Running head: ENHANCING QUALITY SERVICES 1
Quality Improvement Proposal at California District Hospital: Reducing Infant Mortality
Evette Grayson
University of Arizona at Global Campus
Professor Janie Hall
MHA 616 Health Care Management Information System
August 1, 2022
ENHANCING QUALITY SERVICES 2
Background
Setting: California District Hospital is in the spotlight for increasing cases of infant mortality. These
cases are prevalent among black American mothers who lose their children due to racism and
negligence of the health care providers (Senchyna et al., 2019). While this project focuses on the
cases of negligence and understaffing of this hospital, it will also evaluate ways of improving the
quality of health care services with a view to reducing infant mortality. This will ensure that the
hospital provides better services to expectant mothers now and in the future.
Health Care Service
There are various health care services that I can propose for the California district hospital. First,
the hospital is seriously understaffed and the available health care services cannot deal with the
high number of patients (Young et al., 2014). This affects the expectant mothers since they do not
get timely and quality services on time and hence, the majority of them usually end up losing their
children. First, the governor needs to ensure that adequate and quality medical personnel are hired
at California District Hospital. They will improve the quality of services and reduce the infant
mortality rate. Secondly, I also propose that the hospital management forms an inclusion council
that will oversee the daily management of this hospital. This inclusion council will consist of a
group of 5-10 professionals that will ensure that all patients are equally treated and that all
expectant mothers are given quality medical services that will guarantee safe delivery. This will
also help to reduce cases of infant mortality at the hospital (Obucina et al., 2018).
The Problem
We conducted a survey at the California District Hospital. A sample of 100 respondents was
conducted in order to determine the effectiveness of the medical services provided by this health
car ...
What is the difference between Telehealth and TelemedicineDisc
Running head ENHANCING QUALITY SERVICES
1. Running head: ENHANCING QUALITY SERVICES
1
Quality Improvement Proposal at California
District Hospital: Reducing Infant Mortality
Evette Grayson
University of Arizona at Global Campus
Professor Janie Hall
MHA 616 Health Care Management Information
System
August 1, 2022
ENHANCING QUALITY SERVICES
2
Background
Setting: California District Hospital is in the spotlight for
increasing cases of infant mortality. These
cases are prevalent among black American mothers who
lose their children due to racism and
negligence of the health care providers (Senchyna et al.,
2019). While this project focuses on the
2. cases of negligence and understaffing of this hospital, it
will also evaluate ways of improving the
quality of health care services with a view to reducing
infant mortality. This will ensure that the
hospital provides better services to expectant
mothers now and in the future.
Health Care Service
There are various health care services that I can propose
for the California district hospital. First,
the hospital is seriously understaffed and the available
health care services cannot deal with the
high number of patients (Young et al., 2014). This affects
the expectant mothers since they do not
get timely and quality services on time and hence, the
majority of them usually end up losing their
children. First, the governor needs to ensure that adequate
and quality medical personnel are hired
at California District Hospital. They will improve the
quality of services and reduce the infant
mortality rate. Secondly, I also propose that the hospita l
management forms an inclusion council
that will oversee the daily management of this hospital.
This inclusion council will consist of a
3. group of 5-10 professionals that will ensure that all
patients are equally treated and that all
expectant mothers are given quality medical services that
will guarantee safe delivery. This will
also help to reduce cases of infant mortality
at the hospital (Obucina et al., 2018).
The Problem
We conducted a survey at the California District Hospital.
A sample of 100 respondents was
conducted in order to determine the effectiveness of the
medical services provided by this health
care organization. The sample consisted of 60 expectant
mothers and 40 medical providers. This
ENHANCING QUALITY SERVICES
3
survey indicates that 56% of expectant mothers are not
satisfied with the services provided by this
health care organization (Kokko, 2022). According to
them, understaffing at California District
Hospital has resulted in the death of many infants since
the mothers do not receive timely and
quality medical providers. Moreover, only 40% of the
expectant mothers are satisfied with the
4. services while 4% are not sure. Consequently, 70% of the
health care providers only decry
understaffing that leads them to overwork and hence, low -
quality services. They admitted that
understaffing is the real reason for high
infant rates at California District Hospital
(Kokko, 2022).
Barriers to Quality Health Care Services
Various barriers have been identified in the quest to
provide effective medical services in California
District. First, there is a lack of support from the
California District and the leadership in California
State. As Young et al. (2014) state, the hospital
management has on several occasions written to the
district and state requesting reinforcements in terms of
medical personnel. However, the California
government is yet to provide any assistance to this
healthcare organization. Furthermore, Senchyna
et al. (2019) state that the California District hospital has
also failed to form a committee that will
oversee the functions of this health care organization.
There are several laws and regulations
regarding how the hospital needs to operate but there is
no committee to enforce the laws and
5. ensure that the policies are adhered to.
The Intervention
Various organizations such as the Center for Disease
Control and Prevention (CDC) and the
institute for health care improvement (IHI) have written
to California District Hospital and are
ready to help with quality improvement (Obucina et al.,
2018). They have requested this health
care organization to identify the areas that need to be
reinforced. Consequently, they will request
the federal government to provide additional support to
this hospital with a view to providing
ENHANCING QUALITY SERVICES
4
enough medical personnel. Moreover, the IHI also requests
that once the hospital receives
additional health workers, they will have to specifically
assign some of their staff the role of
attending the expectant mothers at all times (Roubinian et
al., 2021). This will help to reduce the
perennial cause of infant mortality in the
future.
6. Process Defect
This process will use the triple aim health care approach
to improve the quality of services at
California District Hospital;
I -improving patient care and ensuring that expectant
mothers receive the best possible treatment
and attention.
R -reducing the cost of medical cover to ensure that
even those without cash or medical insurance
are treated.
E -enhancing the health of patients by hiring more health
care workers to oversee the interests of all
patients including expectant mothers.
Aim (Objective)
The main objective of this intervention process is to
improve the quality of medical services to the
patients’ especially expectant mothers while also ensuring
that they receive medical services at a
relatively low cost
Strategy for implementation
To implement this process, the California Health
7. Organization will rely on the services of an
inclusion council. It is a group of professionals that will
be selected by the state to ensure that they
oversee the transition or the changes. They
will work under the following process;
S -Survey the hospital systems and processes
to identify strong and weak areas.
C -communicate with all the stakeholders within
the hospital about the imminent changes.
ENHANCING QUALITY SERVICES
5
P - Plan how the hospital will receive additional
resources such as adequate personnel and medical
products.
D - Deliver the resources and ensure the plan is
implemented according to the triple aim (Care,
health, and cost).
M - Monitor all the processes and ensure
that patients receive proper medical services.
Measures
The hospital will comply with the triple aim in health
care. The first aim is to reduce the cost of
8. medical services immediately. The second policy is to
ensure that patients are adequately monitored
to improve their care and the third is to ensure that
there is enough medical personnel to provide
proper medical services to the patients.
Barriers to change
The triple aim is a new health care policy and hence,
healthcare providers may initially struggle to
implement this policy (Senchyna et al., 2019). However,
experts will be deployed to implement
this health framework and help the health
care providers understand and internalize this
policy.
Simple rules
Only three rules need to be followed in triple aim
healthcare; reduce the medical costs for patients,
monitor their progress to improve their condition, and
have adequate health personnel to provide
quality medical services.
Cost implications
The process does not require any additional
costs.
9. References
Kokko, P. (2022). Improving the value of
healthcare systems using the Triple Aim
framework:
ENHANCING QUALITY SERVICES
6
A systematic literature review. Health Policy ,
126 (4), 302-309.
Obucina, M., Harris, N., Fitzgerald, J. A.,
Chai, A., Radford, K., Ross, A., & Vecchio,
N. (2018).
The application of triple aim framework in the context of
primary health care: A systematic
literature review. Health Policy , 122 (8), 900-907.
Roubinian, N. H., Dusendang, J. R., Mark, D. G., Vinson,
D. R., Liu, V. X., Schmittdiel, J. A., &
Pai, A. P. (2021).
Incidence of 30-day venous thromboembolism in adults
tested for SARS-CoV-2 infection
in an integrated health care system in Northern California.
JAMA Internal
Medicine , 181 (7), 997-999.
10. Senchyna, F., Gaur, R. L., Sandlund, J., Truong, C.,
Tremintin, G., Kültz, D., & Banaei, N.
(2019).
Diversity of resistance mechanisms in carbapenem-resistant
Enterobacteriaceae at a health
care system in Northern California, from 2013 to 2016.
Diagnostic microbiology and
infectious disease , 93 (3), 250-257.
Young, D. R., Coleman, K. J., Ngor, E.,
Reynolds, K., Sidell, M., & Sallis, R. E.
(2014).
Associations between physical activity and cardiometabolic
risk factors assessed in a
Southern California health care system, 2010–
2012.
If I could give you information
of my life, it would be to show
how a woman of very ordinary
ability has been led by God
in strange and unaccustomed
paths to do in His service what
He has done in her.
Florence Nightingale, 1860
By Lyn S. Murphy and Mark S. Walker
12. MEDICAL MODEL CARE
The Institute of Medicine (IOM,
2001; IOM, 2010) reports the U.S.
healthcare delivery system is challenged
to provide consistent, high-quality care
to all people. In their sentential report,
Crossing the Quality Chasm, the IOM
(2001) outlined strong evidence that
the healthcare system frequently harms
patients and routinely fails to deliver its
potential benefits. Researchers have
cited various contributing factors such
as rapid medical science and technol-
ogy advancements, growing complexity
of care, and changing patient needs.
Healthcare organizations are challenged
to work more efficiently and effectively
while reducing costs and maintaining
high standards of quality and safe care.
Nurses, who are at the forefront of
healthcare, are charged with offering
safe, patient-centered care and practic-
ing to the full extent of their education
and training (IOM, 2010).
Much of today’s healthcare contin-
ues to be based on a “medical model”
TIRED NURSING?
Maya tiredly walked to the Surgical ICU for her third 12-hour
night shift in a row. “All
I do is care for others. Who cares for
me?” she thinks.
13. One of Maya’s patients is a fresh
post-operative coronary artery bypass
graft (CABG) patient. Maya knows her
night will be directed toward extuba-
tion, removing central lines, and getting
the patient ready to move out of the
ICU. Her other patient is Mr. Henry
who has been in the ICU for weeks.
Mr. Henry suffered a massive stroke
following mitral valve replacement
surgery and is paralyzed on one side,
unable to follow simple commands. He
remains ventilator dependent and is
being tube fed. Nursing staff are
frustrated with the family, especially
Mrs. Henry whom staff members feel
is anxious and demanding.
What can help Maya show compas-
sion as she crosses the threshold of
her patients’ rooms during the next
12 hours? How can she attend to
Lyn Stankiewicz Murphy, PhD,
MBA, MS, RN, is an assistant professor
and director of the Health Services,
Leadership, and Management program,
University of Maryland School of Nurs-
ing (UMSON), Baltimore, Maryland. Lyn
attends Mountain Christian Church in Joppa, Maryland
and is involved in European and local missions.
Mark Walker, MS, RN, CNL, works in
the Surgical IMC Unit at University of
15. Koenig, & Larson, 2000). Religion may
be the means by which many express
their spirituality. Similarly, there are
very spirited individuals who do not
follow a religion, and some religious
practices may not be very spiritual for
some people. Regardless of the term,
the issue at hand is that for a major
segment of the population, these
constructs must be understood as
part of the holistic perspective of the
person’s health.
WHOLE PERSON CARE
Spiritual care has been described as
a distinct type of care defined by acts
of listening, compassionate presence,
open-ended questions, prayer, use of
religious objectives, talking with
clergy, guided visualization, contem-
plation, meditation, conveying a
benevolent attitude, or instilling hope
(Chan, 2010; Puchalski & Ferrell,
2010). Spiritual care is helping the
patient make meaning out of his/her
experience or find hope. It involves
caring for the soul in a special kind of
engagement that goes beyond seeing
the physical patient in front of us; it is
observation of the entire patient
with the entire nurse. This has been
described as holistic nursing (Dossey
& Keegan, 2012; Quinn, 1981;
Watson, 2009).
16. This begs the question of whether
nurses separate their “physical caregiv-
ing” such as patient assessments,
turning and positioning, and dressing
changes from their “spiritual caregiving”
such as holding a patient’s hand, active
listening, or offering presence. This
depends greatly on the nurse and his or
her focus, and how he or she thinks
about and approaches the patient.
Christian nurses can look to Christ
to understand whole person care. Jesus
was a true whole person healer who
where providers are most focused on
and comfortable with diagnosing and
treating physical conditions. However,
care should be “patient-centered,
customized according to patient needs,
values, choices, and preferences,”
where the “system should anticipate
patient needs, rather than reacting to
events” (IOM, 2001, p. 3). From this
perspective, nurses are challenged to
deliver care that goes beyond the
diagnosis and treatment of physical
illness. Rather, care should incorporate
“the spiritual dimension in nursing’s
tradition which cannot be separated
from the science of nursing”
(Bradshaw, 1994, p. 169).
Spiritual care “involves serving the
whole person – the physical, emotion-
al, social, and spiritual” (Puchalski,
17. 2001, p. 352). Spiritual nursing care
consists of the activities of care that
bring quality of life, well-being, and
function to patients (Taylor, 2002).
Note that spiritual care may include
the transcendent, meaning making, and
religion. Researchers have repeatedly
demonstrated that patients and families
are particularly inclined to engage in
religious or spiritual guidance during
stressful life events such as healthcare
crises, illness, or death (Koenig, King, &
Carson, 2012). Moreover, 70% of the
U.S. population identifies with a
personal God and an additional 12%
believe in a higher power (Kosmin &
Keysar, 2008). Undoubtedly spiritual
care is important, yet these core values
and principles that “differentiate
nursing from other professions may
have been eroded in contemporary
practice” (Timmins & McSherry,
2012, p. 953).
Sadly, only 12% to 14% of nurses
report receiving spiritual training as
part of their nursing education
(Balboni et al., 2013). Although
numerous studies reveal religious or
spiritual coping helps patients, spiritual
care is not seen as a priority due to
lack of time (Chan, 2010). Nurses also
are reluctant to provide spiritual care
to their patients for fear of “stirring
things up that they will not know
18. how to address” (Jackson, 2011, p. 4),
crossing professional boundaries
(Carr, 2010), or not having access to or
knowing how to utilize spiritual care
experts (Puchalski & Ferrell, 2010). So
although nurses have a strong under-
standing of the importance of holistic
care and agree that providing spiritual
care is critical to patient care, not all
nurses believe they can provide
spiritual care. Nurses who do give
spiritual care provide it infrequently
and often feel inadequate (Cockell &
McSherry, 2012; Wright, 2005).
It’s important to note that spiritual-
ity is a broader concept than religion.
Smith (2006) defined spirituality as
“the matter by which a person seeks
meaning in their lives and experiences
transcendence, the connectedness to
that which is beyond” (p. 41). Similarly,
Sulmasy (2009) summarized spirituality
“as the way in which a person habitu-
ally conducts his or her life in relation-
ship to the question of transcendence”
(p. 1635). Spirituality embraces the
understanding of one’s place in the
universe and the motivational and
emotional foundation for the lifelong
quest for hope and life’s meaning. In
other words, spirituality represents the
“innate human search for the meaning
and purpose of life” (Sadler & Biggs,
2006, p. 270).
20. (Barnum, 2011; Clarke, 2009; Koenig,
2007), but there is “lack of movement
and growth with little evidence of there
being a positive movement towards a
new phase of development” (Clarke,
2009, p. 1666). In other words, although
most nurses know about spirituality,
there remains “ambiguity about how it
is included in practice” (Clarke, 2009,
p. 1666). This is evidenced by the fact
that although nurses have a longstand-
ing and ongoing commitment to the
spiritual dimension of a patient’s care
(Carson & Koenig, 2008; Taylor, 2006),
they do not consistently integrate
spirituality into their practice (Cockell
& McSherry, 2012).
Similarly, Watson (2009) posited that
“nurses are torn between the human
caring values and the calling that
addressed all the needs of those he
healed—physical and spiritual. For
example, in Luke 5:17–26, Christ
healed a lame man not only physically,
but spiritually. For nurses with a
foundation in Christianity, we strive
to live a Christ-like life, treating others
as Christ would (John 13:34-35). We
strive to think and act like Christ
because the Holy Spirit of God
lives within us (John 14:16-17; 1
Corinthians 3:16).
We propose that for the Christian
21. nurse, this type of whole person
nursing can be described as Spirit-
guided care. Spirit-guided care is the
act of removing one’s self as the
motivating force and allowing Christ,
in the form of the Holy Spirit, to
flow through us and guide us in our
care. It is entering into the sacred
work of God, “standing on holy
ground” (O’Brien, 2011, p. 2). In
doing so, we are able to draw on
God’s strength through the Holy
Spirit, and provide care that is truly
holistic in the sense that Christ meant
care to be. The foundation of Spirit-
guided care is how the nurse uses
him or herself as Christ’s hands and
presence as he or she engages in
nursing care.
Spirit-guided care means simultane-
ously focusing on and caring for the
whole patient and family. Rather than
approaching care as a series of tasks or
compartmentalizing aspects of care,
Spirit-guided care conceptualizes the
whole person in every caring act.
Taking a blood pressure becomes an
opportunity for presence and spiritual
assessment; offering presence is seen as
a way to impact blood pressure and
pain levels. Instead of thinking “I’ll
think about spiritual care after I get
meds passed” the nurse consciously
thinks, “What are this patient’s needs,
22. fears, distresses, questions?” as she or he
gives each medication, checks every
pulse. Every patient interaction involves
the whole person.
Providing this level of care
focuses on being as opposed to doing.
Although this is not a new concept to
nursing theory and many have taken
on the task of describing holistic care,
Spirit-guided care is an attempt to
describe care by the Christian nurse
for the whole patient that is guided
by the Holy Spirit. To understand
the differences between Christian
and secular perspectives of holistic
care, see “Holistic or Wholistic?”
in this issue of JCN (Schoonover-
Shoffner, 2013).
HISTORIAL PERSPECTIVES
Spiritual, whole person care has
existed throughout the history of
nursing (Miner-Williams, 2006;
Narayanasamy, 2004). In Greek and
Roman times, prayers to “God or gods
were considered an essential part of
nursing care” (Sawatzky & Pesut, 2005,
p. 21). For centuries, nursing has been
considered a calling; individuals were
While most nurses know
about spirituality, there
remains “ambiguity about
how it is included in practice.”
24. providers (Astrow, Wexler, Texeira,
He, & Sulmasy, 2007; Koenig, 2007);
however, most providers do not engage
in this type of discussion. It also seems
that nursing may be “shrugging off
its spiritual heritage” (Timmins, 2011,
p. 162) in an attempt to embrace the
science of nursing.
Given current challenges, our
healthcare system may seem incompe-
tent and unprepared to address the
spiritual needs of our patients. The
Joint Commission requires spiritual
assessments in hospitals, nursing homes,
home care organizations, and agencies
providing addiction services (Hodge &
Horvath, 2011). Although the purpose
of administering these assessments is to
identify a patient’s spiritual needs and
determine the appropriate steps to
meet needs that emerge, because of
the lack of training and emphasis on
spirituality it is feared these needs are
not being met.
THEORETICAL PERSPECTIVES
Many nursing conceptual frame-
works imbed the concept of spiritual-
ity. In the Neuman’s System model,
the client system is depicted as a
Offering Spirit-Guided Care
25. Maya tiredly walked to the Surgical ICU for her third 12-hour
night shift in a row. Working 7 p.m. to 7 a.m. was not her first
choice; how-
ever, it fits her family’s needs. Lately, managing everyone’s
schedule has become overwhelming. “All I do is care for
others. Who cares for me?” she thinks. She breathes a sigh
of relief knowing that she is off for the next 4 days.
As Maya reviews her assignments, she thinks, “A
double assignment! Why me?” Having two critical patients
is doable but tough. One is a fresh post-operative CABG
patient. Maya knows her night will be directed toward
extubation, removing central lines, and getting the patient
ready to move out of the ICU. Her other patient has been in
the ICU for weeks.
Mr. Henry suffered a massive stroke 2 days following
mitral valve replacement and is paralyzed on one side,
unable to follow simple commands. He remains ventilator
dependent and is being tube fed. Everyone agrees the ICU
is not the proper place for Mr. Henry, but the family is con-
cerned he would not receive the same care on the Stroke
Unit that he is receiving in the ICU. Mr. Henry’s son and
daughter-in-law are expecting their first child in 2 months.
Mrs. Henry feels that if her husband stays in the ICU, he
will receive the care he needs and be healthy enough to
hold his first grandchild.
Many of the nurses refer to Mr. Henry as “the ‘chron’ in
Room 3”—their term for a chronic ICU patient. The nurse
manager has complained the ICU is “losing money on him
every day.”
Mrs. Henry stays at her husband’s bedside during
daylight hours, often reading to him from the Bible. She
has requested the nurses read to Mr. Henry if they have
27. with Mrs. Henry about their mutual faith, and has prayed
with the Henry family. Many of the nurses in the unit are
Christ-followers; however, the unit focuses primarily on the
physical needs of the patients with the goal to transfer as soon
as possible. The nurse giving Maya report whispers, “Good
luck! Mrs. Henry seems to think we have nothing better to do
but talk and hold her husband’s hand.”
Knowing she feels overwhelmed, Maya takes a moment
to silently and intentionally ask God to be with her, give her
extra strength, help her manage time well, and see needs
around her as God does. She recites Matthew 11:28-30
to herself. As she goes in to the post-CABG patient, she
introduces herself and takes his hand even though he remains
heavily sedated. She gently explains what she is doing as
she completes a head-to-toe assessment and checks equip-
ment. Upon leaving, Maya squeezes his hand and tells him
she’ll be back shortly.
As she enters Mr. Henry’s room, Maya quietly asks God to
guide her interactions and bless this family. Maya asks Mrs.
Henry how she and her husband are doing today. She notices
that Mrs. Henry’s eyes are teary and asks, “How can I help?”
Mrs. Henry responds she knows what the nurses say. Maya
closes the door, takes Mrs. Henry’s hand, and sits with her for
a moment, actively listening. She tells Mrs. Henry she knows
“we sometimes seem gruff,” reassuring Mrs. Henry she un-
derstands her concerns and will care for her husband as Mrs.
Henry desires. Knowing their mutual faith, Maya reassures
Mrs. Henry that God loves Mr. Henry and has a plan. She
reminds Mrs. Henry of Psalm 23 and they recite this together.
Maya goes on to talk about the care plan for the night as she
assesses Mr. Henry.
Maya works hard to extubate her post-operative patient
28. and by morning he is sitting up ready to be transferred to the
cardiac rehab unit. Prior to leaving his room for the last time,
Maya takes her patient’s hand and says she wishes the best
for him. He responds, “I know I was not really awake, but I
knew you were here all night, in a comforting sort of way…I
was afraid but sensed you wouldn’t let anything bad happen.
Thank you.”
Maya smiles and says, “That’s what nursing is supposed
to be.”
Before going to report, Maya sees Mrs. Henry and asks
why she is here so early. Mrs. Henry replies, “I need to thank
you…you were so busy last evening yet took the time to talk
and give my husband a bath and make him comfortable. I
have been thinking about what you said about God helping
us and I would like to go up and take a tour of the Stroke
Unit, maybe Mr. Henry would be okay up there….”
As Maya reports to the oncoming shift the nurse manager
says, “Wow! You must be a miracle worker – both of these
patients may move out of the unit today!” Maya smiles and
thinks, “No, I am not a miracle worker, but my God is…”
Reflection Questions:
• Identify ways Maya provided spiritual whole person
care.
• What is unique about Maya’s approach to holistic
care?
• What did Maya do to provide Spirit-guided care?
• What does Maya need to do to continue caring as she
did
this shift?
• How might Maya help her colleagues move from a
“defen-
30. are acting as Christ would act through
the Spirit within us (John 14). God
enables us to live a life of respect,
obedience, and kindness from being
reborn through Jesus and renewed by
the Holy Spirit who has been poured
out on us (Titus 3:1-8). As we live a
Spirit-guided life, God shows the
reality of his presence through us. For
study on how God guides Christians
through the indwelling Holy Spirit,
see the online guide provided as
Supplemental Digital Content at
http://links.lww.com/NCF-JCN/A23.
IMPLEMENTING
SPIRIT-GUIDED CARE
Whole person care is not at the
forefront of nursing care delivery or
education (Carlyle, Crowe, & Deering,
2012; Chan, 2010; Elliott, 2011), so
where does this type of care begin?
Miner-Williams (2006) concluded
that nurses can “provide spirited
nursing care and nursing care spiritu-
ally” (p. 818). The challenge, however, is
that the nurse must be at ease with
compassion fatigue (Slatten, David
Carson, & Carson, 2011; Yoder, 2010).
In the “defensive mode” the needs
of the patient create anxiety in the
nurse, which results in an unconscious
31. display of self-protective behaviors.
These behaviors manifest themselves
as “emotional distancing, excessive
task-orientedness, and derogatory
labeling of the patient such as demand-
ing, uncooperative, or inappropriate”
(Macrae, 2001, p. 71). All of us have
encountered nurses who at times (or
regularly) do not practice from the
caring perspective, having become
hardened, brittle, worn-down, and
almost robot-like in the context of
providing care.
Lastly, Quinn (1981) identified the
“holistic mode” in which the nurse
embraces the patient’s body, mind, and
spirit, and, as a result, acts in a highly
conscious and compassionate manner.
The nurse identifies with his or her
own self and with the patient’s state of
well-being. When this self-awareness
occurs, the nurse is able to move beyond
the typical triggers that initiate the
sympathetic and defensive modes and
function from a holistic perspective.
These theoretical perspectives
speak to whole person care and
describe in part, Spirit-guided care.
However, the theories do not fully
encompass a Christian perspective
and what is intended by Spirit-guided
care, that is, the Holy Spirit dwelling
within the Christian nurse and
guiding his or her care. To understand
32. Spirit-guided care we must turn to
the Bible.
BIBLICAL PERSPECTIVES
The Old Testament makes it clear
that God the Father wants to promote
health and address whole person
needs. Leviticus addresses numerous
health-related concerns as God
presented directives for food, waste,
childbirth, and infections. The Psalms
contain prayers about holistic healing,
such as “O Lord, my God, I cried out
to You, and You healed me” (Psalms
30:2, NKJV), and “He heals the
brokenhearted and binds up their
wounds” (Psalms 147:3, NKJV).
Proverbs provide wisdom regarding
healthy living and Jeremiah confirms
God, the Father, is the source of all
healing, as “Behold, I will bring health
and healing; I will heal them and
reveal to them the abundance of
peace and truth” (Jeremiah 33:6,
NJKV). God heals people physically,
emotionally, and spiritually through-
out the Bible.
The New Testament is replete with
examples of God the Son’s healing
intention and power. Starting in
Matthew, we see “Jesus went about all
Galilee, teaching in their synagogues,
preaching the gospel of the kingdom,
34. Christian and secular perspectives
discuss the importance of the nurse
engaging in spiritual self-care (Barnum,
2011; Dossey & Keegan, 2012; Shelly
& Miller, 2006; Taylor, 2007). For
Christians, spiritual self-care involves
personal time with God in Bible
study, prayer, worship, fellowship
with other believers, and Sabbath rest.
MacKinlay (2008) further posited that
the simple act of providing care can
help the nurse promote his or her
own spiritual well-being. Healthcare
organizations can recognize the value
of Spirit- guided care by integrating
spirituality into communiques and
workshops to raise nurses’ awareness
of spirituality—in them and their
patients.
Spirit-guided care involves a decision
the Christian nurse makes the moment
his or her feet cross the threshold of the
patient’s doorway. It is the conscious
decision to simultaneously tend to the
whole patient including that which is
unseen. Spirit-guided care requires the
nurse to draw on faith in God and how
he relates to us not only as physical
beings, but as spiritual beings. In this
light, the true essence of nursing is
understood—the focus on the total care
of every individual patient from every
aspect of the patient (Sheldon, 2000).
Spirit-guided care is providing care in
God’s presence where there is com-
35. plete fullness of joy and we are able to
love others because he first loved us
(1 John 4:19).
The first step toward the process
of promoting Spirit-guided care is
making the conscious decision to
allow the Holy Spirit to flow through
and be part of care delivery. This is a
mindset that begins with the nurse’s
self-awareness and the awareness of
the “transcendent dimension of life
that is reflected in the patient’s
reality” (Sawatzky & Pesut, 2005,
p. 23). It is the connection of the
nurse to truly be the hands and feet
of Christ to holistically intervene to
restore and maintain the patient’s
whole being, not simply his/her physical
being. Providing Spirit-guided care
encompasses the acts of Christ as a
foundation for our professional
practice.
Using the nursing process as a
framework, we can better understand
the integration of Spirit-guided care
into care delivery. Spirit-guided care
means entering into assessment
attentive to the whole patient and his
or her family. Most general admission
assessments include asking about
spiritual history as a brief screening
tool, and a number of models are
available for deeper spiritual assessment
36. (Puchalski & Ferrell, 2010). This
spiritual history, screening, or assess-
ment may act as a cue to engage the
nurse with the patient in spiritual
whole person care (Burkhart & Hogan,
2008). Spiritual distress, risk for
spiritual distress, and readiness for
enhanced spiritual well-being are
North American Nursing Diagnosis
Association (NANDA) nursing
diagnoses that address the construct of
spirituality. These diagnoses are most
commonly referred to having spiritual
pain, anger, loss, and despair, with the
signs and symptoms including a broad
range of emotions such as crying,
withdrawing, preoccupation, anxiety,
hostility, apathy, and feeling of point-
lessness and hopelessness (Ackley &
Ladwig, 2013).
The next steps of the nursing
process focus on planning and imple-
mentation. Burkhart and Hogan
(2008) describe the role of the nurse as
two-fold in planning/implementation:
(1) creating an environment to increase
the likelihood that a patient will
engage in the care process and
(2) crafting her or his care. Engaging
in Spirit-guided care would mean
the nurse would privately ask God
(prayer) what would best meet patient
needs along with using nursing
knowledge and skill to plan and
37. implement care.
The nurse can evaluate the
outcomes of care based on the
patient’s response. Again, Burkhart and
Hogan (2008) view this as a “positive
or negative emotional response,”
which then leads to “searching for
meaning in the encounter,” “forma-
tion of spiritual memory,” and “nurse
spiritual well-being” (p. 931). In this
light, Spirit-guided care should
facilitate connections to and among
the patient, the nurse and other
providers, the family, the larger
community, and with God and the
patient’s search for meaning.
It is surprising that more schools of
nursing do not include the construct
of spirituality in their curriculum.
Callister, Bond, Matsumura, &
Mangum (2004) found that among
132 baccalaureate nursing programs in
the United States, few had defined
spiritual nursing care in their programs
and fewer reported learning opportu-
nities about spirituality and spiritual
interventions imbedded in their
curriculum. Sadly, educators continue
to report that little attention is given
to spirituality in nursing education
(Balboni et al., 2013).
How could this be changed?
Students could be encouraged to reflect
39. patient may be understood as implicitly
spiritual. Simple things such as empa-
thy, warmth, genuineness, and kindness
contribute to relationship, which in
turn can help meet patients’ spiritual
needs, particularly in situations where
the patient is isolated from his or her
family and community and a meaning-
ful relationship has developed with the
nurse (Hodge & Horvath, 2011).
Given the challenges of today’s
healthcare organizations, nurses are
being called to work more efficiently
and effectively while maintaining high
quality care. As Christian nurses, this
charge is imbedded within our nursing
practice by way of our Christian faith.
We are challenged to “rejoice always,
pray without ceasing, in everything, give
thanks; for this is the will of God in
Christ Jesus for you” (1 Thessalonians
5:16-18, NKJV). Spirit-guided care
is an ethical obligation of Christian
nurses to deliver care as the hands
of Christ once did. Our ability to
incorporate Christ and his healing
power into our professional nursing
practice not only fosters better
outcomes for the patient, but reflects
our commitment as Christians to
demonstrate his love.
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46. commonplace—today. Today's health care providers
and organizations across the continuum of
care have come to depend on reliable HIT
to aid in managing population health effectively
while
reducing costs and improving quality patient
care. Chapter One will explore some of the
most
significant influences shaping the current and
future HIT landscapes in the United States.
Certainly, advances in information technology
affect HIT development, but national private
sector and government initiatives have played
key roles in the adoption and application of
the
technologies in health care. This chapter will
provide a chronological overview of the
significant
government and private sector actions that
have directly or indirectly affected the adoption
of
HIT since the Institute of Medicine landmark
report, The Computer-Based Patient Record: An
Essential Technology for Health Care, authored
by Dick and Steen and published in 1991.
Knowledge of these initiatives and mandates
shaping the current HIT national landscape
provides the background for understanding the
importance of the health information systems
that are used to promote excellent, cost-
effective patient care.
1990s: The Call for HIT
Institute of Medicine CPR Report
The Institute of Medicine (IOM) report The
Computer-Based Patient Record: An Essential
Technology for Health Care (Dick & Steen,
47. 1991) brought international attention to the
numerous
problems inherent in paper-based medical records
and called for the adoption of the
computer-based patient record (CPR) as the
standard by the year 2001. The IOM defined
the
CPR as “an electronic patient record that
resides in a system specifically designed to
support
users by providing accessibility to complete
and accurate data, alerts, reminders, clinical
decision support systems, links to medical
knowledge, and other aids” (Dick & Steen,
1991, p.
11). This vision of a patient's record offered
far more than an electronic version of
existing paper
records—the IOM report viewed the CPR as
a tool to assist the clinician in caring for
the patient
by providing him or her with reminders,
alerts, clinical decision–support capabilities, and
access
to the latest research findings on a particular
diagnosis or treatment modality. CPR systems
and
related applications, such as EHRs, will be
further discussed in Chapter Three. At this
point, it is
important to understand the IOM report's
impact on the vendor community and health
care
organizations. Leading vendors and health care
organizations saw this report as an impetus
toward radically changing the ways in which
48. patient information would be managed and
patient
care delivered. During the 1990s, a number
of vendors developed CPR systems. However,
despite the fact that these systems were, for
the most part, reliable and technically mature
by
the end of the decade, only 10 percent of
hospitals and less than 15 percent of
physician
practices had implemented them (Goldsmith,
2003). Needless to say, the IOM goal of
widespread CPR adoption by 2001 was not
met. The report alone was not enough to
entice
organizations and individual providers to commit
to the required investment of resources to
make the switch from predominantly paper
records.
Health Insurance Portability and Accountability
Act (HIPAA)
Five years after the IOM report advocating
CPRs was published, President Clinton signed
into
law the Health Insurance Portability and
Accountability Act (HIPAA) of 1996 (which is
discussed
in detail in Chapter Nine). HIPAA was
designed primarily to make health insurance
more
affordable and accessible, but it included
important provisions to simplify administrative
processes and to protect the security and
49. confidentiality of personal health information.
HIPAA
was part of a larger health care reform
effort and a federal interest in HIT for
purposes beyond
reimbursement. HIPAA also brought national
attention to the issues surrounding the use of
personal health information in electronic form.
The Internet had revolutionized the way that
consumers, providers, and health care
organizations accessed health information,
communicated with each other, and conducted
business, creating new risks to patient privacy
and security.
2000–2010: The Arrival of HIT
IOM Patient Safety Reports
A second IOM report, To Err Is Human:
Building a Safer Health Care System (Kohn,
Corrigan, &
Donaldson, 2000), brought national attention to
research estimating that 44,000 to 98,000
patients die each year because of medical
errors. A subsequent related report by the
IOM
Committee on Data Standards for Patient
Safety, Patient Safety: Achieving a New
Standard for
Care (Aspden, 2004), called for health care
organizations to adopt information technology
capable of collecting and sharing essential
health information on patients and their care.
This
IOM committee examined the status of
standards, including standards for health data
interchange, terminologies, and medical knowledge
50. representation. Here is an example of the
committee's conclusions:
As concerns about patient safety have grown,
the health care sector has looked to other
industries that have confronted similar
challenges, in particular, the airline industry.
This industry
learned long ago that information and clear
communications are critical to the safe
navigation of
an airplane. To perform their jobs well and
guide their plane safely to its destination,
pilots must
communicate with the airport controller
concerning their destination and current
circumstances
(e.g., mechanical or other problems), their
flight plan, and environmental factors (e.g.,
weather
conditions) that could necessitate a change in
course. Information must also pass seamlessly
from one controller to another to ensure a
safe and smooth journey for planes flying
long
distances, provide notification of airport delays
or closures because of weather conditions, and
enable rapid alert and response to extenuating
circumstance, such as a terrorist attack.
Information is as critical to the provision of
safe health care—which is free of errors of
commission and omission—as it is to the
safe operation of aircraft. To develop a
treatment plan,
a doctor must have access to complete
patient information (e.g., diagnoses, medications,
51. current test results, and available social
supports) and to the most current science
base
(Aspden, 2004).
Whereas To Err Is Human focused primarily
on errors that occur in hospitals, the 2004
report
examined the incidence of serious safety issues
in other settings as well, including ambulatory
care facilities and nursing homes. Its authors
point out that earlier research on patient
safety
focused on errors of commission, such as
prescribing a medication that has a potentially
fatal
interaction with another medication the patient
is taking, and they argue that errors of
omission
are equally important. An example of an
error of omission is failing to prescribe a
medication
from which the patient would likely have
benefited (Institute of Medicine, Committee on
Data
Standards for Patient Safety, 2003). A
significant contributing factor to the unacceptably
high
rate of medical errors reported in these two
reports and many others is poor information
management practices. Illegible prescriptions,
unconfirmed verbal orders, unanswered
telephone calls, and lost medical records could
all place patients at risk.
52. Transparency and Patient Safety
The federal government also responded to
quality of care concerns by promoting health
care
transparency (for example, making quality and
price information available to consumers) and
furthering the adoption of HIT. In 2003, the
Medicare Modernization Act was passed, which
expanded the program to include prescription
drugs and mandated the use of electronic
prescribing (e-prescribing) among health plans
providing prescription drug coverage to Medicare
beneficiaries. A year later (2004), President
Bush called for the widespread adoption of
EHR
systems within the decade to improve
efficiency, reduce medical errors, and improve
quality of
care. By 2006, he had issued an executive
order directing federal agencies that administer
or
sponsor health insurance programs to make
information about prices paid to health care
providers for procedures and information on
the quality of services provided by physicians,
hospitals, and other health care providers
publicly available. This executive order also
encouraged adoption of HIT standards to
facilitate the rapid exchange of health
information (The
White House, 2006).
During this period significant changes in
reimbursement practices also materialized in an
effort
to address patient safety, health care quality,
53. and cost concerns. Historically, health care
providers and organizations had been paid for
services rendered regardless of patient quality
or
outcome. Nearing the end of the decade,
payment reform became a hot item. For
example, pay
for performance (P4P) or value-based purchasing
pilot programs became more widespread.
P4P reimburses providers based on meeting
predefined quality measures and thus is
intended
to promote and reward quality. The Centers
for Medicare and Medicaid Services (CMS)
notified
hospitals and physicians that future increases
in payment would be linked to improvements
in
clinical performance. Medicare also announced it
would no longer pay hospitals for the costs
of
treating certain conditions that could reasonably
have been prevented—such as bedsores,
injuries caused by falls, and infections
resulting from the prolonged use of catheters
in blood
vessels or the bladder—or for treating “serious
preventable” events—such as leaving a sponge
or other object in a patient during surgery
or providing the patient with incompatible
blood or
blood products. Private health plans also
followed Medicare's lead and began denying
payment
for such mishaps. Providers began to recognize
the importance of adopting improved HIT to
54. collect and transmit the data needed under
these payment reforms.
Office of the National Coordinator for Health
Information Technology
In April 2004, President Bush signed Executive
Order No. 13335, 3 C.F.R., establishing the
Office of the National Coordinator for Health
Information Technology (ONC) and charged the
office with providing “leadership for the
development and nationwide implementation of an
interoperable health information technology
infrastructure to improve the quality and
efficiency of
health care.” In 2009, the role of the ONC
(organizationally located within the US
Department of
Health and Human Services) was strengthened
when the Health Information Technology for
Economic and Clinical Health (HITECH) Act
legislatively mandated it to provide leadership
and
oversight of the national efforts to support
the adoption of EHRs and health information
exchange (HIE) (ONC, 2015).
In spite of the various national initiatives
and changes to reimbursement during the first
decade
of the twenty-first century, by the end of
the decade only 25 percent of physician
practices
(Hsiao, Hing, Socey, & Cai, 2011) and 12
percent of hospitals (Jha, 2010) had
55. implemented
“basic” EHR systems. The far majority of
solo and small physician practices continued to
use
paper-based medical record systems. Studies
show that the relatively low adoption rates
among solo and small physician practices were
because of the cost of HIT and the
misalignment of incentives (Jha et al., 2009).
Patients, payers, and purchasers had the most
to
gain from physician use of EHR systems,
yet it was the physician who was expected
to bear
the total cost. To address this misalignment
of incentives issue, to provide health care
organizations and providers with some funding
for the adoption and Meaningful Use of
EHRs,
and to promote a national agenda for HIE,
the HITECH Act was passed as a part of
the
American Recovery and Reinvestment Act in
2009.
2010–Present: Health Care Reform and the
Growth of HIT
HITECH and Meaningful Use
An important component of HITECH was the
establishment of the Medicare and Medicaid
EHR
Incentive Programs. Eligible professionals and
hospitals that adopt, implement, or upgrade to
a
certified EHR received incentive payments. After
the first year of adoption, the providers had
to
56. prove successfully that they were “demonstrating
Meaningful Use” of certified EHRs to receive
additional incentive payments. The criteria,
objectives, and measures for demonstrating
Meaningful Use evolved over a five-year
period from 2011 to 2016. The first stage
of Meaningful
Use criteria was implemented in 2011–2012
and focused on data capturing and sharing.
Stage 2
(2014) criteria are intended to advance clinical
processes, and Stage 3 (2016) criteria aim to
show improved outcomes. Table 1.1 provides a
broad overview of the Meaningful Use criteria
by stage.
Table 1.1 Stages of Meaningful Use
Source: ONC (n.d.a.).
Stage 1: Meaningful Use criteria focus Stage
2: Meaningful Use criteria focus Stage
3: Meaningful Use criteria focus
Electronically capturing health information in a
standardized format More rigorous HIE
Improving quality, safety, and efficiency leading
to improved health outcomes
Using that information to track key clinical
conditions Increased requirements for
e-prescribing and incorporating lab results Decision
support for national high-priority conditions
Communicating that information for care
coordination processes Electronic transmission of
patient summaries across multiple settings Patient
access to self-management tools
Initiating the reporting of clinical quality
57. measures and public health information More
patient-controlled data Access to comprehensive
patient data through patient-centered HIE
Using information to engage patients and their
families in their care Improving population
health
Through the Medicare EHR Incentive Program,
each eligible professional who adopted and
achieved meaningful EHR use in 2011 or
2012 was able to earn up to $44,000 over
a five-year
period. The amount decreased over the period,
creating incentives to providers to start sooner
rather than later. Eligible hospitals could earn
over $2 million through the Medicare EHR
Incentive Program, and the Medicaid program
made available up to $63,500 for each
eligible
professional (through 2021) and over $2
million to each eligible hospital. As of
December 2015,
more than 482,000 health care providers
received a total of over $31 billion in
payments for
participating in the Medicare and Medicaid
EHR Incentive Programs (CMS, n.d.). See
Table 1.2
for primary differences between the two
incentive programs.
Table 1.2 Differences between Medicare and
Medicaid EHR incentive programs
58. Source: Carson, Garr, Goforth, and Forkner
(2010).
Medicare EHR Incentive Program Medicaid EHR
Incentive Program
Federally implemented and available nationally
Implemented voluntarily by states
Medicare Advantage professionals have special
eligibility accommodations. Medicaid
managed care professionals must meet regular
eligibility requirements.
Open to physicians, subsection (d) hospitals,
and critical access hospitals Open to five
types of professionals and three types of
hospitals
Same definition of Meaningful Use applied to
all participants nationally States can adopt a
more rigorous definition of Meaningful Use.
Must demonstrate Meaningful Use in first year
Adopt, implement, or upgrade option in first
year
Maximum incentive for eligible professionals is
$44,000; 10 percent for HPSA (health
professional shortage area). Maximum incentive for
eligible professionals is $63,750.
2014 is the last year in which a
professional can initiate participation. 2016 is the
last year
in which a professional can initiate
participation.
Payments over five years Payments over six
years
In 2015 fee reductions (penalties) began for
those who do not demonstrate Meaningful Use
of a
59. certified HER. No fee reductions (penalties)
2016 is the last incentive payment year. 2021
is the last incentive payment year.
No Medicare patient population minimum is
required. Eligible professionals must have a
30 percent Medicaid population (20 percent for
pediatricians) to participate; this must be
demonstrated annually.
Within the ONC, the Office of Interoperability
and Standards oversees certification programs for
HIT. The purpose of certification is to
provide assurance to EHR purchasers and other
users
that their EHR system has the technological
capability, functionality, and security needed to
assist them in meeting Meaningful Use criteria.
Eligible providers who apply for the EHR
Medicare and Medicaid Incentive Programs are
required to use certified EHR technology. The
ONC has authorized certain organizations to
perform the actual testing and certification of
EHR
systems.
Other HITECH Programs
Many small physician practices and rural
hospitals do not have the in-house expertise
to select,
implement, and support EHR systems that meet
certification standards. To address these
needs, HITECH funded sixty-two regional
extension centers (RECs) throughout the nation
to
60. support providers in adopting and becoming
meaningful users of EHRs. The RECs are
primarily
intended to provide advice and technical
assistance to primary care providers, especially
those
in small practices, and to small rural
hospitals, which often do not have information
technology
(IT) expertise. Furthermore, HITECH provided
funding for various workforce training programs
to support the education of HIT professionals.
The education-based programs included
curriculum development, community college
consortia, competency examination, and
university-based training programs, with the
overarching goal of training an additional forty-
five
thousand HIT professionals. Funding was also
made available to seventeen Beacon
communities and Strategic Health IT Advanced
Research Projects (SHARP) across the nation.
The Beacon programs are leading organizations
that are demonstrating how HIT can be used
in
innovative ways to target specific health
problems within communities (HealthIT.gov, 2012).
These programs are illustrating HIT's role in
improving individual and population health
outcomes and in overcoming barriers such as
coordination of care, which plagues our nation's
health care system (McKethan et al., 2011).
Achieving Meaningful Use requires that health
care providers are able to share health
information electronically with others using a
61. secure network for HIE. To this end,
HITECH
provided state grants to help build the HIE
infrastructure for exchange of electronic health
information among providers and between
providers and consumers. Nearly all states have
approved strategic and operational plans for
moving forward with implementation of their
HIE
cooperative agreement programs.
Affordable Care Act
In addition to the increased efforts to
promote HIT through legislated programs, the
early 2010s
brought dramatic change to the health care
sector as a whole with the passage of
significant
health care reform legislation. Americans have
grappled for decades with some type of
“health
care reform” in an attempt to achieve the
simultaneous “triple aims” for the US health
care
delivery system:
Improve the patient experience of care
Improve the health of populations
Reduce per capita cost of health care (IHI,
n.d.)
Full achievement of these aims has been
challenging within a health care delivery
system
managed by different stakeholders—payers,
providers, and patients—whose goals are
frequently not well aligned. The latest attempt
62. at reform occurred in 2010, when President
Obama signed into law the Patient Protection
and Affordable Care Act (PPACA), now known
as
the Affordable Care Act (ACA).
Along with mandating that individuals have
health insurance and expanding Medicaid
programs,
the ACA created the structure for health
insurance exchanges, including a greater role
for
states, and imposed changes to private
insurance, such as prohibiting health plans from
placing
lifetime limits on the dollar value of
coverage and prohibiting preexisting condition
exclusions.
Numerous changes were to be made to the
Medicare program, including continued reductions
in Medicare payments to certain hospitals for
hospital-acquired conditions and excessive
preventable hospital readmissions. Additionally, the
CMS established an innovation center to
test, evaluate, and expand different payment
structures and methodologies to reduce program
expenditures while maintaining or improving
quality of care. Through the innovation center
and
other means, CMS has been aggressively
pursuing implementation of value-based payment
methods and exploring the viability of
alternative models of care and payment.
63. The final assessment of the success of ACA
is still unknown; however, what is certain is
that its
various programs will rely heavily on quality
HIT to achieve their goals. A greater
emphasis than
ever is placed on facilitating patient
engagement in their own care through the use
of technology.
On the other end of the spectrum, new
models of care and payment include improved
health for
populations as an explicit goal, requiring HIT
to manage the sheer volume and complexity
of
data needed.
Value-Based Payment Programs
Shortly after the ACA was passed, CMS
implemented several value-based payment programs
in an effort to reward health care providers
with incentive payments for the quality of
care they
provide to Medicare patients. In 2015, the
Medicare Access and CHIP Reauthorization Act
(MACRA) was signed into law. Among other
things, MACRA outlines a timetable for the
2019
implementation of a merit-based incentive
payment system (MIPS) that will replace other
value-based payment programs, including the
EHR Incentive Programs. MIPS will use a set
of
performance measures, divided into categories, to
calculate a score (between 0 and 100) for
eligible professionals. Each category of
performance will be weighted as shown in
64. Table 1.3.
Table 1.3 MIPS performance categories
Category Weight (%)
Quality 50
Advancing care information 25
Clinical practice improvement activities 15
Resource use 10
Health care providers meeting the established
threshold score will receive no adjustment to
payment; those scoring below will receive a
negative adjustment, and those above, a
positive
adjustment. Exceptional performers may receive
bonus payments (CMS, n.d.).
Alternate Payment Methods
Providers who meet the criteria to provide
an alternate payment method (APM) will
receive
bonus payments and will be exempt from the
MIPS. Although there are likely to be other
APMs
identified over time, three types are receiving
a great deal of attention currently: accountable
care organizations (ACOs), bundled payments,
and patient-centered medical homes (PCMHs).
ACOs are “networks of . . . health care
providers that share responsibility for
coordinating care
and meeting health care quality and cost
metrics for a defined patient population”
65. (Breakaway
Policy Strategies for FasterCures, 2015, p. 2).
Bundled payments aim to incentivize provider s
to
improve care coordination, promote teamwork,
and lower costs. Payers will compensate
providers with a single payment for an
episode of care. PCMHs are APMs that are
rooted in the
private sector. In 2007, four physician
societies published a joint statement of
principles
emphasizing a personal physician–led coordination
of care. All of the APMs rely heavily on
HIT.
ACOs and PCMHs, in particular, require that
HIT support the organization and its providers
in
the carrying out the following functions:
Manage and coordinate integrated care.
Identify, manage, and reduce or contain costs.
Adhere to evidence-based practice guidelines and
standards of care; ensure quality and safety.
Manage population health.
Engage patients and their families and
caregivers in their own care.
Report on quality outcomes.
HIT Interoperability Efforts
Despite efforts dating back to the first
reports on the need for adoption of
computerized patient
records, complete interoperability among HIT
systems, which is key to supporting an
integrated
health care delivery system that provides
66. improved care to individuals and populations
while
managing costs, remains elusive. The federal
government, along with other provider, vendor,
and professional organizations, however, recognize
this need for interoperability. The ONC
defines interoperability as “the ability of a
system to exchange electronic health information
with
and use electronic health information from
other systems without special effort on the
part of the
user” (ONC, n.d.a). Interoperability among HIT
encompasses far more than just connected
EHRs across systems. Home health monitoring
systems are becoming commonplace,
telehealth is on the rise, and large public
health databases exist at state and national
levels. True
interoperability will encompass any electronic
sources with information needed to provide the
best possible health care.
Some of the more notable efforts toward
HIT interoperability include the efforts by the
government under the direction of the ONC
and several other national public and private
organizations. In 2015, the ONC published
“Connecting Health and Care for the Nation:
A
Shared Nationwide Interoperability Roadmap,” a
ten-year plan for achieving HIT interoperability
in the United States. Figure 1.1 summarizes
the key milestones identified in the ONC
road map.
The ultimate goal for 2024 is “a learning
67. health system enabled by nationwide
interoperability.”
The goal of the learning health system is
to improve the health of individuals and
populations by
“generating information and knowledge from data
captured and updated over time . . . and
sharing and disseminating what is learned in
timely and actionable forms that directly enable
individuals, clinicians, and public health entiti es
to . . . make informed decisions” (ONC,
2015, p.
18).
Figure 1.1 Milestones for a supportive payment
and regulatory environment
Source: ONC (2015).
Health Level Seven International (HL7), a not-
for-profit, ANSI (American National Standards
Institute)–accredited, standards-developing organization,
is focused on technical standards for
HIE. The HL7 Fast Healthcare Interoperability
Resources (FHIR) standards were introduced in
2012 and are under development to improve
the exchange of EHR data. About this same
time
Healtheway, now the Sequoia Project, was
chartered as a nonprofit organization to
“advance the
implementation of secure, interoperable nationwide
health information exchange” (Sequoia
Project, n.d.a). The Sequoia Project supports
68. several initiatives, including the eHealth
Exchange, a group of government and
nongovernment organizations devoted to improving
patient care through “interoperable health
information exchange” (Sequoia Project, n.d.a).
Unlike
HL7, which focuses on technical standards,
eHealth Exchange's primary focus is on the
legal
and policy barriers associated with nationwide
interoperability. Another Sequoia initiative,
Carequality, strives to connect private HIE
networks. Another private endeavor, Commonwell
Health Alliance, is a consortium of HIT
vendors and other organizations that are
committed to
achieving interoperability. Commonwell began in
2013 with six EHR vendors. In 2015, their
membership represented 70 percent of hospitals.
Provider members of Commonwell register
their patients in order to exchange information
easily with other member providers (Jacob,
2015).
Although HIT has become commonplace across
the continuum of care, seamless
interoperability among the nation's HIT systems
has not yet been realized. One author
describes the movement toward HIT
interoperability in the United States not as a
straight path
but rather as a jigsaw puzzle with multiple
public and private organizations “working on
different
pieces”(Jacob, 2015).
Interoperability requires not only technical
69. standards but also a national health information
infrastructure, along with an effective governing
system. Concerns about the misalignment of
incentives for achieving interoperability remain.
Most experts agree that technology is not the
barrier to interoperability. Governance and
alignment of agendas among disparate
organizations
are cited as the most daunting barriers.
Because of its potential to affect seriously
the progress
of interoperability, in 2015, the ONC reported
to Congress on the phenomenon of health
information blocking, which is defined as
occurring “when persons or entities knowingly
and
unreasonably interfere with the exchange or
use of electronic health information” (ONC,
2015).
The report charged that current economic
incentives were not supportive of information
exchange and that some of the current
market practices actually discouraged sharing
health
information (DeSalvo & Daniel, 2015).
Summary
Chapter One provides a brief chronological
overview of some of the most significant
national
drivers in the development, growth, and use
of HIT in the United States. Since the
1990s and the
publication of The Computer-Based Patient
Record: An Essential Technology for Health
Care,
70. the national HIT landscape has certainly
evolved, and it will continue to do so.
Challenges to
realizing an integrated national HIT infrastructure
are numerous, but the need for one has
never
been greater. Recognizing that the technology
is not the major barrier to the national
infrastructure, the government, through legislation,
CMS incentive programs, the ONC, and
other programs, will continue to play a
significant role in the Meaningful Use of
HIT, pushing for
the alignment of incentives within the
healthcare delivery system.
In a 2016 speech, CMS acting chief Andy
Slavitt summed up the government's role in
achieving
its HIT vision with the following statements:
The focus will move away from rewarding
providers for the use of technology and
towards the
outcome they achieve with their patients.
Second, providers will be able to customize
their goals so tech companies can build
around the
individual practice needs, not the needs of
the government. Technology must be user-centered
and support physicians, not distract them.
71. Third, one way to aid this is by leveling
the technology playing field for start-ups and
new
entrants. We are requiring open APIs . . .
that allow apps, analytic tools, and connected
technologies to get data in and out of an
EHR securely.
We are deadly serious about interoperability.
We will begin initiatives . . . pointing
technology to
fill critical use cases like closing referral
loops and engaging a patient in their care.
Technology companies that look for ways to
practice “data blocking” in opposition to new
regulations will find that it won't be
tolerated. (Nerney, 2016)
Many of the initiatives discussed in Chapter
One will be explored more fully in
subsequent
chapters of this book. The purpose of
Chapter One is to provide the reader with
a snapshot of
the national HIT landscape and enough
historical background to set the stage for
why health
care managers and leaders must understand and
actively engage in the implementation of
effective health information systems to achieve
better health for individuals and populations
while managing costs.
72. Chapter 2
Health Care Data
Central to health care information systems is
the actual health care data that is collected
and
subsequently transformed into useful health care
information. In this chapter we will examine
key aspects of health care data. In
particular, this chapter is divided into four
main sections:
Health care data and information defined
(What are health data and health information?)
Health care data and information sources
(Where does health data originate and why?
When
does health care data become health care
information?)
Health care data uses (How do health care
organizations use data? What is the impact of
the
trend toward analytics and big data on
health care data?)
Health care data quality (How does the
quality of health data affect its use?)
Health Care Data and Information Defined
Often the terms health care data and health
care information are used interchangeably.
However, there is a distinction, if somewhat
blurred in current use. What, then, is the
difference
between health data and health information?
The simple answer is that health information
is
73. processed health data. (We interpret processing
broadly to cover everything from formal
analysis to explanations supplied by the
individual decision maker's brain.) Health care
data are
raw health care facts, generally stored as
characters, words, symbols, measurements, or
statistics. One thing apparent about health care
data is that they are generally not very
useful for
decision making. Health care data may
describe a particular event, but alone and
unprocessed
they are not particularly helpful. Take, for
example, this figure: 79 percent. By itself,
what does it
mean? If we process this datum further by
indicating that it represents the average bed
occupancy for a hospital for the month of
January, it takes on more meaning. With the
additional
facts attached, is this figure now information?
That depends. If all a health care executive
wants
or needs to know is the bed occupancy
rate for January, this could be considered
information.
However, for the hospital executive who is
interested in knowing the trend of the bed
occupancy
rate over time or how the facility's bed
occupancy rate compares to that of other,
similar
facilities, this is not yet the information he
needs. A clinical example of raw data would
be the lab
74. value, hematocrit (HCT) = 32 or a
diagnosis, such as diabetes. These are single
facts, data at
the most granular level. They take on
meaning when assigned to particular patients in
the
context of their health care status or
analyzed as components of population studies.
Knowledge is seen by some as the highest
level in a hierarchy with data at the
bottom and
information in the middle (Figure 2.1).
Knowledge is defined by Johns (1997, p. 53)
as “a
combination of rules, relationships, ideas, and
experience.” Another way of thinking about
knowledge is that it is information applied
to rules, experiences, and relationships with the
result
that it can be used for decision making.
Data analytics applied to health care
information and
research studies based on health care
information are examples of transforming health
care
information into new knowledge. To carry out
our example from previous paragraphs, the 79
percent occupancy rate could be related to
additional information to lead to knowledge
that the
health care facility's referral strategy is
working.
75. Figure 2.1 Health care data to health care
knowledge
Where do health care data end and where
does health care information begin? Information
is an
extremely valuable asset at all levels of the
health care community. Health care executives,
clinical staff members, and others rely on
information to get their jobs accomplished. The
goal of
this discussion is not to pinpoint where data
end and information begins but rather to
further an
understanding of the relationship between health
care data and information—health care data
are the beginnings of health care information.
You cannot create information without data.
Through the rest of this chapter the terms
health care data and health care information
will be
used to describe either the most granular
components of health care information or data
that
have been processed, respectively (Lee, 2002).
The first several sections of this chapter
focus primarily on the health care data and
information
levels, but the content of the section on
health care data quality takes on new
importance when
applied to processes for seeking knowledge
from health care data. We will begin the
chapter
exploring where some of the most common
76. health care data originate and describe some
of the
most common organizational and provider uses
of health care information, including patient
care, billing and reimbursement, and basic
health care statistics. Please note there are
many
other uses for health information that go
beyond these basics that will be explored
throughout
this text.
Health Care Data and Information Sources
The majority of health care information created
and used in health care information systems
within and across organizations can be found
as an entry in a patient's health record or
claim,
and this information is readily matched to a
specific, identifiable patient.
The Health Insurance Portability and
Accountability Act (HIPAA), the federal
legislation that
includes provisions to protect patients' health
information from unauthorized disclosure, defines
health information as any information, whether
oral or recorded in any form or medium,
that
does the following:
Is created or received by a health care
provider, health plan, public health authority,
employer,
life insurer, school or university, or health
care clearinghouse
77. Relates to the past, present, or future
physical or mental health or condition of an
individual, the
provision of health care to an individual, or
the past, present, or future payment for the
provision
of health care to an individual
HIPAA refers to this type of identifiable
information as protected health information (PHI).
The Joint Commission, the major accrediting
agency for many types of health care
organizations in the United States, has adopted
the HIPAA definition of protected health
information as the definition of “health
information” listed in their accreditation manuals'
glossary
of terms (The Joint Commission, 2016).
Creating, maintaining, and managing quality
health
information is a significant factor in health
care organizations, such as hospitals, nursing
homes,
rehabilitation centers, and others, who want to
achieve Joint Commission accreditation. The
accreditation manuals for each type of facility
contain dozens of standards that are devoted
to
the creation and management of health
information. For example, the hospital
accreditation
manual contains two specific chapters, Record
of Care, Treatment, and Services (RC) and
78. Information Management (IM). The RC chapter
outlines specific standards governing the
components of a complete medical record, and
the IM chapter outlines standards for managing
information as an important organizational
resource.
Medical Record versus Health Record
The terms medical record and health record
are often used interchangeably to describe a
patient's clinical record. However, with the
advent and subsequent evolution of electronic
versions of patient records these terms actually
describe different entities. The Office of the
National Coordinator for Health Information
Technology (ONC) distinguishes the electronic
medical record and the electronic health record
as follows.
Electronic medical records (EMRs) are a
digital version of the paper charts. An EMR
contains
the medical and treatment history of the
patients in one practice (or organization).
EMRs have
advantages over paper records. For example,
EMRs enable clinicians (and others) to do
the
following:
Track data over time
Easily identify which patients are due for
preventive screenings or checkups
Check how their patients are doing on
certain parameters'such as blood pressure readings
or
79. vaccinations
Monitor and improve overall quality of care
within the practice
But the information in EMRs doesn't travel
easily out of the practice (or organization).
In fact, the
patient's record might even have to be
printed out and delivered by mail to
specialists and other
members of the care team. In that regard,
EMRs are not much better than a paper
record.
Electronic health records (EHRs) do all those
things—and more. EHRs focus on the total
health
of the patient—going beyond standard clinical
data collected in the provider's office (or
during
episodes of care)—and is inclusive of a
broader view on a patient's care. EHRs are
designed to
reach out beyond the health organization that
originally collects and compiles the information.
They are built to share information with
other health care providers (and organizations),
such as
laboratories and specialists, so they contain
information from all the clinicians involved in
the
patient's care (Garrett & Seidman, 2011).
Another distinguishing feature of the EHR
(discussed
in more detail in Chapter Three) is the
inclusion of decision-support capabilities beyond
those of
80. the EMR.
Patient Record Purposes
Health care organizations maintain patient
clinical records for several key purposes. As
we
move into the discussion on clinical
information systems in subsequent chapters, it
will be
important to remember these purposes, which
remain constant regardless of the format or
infrastructure supporting the records. In
considering the purposes listed, the scope of
care is
also important. Records support not only
managing a single episode of care but also
a patient's
continuum of care and population health.
Episode of care generally refers to the
services
provided to a patient with a specific
condition for a specific period of time.
Continuum of care, as
defined by HIMSS (2014), is a concept
involving a system that guides and tracks
patients over
time through a comprehensive array of health
services spanning all levels and intensity of
care.
Population health is a relatively new term
and definitions vary. However, the concept
behind
managing population health is to improve
81. health outcomes within defined communities
(Stoto,
2013). The following list comprises the most
commonly recognized purposes for creating and
maintaining patient records.
Patient care. Patient records provide the
documented basis for planning patient care and
treatment, for a single episode of care and
across the care continuum. This purpose is
considered the number-one reason for maintaining
patient records. As our health care delivery
system moves toward true population health
management and patient-focused care, the patient
record becomes a critical tool for documenting
each provider's contribution to that care.
Communication. Patient records are an important
means by which physicians, nurses, and
others, whether within a single organization or
across organizations, can communicate with one
another about patient needs. The members of
the health care team generally interact with
patients at different times during the day,
week, or even month or year. Information
from the
patient's record plays an important role in
facilitating communication among providers across
the continuum of care. The patient record
may be the only means of communication
among
various providers. It is important to note
that patients also have a right to acces s
their records,
and their engagement in their own care is
often reflected in today's records.
Legal documentation. Patient records, because
82. they describe and document care and
treatment, are also legal records. In the
event of a lawsuit or other legal action
involving patient
care, the record becomes the primary evidence
for what actually took place during the care.
An
old but absolutely true adage about the legal
importance of patient records says, “If it was
not
documented, it was not done.”
Billing and reimbursement. Patient records
provide the documentation patients and payers
use
to verify billed services. Insurance companies
and other third-party payers insist on clear
documentation to support any claims submitted.
The federal programs Medicare and Medicaid
have oversight and review processes in place
that use patient records to confirm the
accuracy
of claims filed. Filing a claim for a
service that is not clearly documented in the
patient record
may be construed as fraud.
Research and quality management. Patient records
are used in many facilities for research
purposes and for monitoring the quality of
care provided. Patient records can serve as
source
documents from which information about certain
diseases or procedures can be taken, for
example. Although research is most prevalent
in large academic medical centers, studies are
conducted in other types of health care
organizations as well.
83. Population health. Information from patient
records is used to monitor population health,
assess
health status, measure utilization of services,
track quality outcomes, and evaluate adherence
to evidence-based practice guidelines. Health care
payers and consumers are increasingly
demanding to know the cost-effectiveness and
efficacy of different treatment options and
modalities. Population health focuses on
prevention as a means of achieving cost-
effective
care.
Public health. Federal and state public health
agencies use information from patient records
to
inform policies and procedures to ensure that
they protect citizens from unhealthy conditions.
Patient Records as Legal Documents
The importance of maintaining complete and
accurate patient records cannot be
underestimated. They serve not only as a
basis for planning patient care but also as
the legal
record documenting the care that was provided
to patients. The data captured in a patient
record
become a permanent record of that patient's
diagnoses, treatments, response to treatments,
and case management. Patient records provide
much of the source data for health care
information that is created, maintained, and
managed within and across health care
84. organizations.
When the patient record was a file folder
full of paper housed in the health
information
management department of the hospital,
identifying the legal health record (LHR) was
fairly
straightforward. Records kept in the usual
course of business (in this case, providi ng
care to
patients) represent an exception to the hearsay
rule, are generally admissible in a court, and
therefore can be subpoenaed—they are legal
documentation of the care provided to the
patients.
With the implementation of comprehensive EHR
systems the definition of an LHR remains the
same, but the identification of the boundaries
for it may be harder to determine. In 2013,
the
ONC's National Learning Consortium published
the Legal Health Record Policy Template to
guide health care organizations and providers
in defining which records and record sets
constitute their legal health record for
administrative, business, or evidentiary purposes.
The
media on which the records are maintained
does not determine the legal status; rather, it
is the
purpose for which the record was created
and is maintained. The complete template can
be
found at
www.healthit.gov/sites/default/files/legal_health_policy_templa
85. te.docx.
Because of the legal nature of patient
records, the majority of states have specific
retention
requirements for information contained within
them. These state requirements should be the
basis for the health care organization's formal
retention policy. (The Joint Commission and
other
accrediting agencies also address retention but
generally refer organizations back to their own
state regulations for specifics.) When no
specific retention requirement is made by the
state, all
patient information that is a part of the
LHR should be maintained for at least as
long as the
state's statute of limitations or other regulation
requires. In the case of minor children the
LHR
should be retained until the child reaches
the age of majority as defined by state
law, usually
eighteen or twenty-one. Health care executives
should be aware that statutes of limitations
may
allow a patient to bring a case as long
as ten years after the patient learns that
his or her care
caused an injury (Lee, 2002). Although some
specific retention requirements and general
guidelines exist, it is becoming increasingly
popular for health care organizations to keep
all LHR
information indefinitely, particularly if the
