While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
Q: Have you found home health care nurses receptive to using new technologies?
A: Yes. I think that nurses, including home health nurses, are open to new technologies. In my experience, home care nurses are generally positive about technology because it often affords them the ability to provide expanded, higher quality and more consistent services to patients.
Q: Please explain the primary findings of “Empowering Home Care Nurses to Efficiently Resolve Medication Discrepancies,” the study you conducted with Stephen M. Setter, PharmD, a professor of pharmacy at Washington State University.
A: The overall purpose of the research was to test a health information technology (HIT)-assisted electronic medical record (EMR) system to determine its impact on home health care nurses’ ability to efficiently detect and resolve medication discrepancies among patients transitioning from hospital to home and to reduce patients’ need for acute care, such as admission to an emergency department, within the first 30 days after hospital discharge.
We found that nurse interventionists were able to resolve over 90 percent of medication discrepancies. And, our initial results do indicate lower levels of acute care utilization among intervention group participants within the first 30 days after hospital discharge. But, we were unable to detect significant differences in the proportion of medication discrepancies resolved among patients in the intervention versus control group. This may reflect a problem with the study methods, because it was difficult to accurately assess and compare the number of discrepancies detected and resolved in the control group.
Nurse interventionists report that the focus on medications that resulted from following the study protocol, as well as their ability to consistently follow-up with patients until the medication discrepancies were resolved, was the most important part of the intervention, rather than any direct benefit derived from the HIT-assisted system.
Q: What are your conclusions about using information technology in home health care to promote safe transitions from hospital to home and avoid medication errors?
A: Information technology is not likely to improve safe transitions and avoid medication problems until an accurate, smooth, convenient and totally seamless and paperless system is realized. Most health care systems, including the one in our research, have a mix of paper and electronic systems. Whenever there is a mixture, the continuity and completeness of the electronic system is weakened. Paper documents, for example, hand-written prescriptions given to the patient and family right at the time of discharge, often do not get transferred to the EMR.
In addition, EMRs from acute care, home care and ambulatory care are often on different platforms and do not easily communicate with one another. Everyone caring for these patients needs to use the same HIT system or the HIT systems must seamlessly exchange information.
Q: What other barriers do you see to using these technologies more widely?
A: The cost of hardware and training, clinician and nurse resistance to using EMRs—they complain that the systems are cumbersome and detract from interaction with the patient.
The nurses in our study also say that it is difficult for them to consistently track what is being done for patients from visit to visit because now, data is entered into a variety of places on the computer making it burdensome to access in an efficient manner. For nurses to look at prior interventions and future care plans, they must view several computer screens which takes significant time. Time limitations often prevent them from doing this as thoroughly as possible and the continuity of patient care may suffer as a result.
Q: Is it difficult to use information technology off-site, outside of a health care setting where technical assistance might be more readily available?
A: This can create challenges, but I don’t think it is that much more challenging in home care. First line help is available by telephone for nearly all systems and telephone assistance is easily accessible for home health care nurses. If the issue cannot be resolved by telephone, the home care nurse will just have to travel to the office, but that is part of the job. Security is a challenge as nurses must be careful not to leave laptops unattended. If stolen, there is great concern about patient record confidentiality.
Q: What’s the learning curve for home health care nurses using new information technologies?
A: I think it’s the same as the curve for other nurses. It varies by nurse and their experience with computers and EMRs. The nurses we worked with were quite adept at using the EMRs and other technology. More recent graduates are very comfortable and well versed in computer applications, but they say the systems they are asked to use are often horribly outdated and extremely inefficient.
Q: In your opinion, did the HIT-assisted system in any way help to protect patients or reduce emergency department visits?
A: As mentioned above, our data is not complete, but our initial results indicate that there is likely a significant reduction in acute care use for patients who received the intervention as compared to patients in the control group who received usual home care services. But the nurses did not think the information technology system helped them to do things that were unique or saved time, because they found paper files quicker and easier to use. They did report that conscientiously focusing on medication discrepancy identification, then consistently following up with the patients and their prescribing providers, allowed them to resolve more medication discrepancies, do more teaching, and better assist the patients with overall medication self-management and adherence. That consistent follow-up and focus on the medications may have been the key to higher quality care.
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