Precision Nursing

The use of population health to manage groups of at-risk people within a population, which may filter down to individuals, may be waning as a newer, more precise health care takes off. As Yuan1 notes, "For decades, cancer treatment has been following the rules of evidence-based medicine supported by population data. Although many breakthroughs have been made, current treatments cannot adequately meet the increasingly recognized unique individual needs of patients." Enter precision health.Precision health "uses omic data within the context of lifestyle, social, economic, cultural and environmental influences to help individuals achieve well-being and optimal health."2(p6) The goal is "individualized treatments to maximize the benefits of any particular intervention for one single individual."3 This new generation of precision in health care includes precision population health, and precision medicine, among others, including precision nursing.Precision nursing involves more precisely defining an individual patient's needs in order to achieve optimal health outcomes across the lifespan.4 This approach to nursing represents an exponential change, from a largely one-size-fits-all approach to targeted care predicated by data on the individual's behavior, physiology, environment, and medical history. Precision nursing emphasizes health promotion, disease prevention, and early intervention. In this column of Technology Today, we will discuss how advances in data and technology are turning our focus to a more precise approach to treating and evaluating patients.In 1999, Francis Collins5 published an article in the New England Journal of Medicine in which he characterized the mapping of the human genome initiated in the early 1990s as an achievement as groundbreaking as the expeditions of Lewis and Clark exploring the newly acquired western United States, Sir Edmund Hillary summiting Mount Everest, and Neil Armstrong stepping on the moon. Collins5 stated, "Scientists wanted to map the human genetic terrain, knowing it would lead them to previously unimaginable insights, and from there to the common good." By June 2000, the first draft of the human genome was largely completed when Collins remarked, "Over the longer term, perhaps in another 15 or 20 years, you will see a complete transformation in therapeutic medicine."6In 2011, the National Academies of Sciences, Engineering, and Medicine coined the term precision medicine, defined as the "tailoring of medical treatment to the individual characteristics of each patient."7(p125) This shifted the paradigm of health care to a focus on using an individual's genetic or genomic profile to inform disease prevention, diagnosis, and treatment.7 As a result, new technologies and the use of omics data, including genomic, proteomics, metabolomics, and microbiomics, for patient care were launched.7In 2015, President Obama announced his Precision Medicine Initiative (PMI) to deliver the right health care to the right person at the right time: "Doctors have always recognized that every patient is unique, and doctors have always tried to tailor their treatments as best they can to individuals. You can match a blood transfusion to a blood type—that was an important discovery. What if matching a cancer cure to our genetic code was just as easy, just as standard? What if figuring out the right dose of a medicine was just as easy as taking our temperature?"8By 2019, as Corwin et al9 astutely pointed out, nurses' ways of knowing were evolving. Aided by advances in data and technologies, nursing continues to move toward a more precise practice with a focus on optimal health outcomes for individuals. This requires a new way of dealing with data and technology.Data are a key driver of precision nursing. Analyzing data from an array of large data sets improves our understanding of an individual's behavior, physiology, environment, and medical history, making it easier to identify precise nursing assessments, interventions, and evaluation.10 For example, being able to combine data from sources such as remote patient monitoring devices and mobile health apps with electronic health records (EHRs) and omic reports yields a more comprehensive 24/7 picture of patients, thereby supporting precision nursing.4Omics is "a term encompassing multiple molecular disciplines that involve the characterization of global sets of biological molecules such as DNAs, RNAs, proteins, and metabolites."11(p1) One type of omics that many nurses are familiar with is genomics, the study of genes and how they function. Others include transcriptomics, proteomics, epigenomics, metabolomics, inflamomics, lipidomics, and glycomics.12 Omic data provides insights into potential biological mechanisms to consider when managing a patient in precision nursing.4Pharmacogenomics combines the fields of pharmacology and genomics and is the study of how an individual's genes affect their response to drugs. For decades, nurses have had front-row seats observing how patients in hospitals respond differently to the same drugs, often with the same dose. The US Food and Drug Administration lists approximately 200 medications with pharmacogenomic biomarkers that can aid in identifying optimal dosing and potential adverse effects in individuals.13Geospatial data reflect characteristics of an individual's environment that can affect health and well-being.9 It represents data not historically collected by nurses or involved in most nurses' practices. Geospatial data includes data on easily accessible health care resources, such as clinics and hospitals as well as health promotion resources like gyms and parks. It also includes data on risks in the individual's environment such as unhealthy exposures from water and soil as well as crime.9When it comes to data enabling precision nursing, it is important to note the rising field of data science, previously discussed in this column.14 Data science is defined as the "interdisciplinary field of inquiry in which quantitative and analytical approaches, processes, and systems are developed and used to extract knowledge and insights from increasingly large and/or complex sets of data."15(p1) It is about turning data into impactful information, which is what precision nursing is about.Advances in biopsychosocial measurement technologies is another key driver of precision nursing. These technologies can generate real-time, contextual, and longitudinal data on individuals through mobile devices such as smart phones, wearables, remote patient monitoring, and other devices. Patient-generated health data adds to the wealth of data on individuals and is collected through patient portals, websites, and mobile apps.A key technology enabling precision nursing is electronic sensors, which are valuable in capturing data on an individual's behavior, physiology, and environment continuously, in real time, and across settings.9 From sleep and activity to surrounding light and noise, to blood alcohol levels and oxygen saturation and more, electronic sensors help provide a more comprehensive picture of an individual.9 The ability of electronic sensors to provide measurement in real time is important in providing more precise prevention, earlier intervention, and evaluation of outcomes.Advances in data, analytics, and technology are lifting the nursing profession out of the environment of "data rich and information poor." Built on an ecosystem of integrated data derived from numerous sources and enabled by technologies, these advances create new implications for nursing.The goal of precision nursing is to achieve optimal health outcomes for individuals across the lifespan. Achieving this goal requires strategic and operational planning for practice, education, and leadership.In precision nursing, a patient's assessment, interventions, and evaluation of care will be influenced by the individual's unique behavior, physiology, environment, and medical history. As such, nurses will be required to know more about each patient than they do today. This results in increased complexity in nursing practice and cognitive load for practicing nurses.Overcoming the challenges associated with precision nursing requires expert informatics support targeting reduction in complexity and cognitive load. The burden of clinical documentation can be reduced by collecting only data that are used and increasing ways to capture data electronically, which will be required in precision nursing.16 With good informatics support, precision assessments will result in precise patient profiles based on behavior, physiology, environment, and medical history data that will be automated with recommendations for individualized, precision care plans and evaluation. Patient education will be largely automated through the use of mobile apps that provide more than information and aid in changing behavior to help reach individualized health goals.17 Behavior change techniques in apps include individualized prompts/cues, real-time feedback, recommendations based on an individual's unique data, and reminders that help them better manage their health.17The biggest implication of precision nursing is the need for learning. Continuing education programs for currently practicing nurses should include content on precision nursing concepts and skills.18 States where continuing education for nursing licensure is mandated should consider online presentations on precision nursing.18 In other states, employer-required continuing education should be considered.18In academia, precision nursing concepts and skills recommended by the American Academy of Nursing (aannet.org), American Nurses Association (nursingworld.org), and other professional organizations should be part of the curriculum. An example of topics to include would be pharmacogenomics-based medication administration as part of pharmacology and every clinical course.18 Undergraduate nurses as well as advanced practice nurses should be prepared to obtain certification in specialties such as genetics/genomics and informatics.18Nurse leaders, in both practice and academia, should routinely advance precision nursing in their strategic and operational plans. The first approach necessitates engineering excellence from the start by ensuring top talent is available to move precision nursing forward.19 As with any exponential change, this will require hiring, developing, and/or outsourcing needed expertise. Inherent in this approach is the need to support continued development of talent dedicated to precision nursing as it continues to evolve. Online development resources include academic preparation from leading institutions, massive open online courses platforms such as www.Coursera.org, www.edx.org, and www.Udacity.com, as well as continuing education through professional organizations such as the National Institute of Nursing Research (NINR.NIH.gov) and the International Society for Nursing and Genetics (www.ISONG.org).Nurse leaders should query information and communication technology vendors on their plans and initiatives to support precision nursing. From a technology infrastructure perspective, it is often quicker and less expensive to build on existing structures that are easily scalable and readily available, such as electronic health records and clinical decision support tools, to support precision nursing practice.18 Leaders should support modernization while implementing policies and procedures for safely incorporating precision health information and services into nursing operations.18 Examples of such policies and procedures include nursing practice policies for bedside nurses as well as advanced practice nurses that include informed consent for genetic testing, as well as indications and mechanisms for timely referral to genetic counselors or specialists.18It is always important to remember that when it comes to data and technology-enabled advances, what some nurses see as progress others will feel as constant change, loss, or something to fear. This must be accepted, acknowledged, and planned for to ensure successful transformation. Communicating a clear vision for the future is an essential first step.Precision nursing is a significant change in how nursing is practiced, as "Precision science incorporates all determinants of health, from the genetic code to the zip code, with a focus on improving precise assessment, diagnosis, and treatment aimed at prevention and cure and improved quality of life, the hallmarks of nursing practice."20(p729) There is much work to be done to advance nursing to precise care incorporating behavior, physiology, environment, and medical history factors of an individual with the goal of optimal outcomes. The biggest implication of precision nursing for the profession is learning. Education for transforming to precision nursing is essential, and it includes education of leaders, academicians, informaticists, researchers, and those who will deliver precision nursing to patients and consumers. To paraphrase Eric Hoffer, in times of change it is the learners that inherit the earth; while the learned find themselves beautifully equipped to deal with a world that no longer exists.21