The federal healthcare system is one of the largest integrated health delivery entities in the world and is a dynamic “systems of systems” architectural model. The system has a long history of innovation, adoption, research, development, implementation, and evaluation in technological advances. Over six decades, federal nursing informaticists have been at the forefront of various professional development initiatives and computer applications (American Medical Informatics Association, 2019). The federal healthcare system supports the growth and advancement of professional nursing roles, standards, and technologies. The discipline of nursing informatics within the federal sector is the origin of numerous innovations and milestones cutting across diverse public healthcare agencies. Collaboration and shared communication among all healthcare professionals are vital to providing the delivery of quality, effective care across the spectrum of nursing care while ensuring the use of nursing processes in the area of informatics. A brief description of some of the federal healthcare entities is described next. The Department of Defense (DoD) Military Health System (MHS) provides global healthcare services to over 9.4 million beneficiaries to include active duty service members, National Guard, and Reserve members, retirees, and their families (Defense Health Agency, 2017). The MHS is composed of over 205,000 Air Force, Army, and Navy healthcare professionals (Flanders, 2019). The MHS manages individual health benefits and costs through the TRICARE program, similar to private insurance companies such as Blue Cross/Blue Shield. MHS healthcare professionals provide care and treatments in a variety of geographic and technical environments, including but not limited to aeromedical evacuations, aboard Navy vessels, in traditional “brick and mortar” inpatient hospitals and medical centers, and in field hospitals within the theater of combat operations. The primary mission of the Department of Veteran’s Affairs (VA) is to maximize the veteran’s activities of daily living throughout the continuum of care. The VA is comprised of an integrated healthcare system reaching across all 50 states and several U.S. territories, with an eligible population of 16 million veterans of which 8.9 million are enrolled at VA facilities (United States Department of Veterans Affairs, 2016). The Department of Health and Human Services (DHHS) is charged with protecting the health of the American public and providing essential human services, such as Medicare and Medicaid. Within DHHS, the U.S. Public Health Service (USPHS) has programs dedicated to disease prevention and control; biomedical research; food and drug protection as well as medical device safety; mental health and substance abuse management; healthcare system and resource enhancements; and medical care for underserved and special needs populations (Commissioned Corps of the U.S. Public Health Service, 2019). The USPHS Commissioned Corps of uniformed public health professionals respond to public health needs and to advancing the science of public health practices. The Indian Health Service (IHS) is another agency within the DHHS. The IHS is the principal federal healthcare provider responsible for providing a comprehensive health service delivery system for approximately 2.6 million American Indians and Alaska Natives who belong to 574 federally recognized tribes (Department of Health and Human Services, 2020). The Office of the National Coordinator (ONC) has the distinct role, under DHHS, to oversee national e-Health programs including the adoption and implementation of electronic health records (EHRs). In particular, the Agency for Healthcare Research & Quality (AHRQ), the National Institutes of Health (NIH), and the National Library of Medicine (NLM) provide research funding supporting the development of clinical informatics and emerging healthcare technologies (United States Public Health Service Nursing, n.d.). An enormous number of innovations and computer programming technologies receive federal grant investments from these agencies. The United States Coast Guard is a military service within the Department of Homeland Security (DHS) consisting of approximately 50,000 active duty (United States Government Accountability Office, 2018) reserve and civilian employees. They have a number of clinics that provide outpatient primary care, but maintain no inpatient facilities, sending their military members into the civilian community through TRICARE or to DoD facilities (Tricare.mil, n.d.). The Federal government plays a critical legislative role in the emergence of healthcare informatics in both the public and private sectors. The primary goal is to share healthcare information. Healthcare reform laws and regulations enacted by Congress expanded the opportunities for nurses to work outside of clinical practice, and to engage in emerging roles like information management and technology. The roles of nursing informaticists were incorporated into healthcare policy, research, consultation, academia, and computer applications. The federal sector presents unique informatics nurse specialist (INS) opportunities largely due to the size of the organizations and the unique missions. Regardless of role or title, nurses with informatics education and training utilize their skills in every healthcare setting, to include military deployments within a combat zone. However, standardization and formalization of nursing informatics roles and responsibilities are at various stages of maturity within each of the federal agencies (American Nurses Association, 2015). Today, federal informatics nurses serve in roles ranging from direct patient care, where informatics is an additional duty, to that of the expert INS, serving in enterprise-level leadership. Significant efforts have been made to formalize and standardize the role of the INS within the federal agencies. Regardless of the maturity level of the organization with regard to INS role development, INSs are actively engaged throughout all levels of the organization. The development and implementation of federal nursing informatics competencies has followed an organizational and facility specific path with the spectrum of career broadening opportunities for federal INSs ranging from data analysis and business intelligence to that of managing the acquisitions and programs for new “cradle to grave” clinical systems. The federal healthcare space consists of an array of career paths and workforce maturity for informatics nurses (American Health Information Management Association, 2006). However, the federal sector shares the commonality of informatics being a transforming career creating multiple new and unique opportunities in leadership and management of change (Gardner, Overhage, Steen, & Munger, 2009; The Tiger Team, 2007). Similarly, the DoD has a rich history of informatics experience. Army medicine formalized the role of the Chief Medical Informatics Officer (CMIO) in 2008, establishing processes and a workforce structure to support clinical informatics and health information technology (HIT) operations within the Army. With the establishment of the CMIO, the leadership successfully obtained authorization for a multidisciplinary informatics skill identifier for the clinical informatics workforce. The skill identifier for nursing requires a Master’s degree in informatics, completion of an Army-specific functional proponent course, and two years of healthcare informatics experience. Navy medicine in 2014 established clinical informatics workforce guidance to ensure military treatment facilities (MTFs) appoint a CMIO and a Chief Nursing Informatics Officer (CNIO) to support EHR transition and the associated changes with how the healthcare delivery system collects, processes, and uses health information (Department of the Navy, 2014). In addition, this guidance outlined workforce training and certification requirements. Once requisite training is complete, an additional qualification designator of clinical informatics can be assigned, which is similar to a certification (Department of the Navy, 2014). The intent of identifying key positions was to have the available expertise required to implement, train, sustain, and innovate new solutions. Several headquarters and specialty command positions also provide full-time nursing informatics positions in clinical informatics. The Air Force similarly identified the need for specialty training and focused career broadening experience in nursing informatics. In 2011, the Air Force began the Nurse Informatics Fellowship Program. In 2013, the clinical informatics consultant positions were realigned, which ultimately created a path at the enterprise and facility level. The tactical level continues to be developed, as those nurses are involved as “superusers” and in working groups that serve as additional duties based on interest. Two recent and major steps to extend informatics nursing in the Air Force include the creations of the CNIO within the Air Force Surgeon General Office in 2014 and the creation of an informatics nurse specialty identifier code in 2017. The specialty identifier code helps to find nurses with various levels of education and experience, novice, intermediate, and expert who can support the limited, but expanding, nursing informatics positions in the Air Force Medical Service. The VA Office of Nursing Informatics outlines nursing informatics roles and career growth opportunities with a focus on governance, clinical transformation, and nursing analytics (United States Department of Veterans Affairs, 2017a). The CNIO position, one of the most developed in the VA, supports the “development and maintenance of standardized information data management reports and analyses of the relationships among staffing levels, skill mix, care delivery models, and patient or resident outcomes for multiple points of care” (United States Department of Veterans Affairs, 2017b). The importance of establishing an “informatics workforce and informatics literacy in the VA” has been supported by past initiatives like the Health Informatics Initiative (hi2), which offers large-scale informatics training events to include Nursing Informatics Boot Camps (United States Department of Veterans Affairs, 2012). The federal nursing sector supports healthcare informatics in diverse practice settings andagencies. A more detailed description and examples is provided in the original 6th Edition chapter (Beaubien et al., 2015). The DoD and the VA have been leaders in the development and implementation of EHRs. The federal health sector provides a wide range of services to active duty service members, National Guard, Reserve members, veterans, retirees, and their families. Multiple environments and tools actively support developing interoperable systems, as a result clinical documentation linking the continuity of care faces many unique challenges. The evolution of the EHR, for the DOD MHS, began in 1988 with the government-owned Composite Health Care System (CHCS) (United States General Accounting Office, 1990). Deployed in the 1990s, CHCS was a first-generation EHR and supported physician order entry (Defense Health Agency—Solution Delivery Division, 2015). The nurse’s role in using this system was to check or validate physician orders and retrieve laboratory and radiology results (Skinner, 2008). CHCS continues to provide different patient views depending on user roles; clinicians are able to view a patient’s current and past medical history and medications (Defense Health Agency—Solution Delivery Division, 2015). Other outpatient functions include verifying eligibility for care and scheduling appointments (Defense Health Agency—Solution Delivery Division, 2015). In 1988, the first application of a commercially developed inpatient record called Clinical Information System (CIS) later to be known as Essentris was implemented at an MHS facility. Initially the inpatient documentation was aimed at labor and delivery units and the ability to capture the wave forms from mothers in labor, meeting the critical need to capture and store wave forms, where traditional wax encoded strips deteriorated. System deployments then moved to the critical care units and eventually into the other inpatient units. By 2011, all 59 MHS inpatient facilities worldwide had Essentris installed and implemented (HealthcareITNews, 1987). The MHS began to explore options for an updated electronic documentation process for recording clinician outpatient encounters. By late 1998 a third version of a concept of operations for Composite Health Care System II, later to be called Armed Forces Health Longitudinal Technology Application (AHLTA) was being circulated. In 2004 the deployment of AHLTA, the DoD’s global EHR, made it the largest ambulatory EHR in the world with a single clinical data repository (CDR), serving over 9 million beneficiaries (Skinner, 2008). AHLTA provides a secure, standards-based, enterprise-wide medical information system that generates, maintains, and provides 24/7 access to the EHRs of active duty military, their family members, and others entitled to DoD healthcare. AHLTA captures information in the fixed facility outpatient environment. The ability to document care onboard ships and within the operational field was later developed to meet the specific needs of the remote/mobile environment. AHLTA-Mobile was designed to capture information on a handheld device and store first responder clinical documentation. Initial injury and illness clinical documentation is then transferred to AHLTA-Theater used in remote locations and onto the Theater Medical Data Store (TMDS). Unique features of the mobile application allow for operations in no to low communications environments, with the ability to prepopulate demographic data (Defense Healthcare Management Systems, n.d.). AHLTA-Theater has the same user interface look as AHLTA and operates in a stand-alone environment utilizing a store-and-forward capability updating information when connected to a network and eventually updating the AHLTA CDR (Defense Healthcare Management Systems, n.d.). In 2006, the TRICARE Online (TOL) Patient Portal deployed to the MHS enterprise, and in 2012 a secure messaging application was purchased and released. Patients can use the portal 24/7 and 365 days per year to access information and services at military hospitals and clinics. Registered patients can use TOL for reviewing and downloading information and results (lab, radiology, prescriptions, vitals, allergies, and immunization); schedule, change, view, or cancel appointments at military hospitals or clinics; receive and send a secure message to their health provider and team; refill or check the status of a prescription; access online health risk assessments; get more information and services when separating from the service. The TOL Patient Portal will eventually be replaced by the MHS GENESIS Patient Portal as MTFs are moving to the new EHR platform MHS GENESIS. Until MHS GENESIS is fully deployed, there will likely be some overlap of services between TOL Patient Portal and MHS GENESIS Patient Portal. In 2015 the DoD contracted with Leidos, Cerner, and Accenture to implement a new enterprise-wide EHR on a commercial platform by Cerner (Sullivan, 2015). In April 2016, the DoD announced that the MHS’s massive EHR modernization project would be coined MHS GENESIS. “The meaning of ‘GENESIS’ is the origin or process of origin,” according to the department, which explained that MHS GENESIS represents “the initial stage of the developmental process of building and implementing an electronic health record by organizing the critical medical and business administrative data needed to provide quality and safe medical care” (Miliard, 2015). MHS GENESIS features a tethered, patient portal, connected directly to the EHR. The new patient portal is called MHS GENESIS Patient Portal and is a consolidated portal with telehealth options and secure messaging included. This effort started in February of 2017. The current system is only available to a small number of the MHS beneficiaries. Full operational capability is expected in 2022 (Health.mil, n.d.-c). MHS GENESIS is managed by the DoD Healthcare Management System Modernization Program Management Office under the Program Executive Office, Defense Healthcare Management Systems (Health.mil, n.d.-a). More than 800 subject matter experts (SMEs) came together to create MHS GENESIS. The SMEs included medical professionals, such as doctors and nurses as well as computer system professionals such as information technologists (Green, 2017). MHS GENESIS integrates inpatient and outpatient best-of-suite solutions that connect medical and dental information across the continuum of care, from point of injury to the MTF. This includes garrison, operational, and en route care, increasing efficiencies for beneficiaries and healthcare professionals. MHS GENESIS will replace select DoD legacy healthcare systems, including but not limited to AHLTA, CHCS, inpatient, and components of the intheater applications (Green, 2017). The VA dates its computerization efforts back to the early 1980s with the advent and subsequent deployment of Decentralized Hospital Computer Program (DHCP) across the VA enterprise. Locally developed applications helped evolve DHCP as new needs and technologies emerged to greatly enhance patient care. DHCP integrated over time and evolved into the Veterans Health Information Systems and Technology Architecture (VistA). VistA is deployed universally across the VA at more than 1500 sites of care, including each Veterans Affairs Medical Center (VAMC), Community-Based Outpatient Clinic (CBOC), Community Living Center, and at nearly 300 VA Vet centers. A key to the evolution of VistA was the development and deployment of the Computerized Patient Record System (CPRS)— a graphical user interface (GUI) that interacts with the VistA common functions and integrated applications via reusable interfaces. VistA, CPRS, and a variety of other VistA-based applications support day-to-day clinical and administrative operations at local VA healthcare facilities (United States Department of Veterans Affairs, n.d.-a). As a component of the VistA-based electronic medical record and the Computerized Physician Order Entry (CPOE), the VA implemented Bar Code Medication Administration (BCMA) in 1994 (Coyle & Heinen, 2005). Since its inception, BCMA has moved through several versions to evolve into a sophisticated solution-driven clinical software. Nurses have continually assisted in the design of the software. In addition, the Indian Health Service (IHS) Office of Information Technology (OIT) Electronic Health Record (EHR) Deployment Team, Veterans Health Administration’s (VHA) Bar Code Resource Office (BCRO), and VA’s OIT continue efforts for BCMA implementation to expand the patient safety benefits of BCMA into IHS and tribal facilities through partnering agreements. My HealtheVet (MHV) is another key component of the VA’s evolution of technology (United States Department of Veterans Affairs, n.d.-a). MHV is the official Personal Health Record (PHR) of the VA. MHV offers enhanced online health tools, services, and resources for both the user and the clinician 24/7 and 365 days per year. MHV offers secure messaging, managing appointments, refilling prescriptions, and downloading personal health records and medical images (United States Department of Veterans Affairs, 2013). Within the VA, the development of the next-generation Electronic Health Record Evolution has been linked to multiple efforts. In 2009, President Barack Obama charged the Departments of Veterans Affairs (VA) and Defense (DoD) to “work together to define and build a seamless system of integration” of EHRs (Lee, 2009). In June 2017, the Secretary of Veterans Affairs David Shulkin announced that the VA would be adopting the same EHR system, MHS GENESIS. The Secretary touted the benefits for service members that transition out of the military and receive medical care through the VA (Green, 2017). The Coast Guard has predominately maintained a paper record except for a few forays into augmenting their paper record with electronic tools such as in 2002 using the DoD’s CHCS adding the Provider Graphical User Interface (PGUI) in 2004 to enhance viewing the data. They maintained their own database and initially the same DoD software baseline. Attempts to migrate to AHLTA never got off the ground and by 2015 a five-year contract to use a Commercial Off-the-Shelf (COTS) EHR also failed (United States Government Accountability Office, 2018). In April of 2018, the DoD announced that they were partnering with the US Coast Guard for MHS GENESIS. It will be adopted for all of their clinics and sick bays. The initial section of this chapter provided details on the number of facilities and the different environments within which the federal partners work. One of the unique challenges is the geographically dispersed federal sector facilities. The DoD manages hospitals and clinics around the world with staff working in all 24 time zones, creating a time management challenge. Similarly, the VA has clinics in some locations located near former military installations such as in the Philippines and Puerto Rico and some in current locations such as Guam. The Coast Guard has a much further reach than our continental coast including remote locations from Alaska to Hawaii and supporting maritime safety where U.S. Navy ships are located such as foreign ports like Kuwait Naval Base. The United States Public Health Service (USPHS) officers who are charged with the health of the entire United States population serve alongside the military on board ships, in MTFs or public sector partners during time of national disasters such as flood and fires (United States Public Health Service Nursing, 2013). Caring for patients utilizing these scattered and diverse networks are a challenge both logistically and physically. Each agency has specific medical missions that drive their requirements for healthcare in these diverse locations. In order to sustain a fit and medically protected force, the DoD operates preventative medicine facilities in undisclosed locations on seven continents. A secondary mission for the DoD is to provide a full-service hospital asset for use by other government agencies involved in the support of disaster relief and humanitarian operations worldwide. This is handled by the hospital ships. The VA’s healthcare mission covers the continuum of care by providing inpatient and outpatient services, including pharmacy, prosthetics, and mental health; and long-term care in both institutional and noninstitutional settings and other healthcare programs such as readjustment counseling.
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Federal Healthcare Sector Nursing Informatics
INTRODUCTION
FEDERAL SECTOR ECOSYSTEM AND LANDSCAPE
FEDERAL NURSING INFORMATICS ROLES AND RESPONSIBILITIES
EVOLUTION OF TECHNOLOGY
Department of Defense
Department of Veterans Affairs
Coast Guard
Size and Complexity
High-Level Requirements and Approval Process
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