JAMIA Open, 0(0), 2018, 1–4 doi: 10.1093/jamiaopen/ooy003 Perspective Perspective 1 2 3 4 Deborah A. Ariosto , Ellen M. Harper , Marisa L. Wilson , Susan C. Hull , Eun-Shim 5 6,7 Nahm and Martha L. Sylvia Department of Patient Care Informatics, Vanderbilt University Medical Center, 3401 West End Avenue, Suite 100B, Nashville, 2 3 Tennessee 37203, USA, University of Kansas School of Nursing, Kansas City, Missouri, USA, University of Alabama at Birming- ham School of Nursing, Family, Community and Health Systems, Birmingham, Alabama, USA, Wellspring e-Health Consulting, Cincinnati, Ohio, USA, Department of Organizational Systems and Adult Health, University of Maryland School of Nursing, Balti- 6 7 more, Maryland, USA, Medical University of South Carolina - College of Nursing, Charleston, South Carolina, USA and Forest- Vue Healthcare Solutions, LLC, Charleston, South Carolina, USA Corresponding Author: Deborah Ariosto, PhD, MSN, RN-BC, Department of Patient Care Informatics, Vanderbilt University Medical Center, 3401 West End Avenue, Suite 100B, Nashville, Tennessee 37203, USA (firstname.lastname@example.org) Received 31 December 2017; Revised 16 February 2018; Accepted 27 February 2018 ABSTRACT The passage of the Affordable Care Act shifted the focus of health care from individual, patient speciﬁc, episodic care, towards health management of groups of people with an emphasis on primary and preventive care. Popu- lation health management assists to attain and maintain health while improving quality and lowering costs. The recent Catalyst for Change report creates an urgent call for harnessing the power of nurses—in our communi- ties, schools, businesses, homes and hospitals—to build capacity for population health. Informatics Nurse Spe- cialists are prepared to bridge roles across practice, research, education, and policy to support this call. Each year, the AMIA Nursing Informatics Working Group convenes an expert panel to reﬂect on the “hot topics” of interest to nursing. Not surprisingly, the 2017 topic was on the current state and challenges of population health. The following summary reﬂects the panel’s perspectives and recommendations for action. Key words: population health, nursing, informatics, NIWG respect they have earned, are well positioned to help shape and im- INTRODUCTION prove our nation’s health status and care infrastructure. The recent Population health is defined as the “health outcomes of a group of Catalyst for Change report (RWJF, 2017) creates an urgent call for individuals, including the distribution of such outcomes within the harnessing the power of nurses—in our communities, schools, busi- group.” The passage of the Affordable Care Act (ACA) shifted the nesses, homes, and hospitals—to build capacity for population focus of health care from individual, patient specific, episodic care, health. Informatics Nurse Specialists (INSs) are prepared and well towards health management of groups of people with an emphasis positioned to bridge roles across practice, research, education, and on primary and preventive care. Population health management policy to support this call. assists these groups to attain and maintain health with an increased Each year, the AMIA Nursing Informatics Working Group focus on shared accountability for the upstream environment, social, (NIWG) convenes an expert panel to focus on a “hot topic” of inter- and community factors that contribute to chronic disease and cost. est to nursing. Not surprisingly, the 2017 topic was on the current 2,3 With more than 3 million nurses in the United States in all sectors state and challenges of population health. The following summary of health care, nurses, because of their role, their education, and the reflects the panel’s perspectives and recommendations for action. V The Author(s) 2018. Published by Oxford University Press on behalf of the American Medical Informatics Association. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact email@example.com 1 Downloaded from https://academic.oup.com/jamiaopen/advance-article-abstract/doi/10.1093/jamiaopen/ooy003/4996946 by Ed 'DeepDyve' Gillespie user on 08 June 2018 2 JAMIA Open, 2018, Vol. 0, No. 0 linkages among community resources and services; developing pop- POPULATION HEALTH IN PRACTICE ulation-focused interventions; and evaluating the impact of the 9,10 Nursing practice is experiencing a paradigm shift from siloed health efforts. Next generation INSs must elevate their support of popu- information technology (HIT) designed to collect data at points-of- lation health efforts through: training and competency in data cap- care within organizations, to data collected along a patient’s health ture from disparate systems; validation and maintenance of data; trajectory, co-ordinated across where they live, work, and play. transformation and analysis of data; inclusion of social determinants However, the health care data collected today is largely designed, of health (SDOH) to address disparities; predictive and prescriptive maintained, and groomed for transactions between providers and analysis; risk stratification; and evaluation of education programs. payers and for managing point-of-care contacts with patients. The Accreditation and certification bodies as well as licensing boards information, communication, and technology infrastructure must: for the graduates of programs must ensure that all nursing students integrate data, creating robust analytic environments designed to from entry to practice to graduate level, including INS students are assemble and assess populations; identify and predict adverse provided learning opportunities to attain these competencies and outcomes; support programs and interventions to address inter- advance graduates who demonstrate these skills. As we move our professional work flow needs across all care venues; and measure emphasis from an acute care focus to population health model, it success. will require rethinking and a shift in focus for many nursing and Nurse leaders, nurses, and INSs are active and innovative in informatics programs. addressing the move from transactional systems to a robust data Recommendations for education: warehouse environment with an operational analytic infrastructure. Nursing education programs must prepare nurses to: Basic capabilities start with patient identity management (PIM) and Tackle the impact of SDOH on improving health and reducing patient/primary care provider attribution. Health Information health inequalities Exchanges (HIE) deal with complex PIM issues and where no HIE 5,6 • Consider community resources and provide learning opportuni- exists, PIM may not be possible. Successful population health ties to build engagement management requires primary care at its core; however; attribution Assess process and outcomes of community-based interventions is, at its best, a compromise among a complex set of methodological choices and, at its worst, fraught with errors in the data collection Nursing informatics graduate programs must prepare the INSs and workflow management process. to: While organizations accountable for care can demonstrate ana- lytic expertise using risk prediction and prescription models, these Manage data capture from disparate systems, beyond the elec- capabilities come at high cost when manually executed, lacking in tronic health record (EHR) scale and efficiency. These challenges make it near impossible for Understand data validation, transformation, and maintenance organizations to make informed, strategic decisions for managing Develop skills in data science and analytics to assess the health the health outcomes of patients, risk contracting, and gaining overall status and risk levels of populations competitive advantage. Evaluate the use of risk stratiﬁcation, as well as predictive and Recommendations for practice include: prescriptive analytics Assemble a workforce of INS’s prepared to manage the complex- ities of population health. POPULATION HEALTH IN RESEARCH Incorporate robust analytic tools that provide near real-time knowledge that bridge patient-centered care across the contin- Population health research investigates various determinants of uum. health, including health care services, individuals’ genetics and Test translational models for moving population health methods 11–13 health behaviors, physical and social environments. Funding and ﬁndings from research into practice. agencies have increased their support for population health research Inform HIT policymakers on practice challenges and barriers to in response to rapidly growing chronic illness populations and sky- achieving population health knowledge. 11–13 rocketing medical costs. For example, the strategic plan of the National Institute of Nursing Research (NINR) focuses on 4 scien- tific themes: symptom science, wellness, self-management of chronic POPULATION HEALTH IN EDUCATION conditions, and end-of-life and palliative care. The Agency for Population health is not a new concept for nursing education. As far Healthcare Research and Quality (AHRQ) supports research initia- back as Florence Nightingale, nurses have fostered a philosophy of tives to improve health care quality and make health care safer, care that focuses on the assessment and management of physical, bi- more accessible, affordable, and efficient. ological, social, psychological, and environmental influences on Health information technology (HIT) is a vital component that patients and populations. This population focus, however, has supports population health research. Some of examples HIT areas diminished over time with a push towards education and compe- includes: meaningful use of EHRs, HIE, interoperability, Big Data, tency development to prepare nurses for acute and critical care. To- and health care analytics. Many studies have demonstrated the im- day, there is a resurgence of interest in population health-based portant roles of HIT components in knowledge discovery and the nursing education, encouraging nurses to reclaim their history and development and implementation of new health interventions while take on key roles in a health care system responsive to the needs of engaging patients in their care. populations. Informatics Nurse Specialists including both researchers and Nurses must be competent in: near real-time assessment and practitioners, have an in-depth understanding of the associations identification of issues negatively affecting health and well-being; among the data, clinical practices and workflow, and track records discernment of patterns from data and populations; creating of using HIT in health-related research. They can also significantly Downloaded from https://academic.oup.com/jamiaopen/advance-article-abstract/doi/10.1093/jamiaopen/ooy003/4996946 by Ed 'DeepDyve' Gillespie user on 08 June 2018 JAMIA Open, 2018, Vol. 0, No. 0 3 contribute to the advancement of population health research by us- Monitor progress on the Ofﬁce of the National Coordinator’s ing robust HIT tools that improve quality of care and patient out- Shared Nationwide Interoperability Roadmap and the 21st Cen- comes and contributing to the development of efficient and tury Cures Act interoperable health care systems. Incentivize data transparency and bi-directional health data ex- Recommendations for research: change bridging institution-centric and person-centric approaches Advocate funding for population-focused nursing education and Enhance nurses’ knowledge about big data and population research, including support of the recommendations laid out in health knowledge the Institute of Medicine’s 2010 report, The Future of Nursing Develop new systems and tools that engage and empower and the RWJF 2017 Catalyst for Change: Harnessing the Power patients to improve quality of care, outcomes, and wellness activ- st of Nurses to Build Population Health for the 21 Century ities. Map data to standardized terminologies and protocols for inter- operability and outcome measurement CONCLUSION Contribute to the science of the associations among the data, clinical practices, and workﬂow. In conclusion, the AMIA NIWG Population Health panel acclaims Research health information systems that can contribute to re- that INSs are in integral roles to actively support capacity building ducing health disparities. for nurses to build population health in the 21st century, aligned with the Catalyst for Change white paper. Informatics Nurse Spe- cialists are critical partners to lead population health, care coordina- tion across settings of care, and inter-professional and community POPULATION HEALTH IN POLICY stakeholder collaboration. Informatics Nurse Specialists are well po- sitioned to influence practice, education, research, and health care The AMIA NIWG panel concluded with an update on public policy policy. Preparing nurses for robust roles to improve population and invited continued engagement in population health efforts sup- health will require clear articulation of nursing’s value proposition ported by AMIA and The Alliance for Nursing Informatics to impact health, cost, and outcomes for both the individual and (ANI). Multiple policy issues impact population health, with only populations; and active engagement in redesigning health data infra- a few highlighted during this event. For example, AMIA’s Policy In- structures to address current gaps. The AMIA NIWG panel of opin- vitational (API 2017) explored “redefining our picture of health,” ion leaders have provided background, identified recommendations, through the lens of how patients experience care, research, wellness, and perspectives to meet the demands of an evolving health care sys- and community—rather than those of provider institutions, payers, tem, including the application of new knowledge and skills. and health IT vendors. Policy recommendations focused on the de- velopment of an integrated, socio-technical ecosystem that enables an individual (the “n-of-1”) to improve the health of populations FUNDING (the “n-of-many”), and vice versa. Implementation of the 21st Century Cures Act and testimony to This research received no specific grant from any funding agency in the Senate Health, Education, Labor & Pensions committee the public, commercial, or not-for-profit sectors. reports progress on: interoperability; secure and trusted bi- directional exchange; Trusted Exchange Framework and Common Agreement (TEFCA); clinician burden; and information blocking. Conflict of interest statement. None declared. The new Centers for Medicare and Medicaid Services “Meaningful Measures” Initiative was launched to reduce regulatory burden and promote innovation in the transition value-based payment. CONTRIBUTORS The fields of public, population, and community health infor- matics offer overlapping perspectives to policy considerations, rec- All authors contributed to overall intellectual content and sections ognizing social, economic, and environmental risk factors as of writing. predictors of health disparities at the individual and community level. Nurse-led population health improvement efforts need to con- sider policies which address SDOH, health inequities, access to af- ACKNOWLEDGMENTS fordable care, and healthy behaviors. Although early in The authors thank our colleagues in the AMIA Nursing Informatics Working development, infrastructure is needed across nursing practice, edu- Group (NIWG) who helped inspire and shape this work: Juliana Brixey, Sa- cation, and research settings to develop and test population-based rah Collins, Kandace Kelly, Laura Heerman-Langford, Judy Murphy, Marisa care and payment accountability models. Alternate Payment Models Wilson, and Ron Piscotty. (APM) and payment reforms that seek to deliver better care at lower cost achieved 29% in 2016, with expected progress toward the goal REFERENCES of 50% by 2018. Policy will continue to evolve to find ways to sig- nificantly improve affordability and value for both consumers and 1. Kindig D, Stoddart G. What is population health? Am J Public Health the health care system. 2003; 93 (3): 380–3. Policy recommendations: 2. U.S. Department of Labor, Bureau of Labor Statistics. Occupational Out- look: Registered Nurses. https://www.bls.gov/ooh/healthcare/registered- Promote health policy that encourages person-centered, inte- nurses.htm#tab-1. Accessed December 28, 2017. grated health care, research, preventive care, and wellness in the 3. The Registered Nurse Population. Findings from the 2008 National Sam- context of a community ecosystem ple Survey of Registered Nurses. 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JAMIA Open – Oxford University Press
Published: May 16, 2018
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