2.  BEFORE Inefficient Costly Manually intensive Crisis-driven model of care delivery  AFTER Efficient Consumer-centric Science-based model  Changes brought by: Skyrocketing cost of healthcare delivery Exposure of patient-safety problems Aging “baby boom” population

3. Key technologies that enable the transformation Attributes of transformed Healthcare Technology Enablers Medical decisions are based on the current state of medical knowledge interpreted within the context of the patient’s complete health profile  Electronic Health Record (EHR)  Electronic, outcomes-based clinical decision support  Wireless communications  Tablet personal computers (PCs), personal data assistants  Continuous speech recognition Current, synthesized clinical knowledge is available at the point of care  Clinical knowledge bases  New models for knowledge representation, integration, and interpretation

4. Errors are detected before information is acted on. Orders and prescriptions are clear and unambiguous Ambulatory and in-patient computerized physician order entry (CPOE) Electronic prescribing Consumers are partners in their own care. Patients with chronic diseases and conditions are monitored continuously Consumer knowledge bases Electronic sensors Wireless communications Radio frequency identification (RFID) tagging Decision support Home health systems Equipment, supplies, patients, and delivery staff are accurately tracked and efficiently managed RFID tagging Wireless communications Supply chain automation

5. Authorization, adjudication, inquiry, billing, and payment are handled electronically in real time Standardized electronic transactions Rules-based decision support Enterprise application integration (EAI) High-quality care is delivered to rural areas High-quality communication services Robotics Telemedicine applications Drugs are dispensed efficiently and safely Robotics RFID tagging

6.  International Council of Nurses (ICN) Code of Ethics for Nurses affirms that: “the nurse holds in confidence personal information” and “ensures that use of technology… compatible with the safety, dignity, and rights of people”  Dependability Is a measure of the extent to which a system can justifiably be relied on to deliver the services expected from it Six attributes: ○ System reliability ○ Service availability ○ Confidentiality ○ Data integrity ○ Responsiveness ○ Safety

7. Guidelines for Dependable Systems 1. Architect for Dependability  Principle: an enterprise system architecture should be developed from the bottom up so that no critical component is dependent on a component less trustworthy than itself 2. Anticipate failures  Consistent with Moore’s law: the speed of processors is doubling every 18 months, while the cost for that computing power is halving within the same time period

8. User Interface CPOE Electronic Prescribing Bar-Code Reader Rules-based Decision Support Single Sign-On Operating Systems Networks User Authentication Access Control Audit Enterprise Architecture Safety Functions Security Functions

9.  Interventions: Application-specific features should be implemented  To detect faults  To fail over to redundant components when faults are detected  To recover from failures before they become catastrophic Security features must be implemented against “opportunities” for malicious attack Safety-critical systems should be designed and built to fail in a safe state  Examples of industries with these systems: aerospace, chemical, nuclear power industries  These methods include: fault tree analysis, failure modes and effects analysis, state-machine hazard analysis, formal verification, and independent verification and validation

10. 3. Anticipate success  Allows valuable input into planning for scalability and future integration 4. Hire meticulous managers  Know failures will occur  Monitor and manage system and network performances  Use middleware to manage the workload across the network  Take emergency and disaster planning very seriously  Develop, maintain, and judiciously exercise plans and procedures for managing emergencies and recovering from disasters 5. Don’t be adventurous

11. ASSESSING THE HEALTHCARE INDUSTRY Year:2004 Student name: Clinical Care Provider Community Subject:Information Technology Dependability GUIDELINEGRADECOMMENTS 1DBuilds systems top down instead of bottom up. Too complex 2DAssumes systems will work 3CAssumes systems and networks are infinitely expandable and adaptable, but does not plan for system expansions and consolidations 4CSometimes, but doesn’t give them adequate support 5CYes and No

12. Complies with security regulations Insists on sound science as the foundation of good science Recognizes the importance of correct data Insists on sound systems engineering as the foundation of dependable systems Understands the role of security in system dependability, service availability, data integrity, and patient safety Systems play well together Optimistic attitude Values information technology as core business asset X X X X

13. HEALTHCARE ARCHITECTURES  HIPAA prescribes administrative, physical, and technical safeguards for protecting the confidentiality and integrity of health information and the availability of critical system services  8 required administrative safeguards: Security management Assigned security responsibility Information access management Security awareness and training Security incident procedures Contingency planning Evaluation Business associate contracts

14. 5 specified physical safeguards: ○ Access control, including unique user identification and an emergency access procedure ○ Audit controls ○ Data integrity protection ○ Person or entity authentication ○ Transmission security

15. ANTICIPATING FAILURES  Therac-25 (example of failure to anticipate failures) Occurred between June 1985 and January 1987 Overdosed 6 people resulting to deaths and serious injuries ○ Initial response was a temporary “fix” distributed as a memo containing a warning not to use the up-arrow key for editing, removing the key cap and using electrical tape to fix switch contacts in an open position ○ Failures identified: overconfidence in the software and overconfidence in risk assessment Due to this, FDA has improved its reporting system and augmented its procedures and guidelines to include software

16. ANTICIPATING SUCCESS  The clinical care provider community Expects their software applications, computer systems, and networks to work Assumes their systems will work as well as any other medical equipment However, they do not foresee that their business success may increase their need for processing power and networking capability ○ Nor they foresee mergers’ and acquisitions’ creating the need to consolidate their systems with those of another healthcare enterprise  Example: Boston CareGroup

17. IT MANAGEMENT  Clinical care provider community Have hired IT managers who: ○ Appreciate the important role of IT in a healthcare environment ○ Recognize the need for a dependable systems that can anticipate and recover from failures ○ But hired IT managers may not understand the fragile nature of IT or the importance of guideline 1 These IT environments tend to be loose composites of proprietary, departmental systems, designed for specific business functions

18.  Healthcare’s spending for IT lags far behind other industries Healthcare invested only 2% of its revenue in IT compared to 10% for other information- intensive industries Other industries spend $8000 per worker per year for technology, compared to $1000 per worker for healthcare Thus, even IT managers who are conscientious, meticulous, and capable often forced to operate within meager budget

19. ADVENTUROUS TECHNOLOGIES IN HEALTHCARE  The most difficult to assess  Healthcare clinicians, historically and typically are very resistant to change

20. CHAPTER 16

21.  NMDS visionary work begun in the US in 1980s by Werley and Lang  History: NMDS – identifies essential, common, and core data elements to be collected for all clients receiving nursing care ○ A standardized approach that facilitates the abstraction of these minimum, common, essential core data elements to describe nursing practice from both paper and electronic records ○ Intended for use in all settings ○ Conceptualized through a small group work at the NISs conference held in 1977 at the University of Illinois College of Nursing

22. Developed during the 1985 conference at the University of Wisconsin-Milwaukee School of Nursing through the efforts of 64 conference participants Included 3 broad categories of elements: ○ Nursing care Nursing diagnosis Nursing intervention Nursing outcome Intensity of nursing care ○ Patient or client demographics Personal identification Date of birth Sex Race and ethnicity Residence

23.  Service elements  Unique facility or service agency number  Unique health record number or patient or client  Unique number of principle registered nurse provider  Episode admission or encounter date  Discharge or termination date  Disposition of patient or client  Expected payer for most of this bill  AIM of the NMDs:  Not to be redundant of other data sets but rather to identify what are the minimal data needed to be collected from records of patients receiving nursing care  Developed by building on the foundation established by the US UHDDS

24. 8 benefits of NMDS adaptation and implementation: ○ Access to comparable, minimum nursing care, and resources data on local, regional, national, and international levels ○ Enhanced documentation of nursing care provided ○ Identification of trends related to patient or client problems and nursing care provided ○ Impetus to improved costing of nursing service

25. ○ Improved data for quality assurance evaluation ○ Impetus to further development and refinement of NIS ○ Comparative research on nursing care, including research on nursing diagnoses, nursing interventions, nursing outcomes, intensity if nursing care, and referral for further nursing services ○ Contributions toward advancing nursing as a research-based discipline