Industry’s Voice in Health Policy (Springer Series on Industry and Health Care)

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Only in the last decade have leading hospitals and integrated institutions begun to leverage their information systems by adapting and deploying systems-engineering tools and techniques to analyze, control, and optimize aspects of their operations. As NHII and interoperability and data-interchange standards in particular advances, more and more health care organizations would be able integrate their clinical, administrative, and financial information systems internally, as well as link their systems with those of insurers, vendors, regulatory bodies, and other elements of the extended health care delivery enterprise.

The NHII would lead to significant improvements on the environmental level of the health care delivery system. With advances in interoperability standards and other tools and technologies, the NHII would enable connectivity both within and across levels of the delivery system. For example, the NHII could accelerate the flow of health care quality data from providers to the Center for Medicare and Medicaid Services and private insurers, data on evidence-based-medicine trials to the Agency for Healthcare Research and Quality, data on infectious diseases and bio-hazards to the Centers for Disease Control, and data on post-introduction adverse drug events to the Food and Drug Administration FDA.

NHII could also accelerate the interfacing of the expanding genomic and phenotypic clinical knowledge databases. Very serious privacy concerns must be addressed, as well as training issues at all levels of the health care system. Ensuring reliability will require a very large-scale distributed computing system. Clearly, it will take a national effort to develop an infrastructure capable of connecting, integrating, and supporting diverse information systems and applications at facilities nationwide. Although individual functions might still vary from facility to facility, the operating framework used for storing records and the protocols by which information is passed between locations and systems must be standardized.

At every level of the health care system, the focus should be on the patient, and the goal should be to ensure effective interactions between the patient and doctor or health care delivery team. Developing such a system in the coming decade is not an option. It is an absolute necessity for achieving the IOM vision of a patient-centered, high quality health care system. The remainder of this chapter is divided into two sections. The second focuses on emerging technologies based on wireless communications and microelectronic systems that have the potential to radically change the structure of the health care delivery system and advance the patient-centeredness and quality performance of the system.

Above all, the implementation of NHII must be part of a comprehensive transformation of health care delivery. If health care data are standardized, they become understandable to all users. In the area of data-interchange formats, in which engineering has played an important role, a number of mature standards, recently endorsed by the secretary of DHHS, address some of the required domains:.

To accelerate the development and adoption of health care data standards, IOM recommended a significant increase in the technical and material support provided by the federal government to ongoing public-private partnerships in this area IOM, To ensure that the emerging NHII can support next-generation clinical information systems and applications, it is critical that research on advanced interface standards and protocols continue apace and that standards-related issues concerning the protection of data integrity, controlled access to data, data security, and the integration of large-scale wireless communications be addressed early on.

There is also a pressing need for low-cost tools for standardizing new and legacy digital data without disrupting the clinical work flow PITAC, Other industries that had to accommodate conflicting standards e. Stable funding for research in all of these areas will be essential. These challenges are neither new nor unique to health care.

Indeed, engineers, computer scientists, and researchers and practitioners in other disciplines have been working on them for more than a decade to meet the needs of financial services, telecommunications, and national defense. Clinical information systems provide a mechanism for sharing data collected from various sources e. Data become available to clinical information systems via direct entry at the point of care, off-line entry through abstraction from other media, such as handwritten notes, and data collected by other systems, such as laboratory systems or monitoring devices.

The data can take many forms—including free text, coded data, speech, document imaging, clinical imaging e. In the following section, four core components of clinical information systems are described: 1 EHRs; 2 CPOE systems; 3 digital sources of medical evidence; and 4 decision-support tools.

Attention has been focused in the creation of EHRs since the s, and in , IOM set forth a vision and issued a call for nationwide implementation of computer-based patient records that would be paperless and instantly available throughout the health care system in forms readily understandable to physicians and other providers at point of care and specialists, perhaps in a different location IOM, However, the rate of progress toward realizing this vision has been glacial. Only a fraction of hospitals have implemented comprehensive EHR systems, although many have made progress in certain areas, such as computerized reporting of laboratory results Brailer, Rates of adoption of EHR systems are higher in ambulatory care settings—probably about 5 to 10 percent of physician's offices—but these systems vary greatly in content and functionality IOM, Although some cases of failed EHR systems have been documented, many more examples show cost savings and quality improvements yielded by EHR systems Clayton in this volume; Littlejohns et al.

EHRs have been instituted in health care settings in the public and private sectors, and a few communities and systems have implemented secure systems for the exchange of data among providers, suppliers, patients, and other authorized users. The Veterans Health Information Systems and Technology Architecture VistA supports a continuum of care, from intensive care units and other inpatient areas, to outpatient care settings, more Automation of Clinical Practice at Mayo Clinic. The Automation of the Clinical Practice ACP Project at Mayo Clinic in Jacksonville, Florida, undertaken in , includes computer-based patient records and mechanisms for automated charging and order more All of these are exceptions to the rule, however.

In most hospitals, orders for medications, laboratory tests, and other services are still written on paper, and many hospitals do not even have the capability of delivering laboratory results and other test results in automated form. The same situation prevails in most small practice settings, where little if any progress has been made toward creating electronic records IOM, A patient's EHR must also include long-term data and information about the patient's daily life.

This information will be useful not only in the planning and delivery of progressive care, but will also provide evidence for assessing different clinical interventions. Patient-centered health care delivery in the broadest sense must also focus on what the patient really wants from the entire health care community—the best physical and mental function in daily living possible within the constraints of the patient's physical condition.

NHII is a first step toward obtaining data and information necessary for coordinating care in the clinic and hospital. Although databases are effectively managed in select locations, efforts must continue to develop secure, dispersed, multiagent databases that can serve both providers and patients effectively and efficiently. Using CPOE systems for entering orders for tests, drugs, and other procedures has led to reductions in transcription errors, which have led to demonstrable improvements in patient safety.

When CPOE systems are integrated with other core clinical applications, their impact on patient safety is even greater. One component of a CPOE system is computerized decision support. CPOE systems that include data on patient diagnoses, current medications, and history of drug interactions or allergies can significantly reduce prescribing errors Bates et al. CPOE systems also improve the quality of care by increasing clinician compliance with standard guidelines of care, thereby reducing variations in care. For example, a study by Shojania et al. Despite many documented benefits of CPOE systems—improvements in the quality of patient care, decreases in medication errors, and decreases in overall costs—they have not been widely implemented.

In the only study that has rigorously examined the adoption of CPOE by hospitals in the United States, less than 2 percent of hospitals were found to have CPOE systems completely or partially available and to require that physicians use them Ash et al. Nevertheless, a few success stories have been well documented, notably the Brigham and Women's Hospital in Boston, Massachusetts, and the Regenstrief Medical Record Systems.

One of the most frequent causes of errors and failures to carry out planned treatments has been a lack of integration of orders and results. Branching logic based on results can be used to verify that each step in the treatment is accomplished. The system described would not only reduce errors, such as missed handoffs and unnecessary waiting times, it would also interact with enterprise systems for supply-chain management and capacity planning.

Another key component of the health information infrastructure, digital sources of evidence—including bibliographic references, evidence-based clinical guidelines, and comparative databases—is essential for evidence-based practice. Currently, most digital sources of evidence are stand-alone systems that are not integrated into clinical information systems. The challenge for practitioners is to use these sources of evidence in combination with their experience and expertise to make clinical decisions Bakken, However, as the medical-evidence base continues to expand exponentially and more and more clinicians accept the validity of best-demonstrated practices for diagnosis and treatment, there is mounting interest in integrating rapidly expanding digital sources of evidence including genomic and phenotypic [clinical] data into decision-support tools that can be fully integrated into care processes.

At the same time, fueled by the rapidly expanding medical-evidence base, there is a growing awareness among care professionals of the need for customization of best demonstrated practice rules for almost all patients. Another emerging area is translational medicine, the use of the results of the genome project to predict and customize treatment. The standardization of health care data, the development of digital sources of medical evidence and knowledge, and the creation of EHRs will all facilitate the use of decision-support tools, which are key components of clinical information systems.

Decision-support tools that are fully integrated into the care process will enable both care providers and patients to access medical knowledge relevant to the patient's care. They may, for example, identify negative interactions between a drug the patient is already taking and an additional drug that might be prescribed. A necessary platform for decision-support tools is the clinical-data repository, a database that collects and stores patient care information from diverse sources. Clinical-event monitors, which work with clinical-data repositories in support of real-time delivery of care, are usually triggered by clinical events e.

The event monitor combines clinical rules, the triggering event, and information present in the repository to generate alerts, reminders, and other messages important to the delivery of care. For more than 20 years, departmental systems e. But there is no health care process-management system in which all information concerning a patient's history is gathered in one place in standardized text where the appropriateness and strategy of orders for patient care can be checked.

Equally important, a health care process-management system would ensure that the result of each step in treatment was entered into the record and communicated to all relevant parties. The collection of data, the consideration of the decision support offered, followed by the ordering and carrying out of the diagnostic and or treatment plan is an iterative process. As results are entered, the next steps in the care process are instituted.

This area of research, which combines expertise in cognitive and software engineering, behavioral science and cooperative work, and computer and cognitive sciences, focuses on the development of techniques and concepts that facilitate interactions between people and computers Winograd and Woods, ; Woods, Health care computer systems have been administrator-centered or billing-centered systems rather than provider-centered or patient-centered systems.

However, software and telecommunications capabilities are being expanded, although slowly, to achieve continuity of care without losing sight of economic and other pressures Box Designing Computer Systems for Health Care. Software-intensive systems are the norm for all modern high-performance systems. But simply extending the reach of computer technology will not guarantee high performance in a complex setting like health care.

Areas for research include hardware interfaces, as well as sociological and psychological aspects of the use of computerized systems by physicians and other health care workers. Because software-intensive systems perform valuable functions, the consequences of failure are generally serious. For example, developers may assemble modules, each apparently dependable, but, when they are integrated, problems and weaknesses emerge. Usability failures are also an issue. In some cases, the initial software-intensive system may be dependable, but changes in use over time may lead to changes in the software that lead, in turn, to unnoticed side effects that can introduce weaknesses in the system.

Another type of failure can occur when cost overruns in the development process prevent the project from ever reaching the commercialization stage. In some instances, noncritical software that interacts directly or indirectly with critical functions introduces failures and weaknesses NRC, ; Rae et al. As these and other forms of software-system failure show, investments in clinical information systems must be complemented by investments in research on software dependability.

Opportunities for improvement and research include: better human-computer system interfaces; software to improve the interoperability of systems from various vendors; systems and accompanying business models for spreading costs among multiple users; and software dependability in the context of health care delivery. The delivery of quality care, especially in a highly fragmented delivery system, requires that both clinicians and patients have access to complete patient information and decision-support tools and that communications among clinicians and between clinicians and patients are effective.

The Internet and the World Wide Web have provided patients with unprecedented access to health information and made possible more continuous, asynchronous communication between patients and their care providers.

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Meeting the current and emerging communications needs of health care will require a combination of wireless and fixed-line networks. Because of financial constraints, creating different systems for different settings will not be feasible, however. Vendors of hardware and software components of the system will need system transparency, which can only be achieved once standards have been adopted. The challenge will be to generate a robust, but flexible system that can be duplicated in many different circumstances without requiring major modifications; the system must be based on technology that can be rapidly diffused and at low cost.

Five technical factors are important in planning for the implementation of communication networks: 1 bandwidth requirements and availability; 2 latency in transmission throughout the network; 3 continuous availability of the network; 4 confidentiality and security of data; and 5 ubiquity of access to the network NRC, Enabling patients to communicate effectively with health care providers without face-to-face meetings will require many improvements in electronic communications.

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The Internet and World Wide Web provide a framework for communication links, and a few large provider organizations have demonstrated the potential of these technologies. But making them accessible to large populations in a health care community will require experimentation and research Perlin et al.

Other issues that must be addressed include ensuring the confidentiality and security of transmissions and health care data. In the preceding discussion of major components of the NHII, a number of technical impediments to implementation of these systems were identified e.

Educational barriers are discussed in Chapter 5. At the present time, several factors severely undercut the returns health care providers might expect to capture on their investments. This lack of connectivity, in turn, has severely limited improvements in efficiency and quality.

Another major barrier is the prevailing reimbursement arrangement for health care services, which does not reimburse care providers differentially on the basis of quality of care. Contrast this with incentives for provider organizations to invest in new diagnostic equipment, such as MRI machines, which begin to generate revenue as soon as they are up and running.

Nevertheless, the barriers persist. The committee believes that as conceptual and material progress is made in measuring quality and productivity in health care, significant returns on investment at all levels of the health care system will be demonstrated NRC, ; Triplett, , In addition, many clinicians have a very limited understanding of the potential uses, impacts, and benefits of advanced information systems for the production and delivery of care.

Thus, the benefits of change are not immediately visible, but the costs are. Not surprisingly, then, there has been significant resistance to innovation and changes in work processes and the division of labor among health care professionals. The cultural and organizational factors that have contributed to a rigid division of labor in many areas of health care often impede the introduction and exploitation of tools, technologies, and other innovations that could improve quality and productivity in health care see Bohmer, this volume; Christenson et al.

Finding A critical step toward realizing the National Health Information Infrastructure will be the development and widespread adoption of network standards for health care data and software. Research must focus on standards-related issues concerning the integrity of data, controlled access to data, data security, and the integration of large-scale wireless communications. There is also a pressing need for low-cost tools for standardizing new and legacy digital data without disrupting clinical work flows.

Progress in systems interoperability and data standards is likely to improve remote access to self-care educational tools, patient health records, and health care provider and insurer services scheduling, billing, etc. Cross-sector learning and research on information and communications standards among federal agencies, health care insurers, and health care providers represents a potentially vast source of knowledge and advancement.

The Internet and World Wide Web provide a framework for communication links, but making them accessible to large populations in a health care community to promote communication between patients and health care providers will require experimentation and research, particularly to ensure the confidentiality and security of transmissions of health care data. However, many barriers will have to be overcome before it can be implemented. Recommendation The committee endorses the recommendations made by the Institute of Medicine Committee on Data Standards for Patient Safety, which called for continued development of health care data standards and a significant increase in the technical and material support provided by the federal government for public-private partnerships in this area.

The committee endorses the recommendations of the President's Information Technology Advisory Council that call for: 1 application of lessons learned from advances in other fields e. The committee applauds the U. Department of Health and Human Services year plan for the creation of the National Health Information Infrastructure and the high priority given to the creation of standards for the complex network necessary for communications among highly dispersed providers and patients.

Special attention should be given to issues related to large-scale integration. Funding for research in all of these areas will be critical to moving forward. These initiatives include efforts to reimburse providers for care episodes or other bundling techniques e. The emerging technologies in wireless communications and microelectronic systems described in this section have the potential to advance the patient-centeredness and quality performance of the health care delivery system and to change the structure of care delivery in the process.

Microelectronics promises to be a powerful tool for meeting quality and productivity challenges in health care delivery, provided that resources can be marshaled in a rational way. The microelectronics revolution began in the s with the advent of integrated circuits and has since revolutionized data processing, communications, and control. The number of transistors that can be integrated on a silicon chip the size of a finger-nail has increased from about 2, on the first micro-processor to about ,, today; the speed of these chips has increased more than a thousand-fold.

At the same time, the number of bits of memory on a chip has increased by a factor of more than a million, and costs have decreased just as precipitously. Low-cost disk storage is now approaching a density of more than 40 gigabytes per square inch. In short, the processing and storage of data, the creation of information and knowledge based on those data, and the efficacy of decisions have improved exponentially.

In the coming decades, as the number of nurses and physicians decreases, monitoring and diagnostics will have to improve dramatically. Efforts to develop sensors using integrated circuit technology has resulted in microelectro-mechanical systems, which can be combined with microelectronics and wireless interfaces to create wireless integrated microsystems WIMS for use in health care delivery.

In the near future, WIMS will be merged with sensors with embedded microcomputers and minute wireless transceivers a cubic centimeter in size or smaller that operate at power levels of less than 1 milliwatt, consistent with long-term operation fueled by batteries maintained by energy scavenged from the environment Wise, , These new devices could potentially provide continuous monitoring of critical functions, thereby turning every hospital room into an intensive care facility.

WIMS devices small enough to be worn comfortably and unobtrusively could communicate with a bedside receiver that communicates, in turn, with monitoring stations and a larger health care facility. The system just described would go a long way toward meeting the objective of the Leapfrog Group of having an ICU physician present in every hospital at all times Leapfrog Group, WIMS systems are still scarce, and their performance is limited, but they are emerging. Blood oximeters, heart rate monitors, and temperature sensors could all be components of WIMS; swallowable capsules for viewing the digestive tract are already in use Fireman, ; Pelletier, ; Pennazio et al.

Wearable devices that monitor blood pressure hypertension , breathing patterns sleep apnea , and other variables will certainly be available in the near future see Budinger in this volume. The major challenges to their use are interfaces with the body itself. Swallowable capsules for all kinds of internal viewing and measurements could significantly improve diagnoses of a variety of conditions and thus could improve the quality of health care. DNA analysis chips will bring advances in genetics into the hospital, and even the local doctor's office Burns et al.

However, the impact of these developments on costs will be indirect. In addition, privacy issues must be addressed before they can be widely used. WIMS for health care are expected to be technically feasible in the coming decade, but to reduce costs, they must be part of a complete system. Bedside receivers and wearable monitors might be technical triumphs, but they could also lead to economic disaster for the company that produces them unless they fit into a larger system.

A similar situation has existed for at least 20 years in the process-control industry. Although prototypes of sophisticated sensors have been produced, they are still not widely used because controllers that can exploit their features have not yet been developed. In the transportation industry, the entire control system of the automobile engine had to be redesigned to take advantage of microprocessors and electronic sensing. Comparable redesigning of the health care system will be necessary at every level to take advantage of WIMS. The application of WIMS technologies in the hospital promises to significantly improve the quality and patient-centeredness of inpatient and ambulatory care.

The potential impact of WIMS on home care and the quality of life for senior citizens and chronically ill patients is even greater Whitten et al. Moving WIMS technology into the home is being seriously considered by makers of home communications equipment. With properly integrated home-based WIMS systems, patients could be monitored on a continuous basis and care professionals alerted automatically when events merit attention. Continuous or at least more frequent home monitoring of the health status of elderly and chronic care patients could notify clinicians of the need for timely therapeutic interventions that could avoid hospitalizations and shorten hospital stays, thus reducing the costs associated with the care of the patient over time see Budinger in this volume.

Moreover, home-based WIMS could facilitate safe home environments and the activities of daily living that are so important for the health of the elderly and chronically ill. The main technical problems in the development of WIMS are largely related to reliable interfaces between sensors and the body and ensuring that sensors are capable of differentiating between instrumentation artifacts and physiological events.

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WIMS may also have therapeutic uses. The development of wireless implantable microsystems has been the subject of research for 40 years or more, but, to date, few devices have been developed besides pacemakers. Pacemakers have become increasingly sophisticated electronically, but their interfaces with the body are primarily via electrodes.

Nevertheless, they have set the stage for the emergence of new devices in the coming decade. For example, cardiovascular catheters have been used for diagnosing cardiac conditions for many years, and pressure sensors small enough to be mounted directly on catheters have existed for some time Chau and Wise, ; Ji et al. In fact, catheter-based electronics for improving diagnostic capabilities are long overdue. Another example is stents, which are widely used for treating coronary occlusions and now have chemical coatings to prevent re-stenosis.

In the near future, stents may also be used as platforms for instrumentation, such as wireless sensors for monitoring blood pressure or blood flow that could be activated by a radio frequency wand positioned over the chest. Significant challenges remain involving range, accuracy, and size, but such systems may be feasible soon Collins, ; DeHennis and Wise, ; Stangel et al. Wireless sensors could also be used in intracranial, intraocular glaucoma , and intra-arterial applications.

Miniature biocompatible packages that can exist for many decades in the body are also being developed for long-term use in chronic conditions Ziaie et al. WIMS could also have a dramatic impact on the treatment of conditions involving the central nervous system. More than 90, cochlear implants are in use worldwide today, enabling many profoundly deaf and severely hearing-impaired individuals to function normally in a hearing world House and Berliner, ; Spelman, Even though their performance is still limited and there is some opposition to them in the deaf community, these devices may render most kinds of deafness treatable disorders in the next two decades.

In the United States alone, more than 2 million people are profoundly deaf, and 20 million are severely hearing impaired. There is considerable interest in treating other neurological disorders using WIMS. Visual prostheses have recently received considerable attention but are still at a very early stage of development Lui, The same is true of prostheses for severe epilepsy and paralysis. For example, an implanted electrode array might detect the onset of an epileptic seizure and provide local electrical stimulation or drug delivery to prevent the spread of the seizure.

Functional neuromuscular stimulation FNS is being used to help quadriplegics stand and even walk, and the use of dense electrode arrays to capture control signals directly from the motor cortex has recently enabled primates to control robotic arms Chapin et al. Combining FNS with cortical control could lead to at least limited closed-loop activation of paralyzed limbs Wise et al. And the use of deep brain stimulation in the subthalamic nucleus to eliminate the manifestations of Parkinson's disease has yielded impressive results and is now approved for human use Limousin et al. Although all of these devices are still at a relatively early stage of development Table , some are gaining acceptance now, and many could be in wide use in the next 20 years, which could substantially impact the quality of health care and the costs of rehabilitation.

Microsystems implemented as wearable and implantable devices connected to clinical information systems through wireless communications could provide diagnostic data and deliver therapeutic agents for the treatment of a variety of chronic conditions. In fact, WIMS could potentially restructure care delivery in the hospital. There is no question that microdevices can and will significantly improve the daily lives of many people. The barriers to the realization of this vision are significant, however.

Industry’s Voice in Health Policy | Richard H. Egdahl | Springer

For patients to take on greater control and responsibility for their own care, they will have to be educated or able to educate themselves. In addition, patients must continue to have access to trusted sources of advice and counsel. Changes in the division of labor between patients and care teams implicit in the self-care model will also have a profound impact on the roles, work processes, and division of labor among members of the patient's care team.

Resistance to change, especially if roles, authority, and jobs are threatened, may arise among care professionals and organizations that deliver services both within and outside of hospital setting e. Current reimbursement systems may also present barriers if care providers are not reimbursed for e-visits, patient modules, remote care services, and so on.

The implications of the self-care model for the health care industry are profoundly disruptive. The move toward self-care could be considered threatening to businesses e. The current complex mix of professional licensing, regulation, liability law, and other constructs established to ensure the health care safety and reliability also pose barriers. The current hierarchical culture and rigid division of labor in the health care profession could make the reallocation of responsibilities and changes in the roles of care team members extremely contentious.

Wireless integrated microsystems could have an enormous beneficial impact on the quality and cost of health care, especially home health care. Microsystems implemented as wearable and implantable devices connected to clinical information systems through wireless communications could provide diagnostic data and deliver therapeutic agents for the treatment of a variety of chronic conditions, thereby improving the quality of life for senior citizens and chronically ill patients.

The use of wireless integrated microsystems technologies in hospitals and clinics promises significant improvements in the quality and patient-centeredness of inpatient and ambulatory care. Microdevices that could provide continuous monitoring of critical functions could turn every hospital room into an intensive care facility. Wireless integrated microsystems for health care are expected to be technically feasible in the coming decade, but to reduce costs, they must be part of a complete system. Significant cultural and organizational barriers will have to be overcome for the full benefit of WIMS to be realized.

Public- and private-sector support for research on the development of very small, low-power, biocompatible devices will be essential for improving health care delivery. Engineering research should be focused on defining an architecture capable of incorporating data from microsystems into the wider health care network and developing interface standards and protocols to implement this larger network. Microsystems research should be focused on the following areas:. Timely, accurate information is critical to the efficient operation of large dispersed systems. Although the health care system has been slow to recognize this, efforts are now under way to rectify the situation.

But it is imperative that research, development, demonstration, and training be expanded and accelerated. Putting together a system that can make use of information microtechnology, nanotechnology, and biotechnology and ensure that applications are widely available and affordable will require coordination at the national level among device manufacturers, clinicians, and hospital systems. However, unless the approach is coordinated, the impact of new technologies could improve health care for a few but increase costs for everyone else and move the overall system even farther away from providing patient-centered care.

Turn recording back on. National Center for Biotechnology Information , U. Hear exclusive interviews, panel discussions, and news segments covering topics in nursing like innovation, cultural competency, and nursing today. Subscribe to the YouTube channel and check out the book at www. Inspiring compassionate professional nursing in the criminal justice system. This lecture series features highly-rated talks by outstanding speakers who presented at University of Washington events. Earn contact hours as you listen to experts discuss healthcare trends, legal and professional issues, self-care, patient safety and best practice—with a focus on evidence-based nursing.

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    Elizabeth shares informati We routinely misinterpret patients' wishes around medical interventions. Emergency physician Dr. Fred Mirarchi may have a way to fix that. Rachel is a serial entrepreneur and the founder of Online Coach University, a business mentorship platform that teaches hundreds of online coaches how to build six figure businesses through social media. Rachel, herself, has grown two 7-figure businesses without spending a dime on advertising. Fraud schemes have migrated in recent years, exposing inherent vulnerabilities in how most organizations authenticate users.

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    Diego Szteinhendler of Mastercard outlines new strategies and tools for evolving authentication practices beyond solely payments security. Many people use toothbrushes to remove the plaque that builds up on the surface of teeth, but what about getting to the plaque between the teeth? Should we be using dental floss or interdental brushes to help?

    An effective third-party risk management program starts with asking the right questions, says Brad Keller, chief strategy officer and senior vice president at the Santa Fe Group, a strategic advisory company, who spells out key issues to address. In Cuba, the neighborhood is not only the center of public life, it is the center of the health care system as well. Primary care is delivered at a consoltorio, a community-based clinic staffed by doctors, nurses, and even statisticians.

    When Commonwealth Fund staff traveled to Cuba recently to learn about its primary care system, they discover Get ready for a double shot of nurse podcaster awesome sauce! Nurse Keith is a holistic career coach for nurses, as well as a professional podcaster, published author, well-known She was part of a group that recently toured the Customs and Border Patrol Detention Center in Clint, Texas where hundreds of children who have been separated from their families are being held.

    In this episode The latest edition of the ISMG Security Report discusses Cloudflare's harsh criticism of Verizon over an internet outage it labeled as a "small heart attack. She will also make a very exciting announcement that will show how much this small, all volunteer, non-profit is reaching out to help FTD families. This is the organizatio The Senate Finance Committee delayed action on a potential drug pricing legislative package until after the July 4 recess June July 8.

    Let's send them back to their home states with But we all know some of the real reasons…. We chat with Aleksey on some of these unspoken truths. When listener Caven wrote in asking why CCOM graduates don't include hardly any specialists and why they all seemed to be going into primary care, Dave was puzzled. While it's true that a state school like ours, serving a rural part of the country, emphasizes primary care, he knew that not 'everyone' goes into primary care. On further questioni