of the electronic health record in the practice setting? − What is the relationship between health setting characteristics and the nurses’ perceptions of their CIS? − What is the relationship between the nurses’ characteristics and the nurses’ perceptions of their CIS? − What is the relationship between CIS characteristics and the nurses’ perceptions of their CIS?  What are the related core HIT competencies that should be covered in nursing education? © Texas Nurses Association, 2015 14

15.  A descriptive and exploratory research study of the current nursing workforce in Texas, using a previously validated survey instrument, was conducted in select acute care facilities and their associated acute care, ambulatory/episodic care and long term care (LTC) units (Texas Workforce Center), collectively “Health Care Organization” to answer the research questions. © Texas Nurses Association, 2015 15

16. Qualitative analysis of participant comments [n = 300+] © Texas Nurses Association, 2015 16

17. First page of the TNA/TONE state wide online survey © Texas Nurses Association, 2015 17

18. Demographic information about EHR functionality (5 of 24 items) © Texas Nurses Association, 2015 : Meaningful Use Maturity Index for Nursing* (*McBride & Tietze, 2015) 18

19. Clinical Information System Implementation Evaluation Scale (CISIES) © Texas Nurses Association, 2015 19

20. THE POWER OF INFORMATICS Adoption – Analytics - Outcomes © Texas Nurses Association, 2015

21. TNA-TONE Push #1 TNA-TONE Push #2 © Texas Nurses Association, 2015 Total N=1,178 21

22. © Texas Nurses Association, 2015 Rural respondents were 52.7% acute care & 10.2% ambulatory Urban respondents were 52.7% acute care & 11.5% ambulatory 22

23. THE POWER OF INFORMATICS Adoption – Analytics - Outcomes © Texas Nurses Association, 2015 *McBride, S. & Tietze, M. (2015)

24. © Texas Nurses Association, 2015 Meaningful Use Maturity Index for Nursing Sample of 3 of the 24 Item scale aligned with Meaningful Use Stage 1 Measures 0.889 Cronbach’s Alpha Mean of 56.53 (SD 13.85) Range 0 - 72 Content Validity using Lynn’s method Lynn, M.R. “Determination and Quantification of Content Validity.” Nursing Research Vol. 35 No. 6 (1986) 24

25. THE POWER OF INFORMATICS Adoption – Analytics - Outcomes © Texas Nurses Association, 2015

26. Positive Neutral Negative © Texas Nurses Association, 2015 26

27. < 0.5 CISIES Indicates Dissatisfaction 0.5-1.99 Indicates Neutral or Not Completely Satisfied 2-5 Indicates Satisfied Gugerty, B., Maranda, M., Rook, D. (2006). The Clinical Information System Implementations Evaluation Scale, pp. 621-625. In H. A. Parks, P. Murray, & C. Delaney (Eds.) Consumer-centered computer-supported care for healthy people. Landsdale, PA: IOS Press. © Texas Nurses Association, 2015 27

28. © Texas Nurses Association, 2015 CISIES 37 Survey Questions Cronbach’s Alpha 0.881 49.8% Strongly agree or Agree That the system is more efficient than the old way of doing things 16.2% disagree or strongly disagree 28

29. THE POWER OF INFORMATICS Adoption – Analytics - Outcomes Comparing Relationships © Texas Nurses Association, 2015

30.  What are key issues with the current deployment of the electronic health record in the practice setting? − What is the relationship between health setting characteristics and the nurses’ perceptions of their CIS? − What is the relationship between the nurses’ characteristics and the nurses’ perceptions of their CIS? − What is the relationship between CIS characteristics and the nurses’ perceptions of their CIS?  What are the related core HIT competencies that should be covered in nursing education? © Texas Nurses Association, 2015 30

31. © Texas Nurses Association, 2015 Institution 31

32. © Texas Nurses Association, 2015 Institution 32

33. © Texas Nurses Association, 2015 Region 33

34. © Texas Nurses Association, 2015 Magnet Status 34

35. Hospital Bed size 35

36.  What are key issues with the current deployment of the electronic health record in the practice setting? − What is the relationship between health setting characteristics and the nurses’ perceptions of their CIS? − What is the relationship between the nurses’ characteristics and the nurses’ perceptions of their CIS? − What is the relationship between CIS characteristics and the nurses’ perceptions of their CIS?  What are the related core HIT competencies that should be covered in nursing education? © Texas Nurses Association, 2015 36

37. © Texas Nurses Association, 2015 Position 37

38. © Texas Nurses Association, 2015 50% Direct Patient Care? 38

39. © Texas Nurses Association, 2015 Age 39

40. © Texas Nurses Association, 2015 Nursing Practice Years 40

41.  What are key issues with the current deployment of the electronic health record in the practice setting? − What is the relationship between health setting characteristics and the nurses’ perceptions of their CIS? − What is the relationship between the nurses’ characteristics and the nurses’ perceptions of their CIS? − What is the relationship between CIS characteristics and the nurses’ perceptions of their CIS?  What are the related core HIT competencies that should be covered in nursing education? © Texas Nurses Association, 2015 41

42. © Texas Nurses Association, 2015 EHR System Vendors 42

43. © Texas Nurses Association, 2015 M U N S I 43

44. THE POWER OF INFORMATICS Adoption – Analytics - Outcomes Modeling Relationships © Texas Nurses Association, 2015

45.  Mathematical process during which a larger set of variables is reduced to: − discover patterns among the variables − Reduce the observed variables to a much smaller number of variables called factors.  We will examine categories or “factors” of clustered questions we have identified in the MUNSI and CISIES, we need you to: − Indicate “yes” I agree, or “no” I do not agree − If “no”, then suggest what you would “name” the category of questions © Texas Nurses Association, 2015 45

46. MUNSI CISIES CDS © Texas Nurses Association, 2015 46

47. THE POWER OF INFORMATICS Adoption – Analytics - Outcomes Themes © Texas Nurses Association, 2015

48. 48

49.  Electronic Med. Rec.= 75 (6.4%)  Charting = 65 (5.5%  Nurses = 42 (3.6%)  Information = 52 (4.4.%)  Computer Sys. = 189 (16%)  Software = 110 (9.3%)  Patient = 82 (7%)  Care = 40 (3.4%)  Time = 41 (3.5%  Health = 16 (1.4%)  Questions = 23 (2%)  Healthcare = 61 (5.2%)  Drugs = 20 (1.7%)  Physicians = 31 (2.6%) © Texas Nurses Association, 2015 49

50.  Most effective in identifying concepts and themes.  We will examine categories or “themes” we have identified in the qualitative analysis, four examiners are looking at detailed text and have done the following: − Indicate “yes” I agree, or “no” I do not agree − If “no”, then suggest what you would “name” the category of questions  We need you indicate whether or not you believe we have “named” these themes correctly given subcategories associated with the themes/concepts. © Texas Nurses Association, 2015 50

51. Major and Minor Themes  System design/usability − Interoperability  Patient safety and quality − Documentation/legality  Time − Ns-pt time reduced/inefficiency  Support − IT, administrative, competency  Workflow − Med admin, work-arounds  Distress − Aggravation, voice not heard  Communication − Reduced consultation among clinicians © Texas Nurses Association, 2015 51

52. 52 1. Utilize satisfied characteristics to improve dissatisfied & utilize dissatisfied characteristics to inform improvement strategy 2. Integrate with relationship to design/usability 3. Focus groups exploring clinician-based solutions 4. Focus groups exploring designer-based solutions (vendor and IT implementation) 5. Assess/deploy needed resource support throughout organization 6. Institute leadership-adopting a culture of improvement related to health IT openly monitor progress 7. Provide collegial approach, interprofessional solutions and openly monitor progress 8. Emphasize open, consistent, throughout organization 1. System design/usability 2. Patient safety and quality/legality 3. Time: away from patient care delivery 4. Time: inefficiency 5. Support 6. Workflow 7. Distress 8. Communication © Texas Nurses Association, 2015

53. Analysis, Summarize Findings & Prepare Report Report to TNA/TONE Boards with recommendation on high level priorities based on the evidence Formulate Intervention Strategies based on the evidence Deploy Strategies Across Texas Target Follow-up Study to determine impact of interventions June-Aug 2015 Sept 2015 Oct-Dec 2015Jan-Dec 2016Oct-Dec 2017 53

54.  Mari Tietze, PhD, RN-BC, FHIMSS − Associate Professor − Texas Woman’s University − mtietze@twu.edu  Susan McBride, PhD, RN- BC, CHIMS − Professor − Texas Tech University Health Sciences Center − Susan.McBride@ttuhsc.edu 54

55. 55