NURS 4005 – Topics in Clinical Nursing Essay 

The problem of information transfer between healthcare sectors and across the continuum of care was examined using a mixed methods approach. These methods include qualitative interviews, retrospective case reviews and an informatic gap analysis. Findings and conclusions are reported for each study.
Qualitative interviews were conducted with 16 healthcare representatives from 4 disciplines (medicine, pharmacy, nursing, and social work) and 3 healthcare sectors (hospital, skilled nursing care and community care). Three key themes from a Joint Cognitive Systems theoretical model were used to examine qualitative findings. Agreement on cross-sector care goals is neither defined nor made explicit and in some instances working at cross purposes. Care goals and information paradigms change as patients move from hospital-based crisis stabilization, diagnosis and treatment to a postdischarge care to home or skilled nursing recovery, function restoration, or end of life support. Control of the transfer process is variable across institutions with little feedback and feed-forward. Lack of knowledge, competency and information tracking threatens sector interdependencies with suspicion and distrust. NURS 4005 – Topics in Clinical Nursing Essay Paper

Sixty-three patients discharged between 2006 and 2008 from hospitals to skilled nursing facilities were randomly selected and reviewed. Most notably missing are discharge summaries (30%), nursing assessments or notes (17%), and social work documents (25%). Advanced directives or living wills necessary for end of life support were present in only 6% of the cases. The presence of information on activities of daily living (ADLs), other disabling conditions, and nutrition was associated with positive outcomes at the 0.001, 0.04 and 0.08levels. Consistent geriatric information transfer across the continuum is needed for relevant care management.

An interoperability gap analysis conducted on the LINC (Linking Information Necessary for Care) transfer form determined its interoperability to be the semantic level 0. Detailed Clinical Models representing care management processes are challenged by the lack of consensus in terminology standards across sectors. Construction of information transfer solutions compliant with the Centers of Medicare and Medicaid Services (CMS) Stage 2 meaningful use criteria must address syntactic and semantic standards, map sector terminologies within care management processes, and account for the lack of standard terminologies in allied health domains. NURS 4005 – Topics in Clinical Nursing Essay Paper

The aging of America is generating new economic and patient safety challenges to the delivery of healthcare (1). Changing patterns of healthcare utilization raise interesting research questions about continuity of care; transfers in care; and risk amelioration across the continuum of care. The trend in healthcare utilization patterns for aging adults (65 and older) is more frequent hospitalizations for shorter periods of time (1). As a result, aging adults are being discharged back into a variety of community care placements including: 1) their own homes; 2) other institutional care (nursing homes, rehabilitation centers, assisted living facilities); or 3) in-home healthcare and community care services (2). Increasing responsibility is being placed on the receiving entity, and as a result, the transfer of relevant medical care information becomes imperative.
Rapid, accurate, and relevant information exchange is vital for those with increasing age, co-morbidities, multiple medications, and multiple interfacility transfers. Poor information exchange, can in turn, contribute to poor discharge outcomes and adverse events. The thesis of this dissertation proposes that improved information transfer will improve the quality of care across the continuum, resulting in a) decreased hospital readmissions, b) extended lengths of stay, c) emergency room visits, or d) patient injury. The goal of this dissertation
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is to evaluate the pattern of information transfer between healthcare sectors and to assess the association between information transfer and patient outcomes. The changing landscape of healthcare delivery significantly increases the complexity of the information transfer problem and this dissertation looks to biomedical informatics for solutions. NURS 4005 – Topics in Clinical Nursing Essay Paper
Chapter 1 provides an overall introduction to the research theory of Joint Cognitive Systems (JCS). JCS lays the groundwork for the research perspective. A Health Information Technology (HIT) Evaluation model is presented as an evaluation framework to coordinate the research aims. Chapter 1 ends with an overview of the dissertation’s research aims. Chapter 2 presents the background literature for contextual understanding of the problem. The background literature includes a description of aging demographics; a discussion about the continuum of care context; an analysis of the problem with transitions in care; and presents information technology as a solution. This research addresses the following questions:
1) What are clinicians’ experiences, factors and issues associated with information transfer across the care continuum?
2) What are the patterns of information transferred from hospital care to nursing home care at the a) document level; b) care management level; c) clinical concept level; and d) patient outcomes level?
3) What are the interoperability issues and challenges across institutions at the a) document level, b) care management level; c) clinical concept level and d) with the LINC transfer form?
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Chapters 3, 4 and 5 present three research studies and their corresponding aims, methodologies, findings, and limitations. Study 1(reported in Chapter 3) explores the experiences with information transfer from the perspectives of four disciplines and across three healthcare sectors within the framework of Joint Cognitive Systems. Study 2 is divided into four parts and is described in Chapter 4.Information transfer is described at the document level, at the care management level, at the clinical concept level and at the patient outcome level. Chapter 5 builds on findings from study 3 by analyzing issues of semantic interoperability. Three informatics examples (documents, care management processes and clinical concepts) are presented. Chapter 6 discusses overall conclusions, contributions and future directions. Finally, the Appendices include a glossary of terms (Appendix A), the qualitative interview instrument (Appendix B), the LINC transfer form (Appendix C) and a local example (Appendix D) of an application of the LINC data elements. NURS 4005 – Topics in Clinical Nursing Essay Paper

Joint Cognitive Systems Theoretical Framework
Joint Cognitive Systems (JCS) are the collaborative undertakings of humans in complex environments and a component of Cognitive Systems Engineering and its focus is on “how humans can cope with and master the complexity of processes and technological environments” (3) (p. 1).JCS employs a “systems” view that emphasizes the interdependence of human cognition and the environmental context in which work occurs. Rather than viewing work as the separate interaction of disparate individuals exchanging information or a sterile act of information exchange through document transfer, work can be seen as a “joint cognitive system.” When the
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JCS is modeled and understood, joint functions can be facilitated and improved to achieve a desired outcome.
Successful performance of the JCS is based on appropriate control, mastery of variation and maintenance of orderliness. The components of a JCS include: goal orientation, enhancement of control and co-agency between participating parties. Goal orientation refers to the degree to which the goals of the different components of the system are aligned and for this research the goals of the system are patient safety and continuity of care across sectors. Cross-sector goal alignment is challenging given the varying contexts of each sector. For example, inpatient hospital goals encompass medical crisis stabilization, diagnostic investigation, disease interventions and the initiation of therapy. Long-term community care goals focus on medical recovery, function restoration, end of life support, care coordination and clinical care management processes. Aligning goals of care across the differing contexts requires understanding of the commonalities and differences between the sectors and examining the clinical continuity interfaces between them.
The second component of the JCS model is control. Being in control of a process is defined as knowing what has happened (the past) and having the information to anticipate what will happen (the future). Enhancing control requires sufficient knowledge and time, limited task loads, clear alternatives or procedures, sufficient resources and the ability to evaluate and plan. Sufficient knowledge includes understanding the deeper context as well as current dynamics. The lack of readiness or preparedness for unexpected events could result in delays, lack of resources and unavailable information. Additionally, once
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something has been identified, the question arises as to whether there is the capacity and resources available to manage it.
Sufficient time includes the ability to predict what is likely to happen as well as having time to handle unexpected events. Each determinant is used to frame findings from the qualitative interviews. Lack of performance with any of these determinants moves a process towards a state of “loss of control.” Managing these conditions enables the actor to maintain control and to minimize entropy, that is “maintaining a dynamic equilibrium…in an unpredictable environment.”(3)(p. 46). Loss of control in any system regardless of environment creates likely conditions for error.
Co-agency is the third component in understanding the JCS model. Actions from all participants and the environment are part of a larger stream of interdependencies and interrelatedness. Co-agency includes both the human-to-human interactions as well as the human-to-technology interactions. The human-to-human interaction is represented by the transfer of information between health professionals and the human-to-technology interactions are relevant to the development of an informatic solution. Understanding the interdependencies and interrelatedness is paramount to this dissertation thesis.
Health Information Technology Evaluation
Evaluation research includes the perspectives of stakeholders and is to be done in a manner that is useful. To be useful, this evaluation focuses on developing a system determined by users’ needs(4).The Health Information Technology (HIT) model (5) provides a framework for coordinating the research. NURS 4005 – Topics in Clinical Nursing Essay Paper
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aims of this dissertation. The HIT evaluation steps include: 1) understanding the problem; 2) understanding the causes, factors and issues; 3) understanding measurements and data requirements; 4) implementing a proposed solution, and measuring and evaluating the outcome. Findings from each of the research studies will fulfill the goals of the first three steps of the HIT model.
Each study builds on the lessons learned from the previous study. Research questions #1 and #2 explore health professionals’ experiences with information transfer in order to understand the problem from a user’s perspective. Research questions #3 and #4 look more closely at the causes, factors and issues associated with information transfer. Research questions #5 and #6 analyze the problem at the information element level to determine the basis for solution development. Recommendations for a proposed solution are discussed in the final chapter in anticipation of postdoctoral research.

The United States (U.S.) healthcare industry is comprised of several sectors which deliver care to patients. These sectors include ambulatory care, hospital care, and long-term care (posthospital care). Ambulatory care is comprised of doctor’s office visits, outpatient imaging and laboratory services, pre-hospitalization urgent care, and same day surgeries. Hospital care includes emergency room services, intensive care, medical-surgical services, oncology care, labor and delivery services, and other specialized services needing hospital-based round the clock monitoring and service delivery. Post-hospital care is defined as “health, personal care, and social services given over a sustained period to persons who have lost some capacity for self-care because of a chronic illness or condition” (8).
The posthospital care sector provides a broad array of health and social services including skilled nursing care, assisted living facilities, community residential care, home healthcare, assistive technologies, adult day care, respite care, personal care, as well as other supportive health and human resources. Social care of the elderly (known as elder care) is the provision of services such
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as assisted living, adult day care, respite care and personal home care services
intended to support a senior’s desire to “age in place.” Social care of the elderly
has traditionally fallen to family members and varies by culture and country but
falls mostly onto the shoulders of women (9). The integration of medical with
social care is not without its advocates and economic pressures (10, 11). Recent
policy statements are calling for interoperability across the delivery of health and
human services.
Social care in the U.S., is paid for by the individual, family, or if income
eligible, by county governmental sources. As medical expenditures have
increased and the political will to cut costs has intensified, social care as a cost
effective alternative is being explored. One such example is a Medicaid Waiver
for keeping disabled patients in their homes and paying for social care support in
order to keep patients out of skilled nursing facilities. Establishing care delivery
which bridges rehabilitation services, medical services, and social support care
for the disabled (12) in a more cost effective manner reflects the goals of the
independent living movement. European countries have progressed further
towards integrating medical and social care both within and outside the
healthcare sector (13, 14).
Approximately $1.2 trillion was spent in 1999 on healthcare in the U.S.
with projections reaching $2.6 trillion in 2010 (15). Health expenditures reached
$2.3 trillion in 2008 representing 16% of the Gross National Product (16) with
approximately 47% paid for through public funding. It has been projected that
governmental programs will be paying more than 50% of healthcare expenditures
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by 2012 (17). Thirty-one percent of the expenditures was spent for hospital care,
5.9% on skilled nursing care, 21% on physician and clinical care, and 10% on
prescription drugs (16).Health expenditures increase with age and disability.
Expectations on hospitals to lower their length of stays, to improve hospital
discharge timing, and to provide more cost efficient care is increasing pressure
on post-hospital services. NURS 4005 – Topics in Clinical Nursing Essay Paper
In a recent study of Medicare recipients, a comparison of costs between
those who were treated by primary care physicians versus those who were cared
for by hospitalists determined that hospital costs were lower in those cared for by
hospitalists. This study concluded that1) Medicare care costs 30 days post
discharge were significantly higher overall while hospital length of stay was
lower, 2) patients were less likely to be discharged home, and 3) patients were
more likely to have emergency room visits, readmissions and nursing facility
visits (18).
The Centers for Disease Control (CDC) predicts that by the year 2030,
seniors will demand even more long-term care, resulting in a demand for over 2
million beds in skilled nursing care (19). Governmental programs are the payer of
first choice for those 65 and older. As age increases and health status
decreases, healthcare expenditures increase. Additionally as the number of comorbidities
increases with age, so does the cost of care. Those individuals with
five or more conditions incur nearly five times ($25,132) the average costs
compared with those without chronic conditions ($5,186). Skilled care versus
community care also results in a $5 to $1 ratio (1). More frequent hospitalizations
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for shorter time periods (quicker and sicker) is the trend for aging adults in the
U.S.(20). Rates of hospitalization for those 65 and older have increased from
306 per 1000 Medicare enrolleesin1992 to 336 in 2007. Correspondingly,
hospital inpatient lengths of stay decreased from 8.4 in 1992 to 5.6 days in 2007.
There are significant pressures on the post-hospital sector to provide more
complicated care to sicker patients and at lower reimbursement rates. As of
1997, there were 17,000 skilled nursing facilities in the U.S. providing health and
residential care to over 1.6 million residents annually (21). Skilled nursing facility
stays have increased significantly from 28 per 1000 Medicare enrollees in 1992
to 81 in 2007. The number of physician visits and consultations have also
increased from 11,359 per 1000 Medicare enrollees in 1992 to 13,914 in 2005
while home healthcare visits dropped from 3,822 per 1000 in 1992 to 3,409 in
2007 (1).
As patients navigate healthcare transitions, the amount of information
needed is increasing. As patients move across the continuum of care, types and
formats of information will vary. Additionally, the need for information relevant to
both medical and social care will increase. Information variability, types, and
quantity tailored to the users’ needs will challenge effective information transfer.
Patient-Centered Medical Home
The patient-centered medical home (PCMH) is a conceptual healthcare
delivery model that originated from the pediatric healthcare system in the 1960s.
With the continuing fragmentation of the healthcare delivery systems across
sectors, disciplines, and care levels, the intent of PCMH was to provide an
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organizational mechanism for managing care. In 2007 a set of joint principles on
behalf of PCMH were developed by four national physician associations (22). NURS 4005 – Topics in Clinical Nursing Essay Paper
The goal of this national consensus is to coordinate care across a patient’s life
span emphasizing quality and safety, access to care, use of heath care
technologies and an appropriate incentive policy to achieve good patient
outcomes.
The use of information technology is identified as a vital infrastructure to
the care management of patients across a life span. The PCMH concept as
applied to geriatric populations will need to be adjusted in order to integrate the
social and medical care of the elderly. Issues of legal barriers as they relate to
psychiatric or substance abuse information, differing formats of information
including structured and coded data versus narrative text, and differing
terminologies all play a role in achieving information integration in medical and
social care environments.
Care Management
“Care Management” is a broad conceptual framework which
encompasses management of chronic diseases such as diabetes (23),
integration of the Chronic Care Model with clinical information systems (CIS)
(24), or a combination of medical management practices such as utilization
management, case management and disease management (25). Care
management is defined as: “a set of activities designed to assist patents and
their support system in managing medical conditions and related psychosocial
problems more effectively with the aims of improving patients’ functional health
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status, enhancing coordination of care, eliminating the duplication of services,
and reducing the need for expensive medical care” (26) (p. 1521).
Effective care management includes monitoring and feedback, completion
of the care plan, and communication and collaboration of all team members (24). NURS 4005 – Topics in Clinical Nursing Essay Paper
Recommended CIS components include clinical information access, accepted
standards of care with reminder systems, and communication infrastructures
between team members. Clinical information is but one component of the
information transfer process following a hospitalization. Clinical decision making
includes biomedical information necessary for the diagnostic and disease
resolution component of medicine as well as contextual information (27).
Care management information in the posthospital world requires both
biomedical and contextual information. Contextual information encompasses the
patient response, his/her environment, and changes over time. Nonmedical care
management includes issues of bowel and bladder management, pain
management, restoration of function, behavioral management, risk management
and end-of-life support. Information transfer which incorporates the contextual
information of these care management processes are critical to the patient, the
patient’s caregiver as well as any health and social care services involved in the
patient’s care. In a recent publication by the HMO Workgroup on Care
Management, a core set of data element are proposed as the necessary
information elements for exchange across the continuum of care. This report
included a Universal Health Plan and Home Health Authorization Form from the
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Commonwealth of Massachusetts as an example of a care transition communication tool.
The Problem of Transitions in Care
The prevalence of transitions in care occurs frequently in the senior population, occurring at least once in 40% of patients and as frequently as five or more times in 6.3% of seniors (28, 29). Murtaugh and Litke found that close to 18% of the elders in their cohort had one or more transitions in a 2 year period. Women were more likely than men to have at least one transition and the probability of transition increased with age (30). Approximately one third of the transitions were from hospitals to a post-acute care or long-term care setting. Many of the hospitalizations were avoidable, with five conditions (heart failure, pneumonia, kidney or urinary tract infection, volume depletion including dehydration, and angina) accounting for 75% of potential avoidable hospitalizations. In one British study, older adults averaged 35 hospital days in the last 2 years of their lives. Additionally, the older adults averaged 4.2 admissions in the 3 years prior to death (31). NURS 4005 – Topics in Clinical Nursing Essay Paper
Transitions Cause Adverse Events
and Poor Outcomes
Care transitions add significant complexities to assuring patient safety. The Joint Commission (TJC), the Institute of Medicine (IOM) and other accrediting bodies have recognized “transitions in care” as high-risk for the occurrence for adverse events. Recently TJC identified continuum of care issues and “hand offs” as high priority patient safety goals (32). The risk for adverse events or poor outcomes for seniors within hospital and discharge care
environments is well documented (30, 32-42) and transitions compound this risk.
An adverse event is defined as “an injury resulting from a medical
intervention, or in other words, not due to the underlying condition of the
patient”(43) ( p.4). Adverse events are comprised of multiple types including but
not limited to adverse drug reactions, medication errors, procedure related
events, and high risk medications. Adverse events can also contribute to the
reason for extended care either in hospitals or skilled nursing care.
Murtaugh and Litke conducted an assessment of the transitions through
post-acute and long-term care settings looking for patterns of use and outcomes
(44). Their study consisted of a two year longitudinal analysis of short-stay
hospitalizations and postacute care settings for those 65 and older. The
researchers determined that 22.4% of elderly patients transferred between
hospital and long-term care experienced subsequent health problems. Frequent
transitions from hospitals to home care results in high rates of emergency room
visits, preventable hospitalizations, and institutional placement following
discharge. They observed that: “A change in surroundings can be disorienting,
and new providers may lack timely and complete information about a person’s
medical history, prescription drug regimen, care preferences, and immediate care
needs” (30) (p. 228).
Cooper found that upwards of 15.7% of long-term care resident
hospitalizations were for adverse drug events (ADEs) (45). Boockvar and
colleagues recently studied the adverse events due to discontinuations in
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medications in patients experiencing care transitions and have identified 14
medications which were high risk for ADEs during the hospital-nursing home
transfer process (46). In 2003, Moore and colleagues specifically studied
medical errors related to discontinuity of care from inpatient to outpatient and its
impact on re-hospitalization(47). The researchers concluded that a significant
relationship existed between work-up errors and re-hospitalization within 3
months after the first outpatient primary care visit. This did not hold true,
however, for medication continuity errors and test follow-up errors. The authors
found a 42% prevalence of medication continuity errors, 12% work-up errors, and
8% test follow-up errors in the study population. The focus of the research was
on a broad adult population and not limited to the elderly. NURS 4005 – Topics in Clinical Nursing Essay Paper
Readmission rates to hospitals post discharge is a particularly important
indicator of quality of care and is currently a high priority for both the Veterans
Administration (VA) and CMS. Greater than 45% of patients discharged from the
hospital into the nursing home were readmitted from the nursing home back into
a hospital within 180 days after the first admission (38). The problem of
readmission has resulted in several strategies to reduce rates which include the
publication of readmission rates by the CMS (48); randomized trials of care
coordination (49); care management strategies for specific disease states (50,
51); and automated information exchange strategies (52-57).
Information Transfer Errors
Information transfer errors are a significant contribution to poor outcomes,
especially for seniors. Information error types can include: 1) omission or
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missing information;2) accuracy or correctness of the information; 3) precision or
specificity of the information;4) quantity or sufficiency of the information;5)