Apple's de facto pro video editing suite, Final Cut Pro X, earns new tricks and performance enhancements in its latest update. Optimised for the new 2017 iMac Pro, FCP X can now 360-degree VR video, and full-resolution 8K video, for the first time ever on a Mac.
360-degree VR video support is also extended to FCP companion apps—Motion and Compressor.
FCP X now lets pro editors create VR content, with the ability to import, edit and deliver 360-degree video and view the project in real-time through a connect HTC VIVE headset with SteamVR.
Editors can add 360-degree titles in 2D or 3D, apply blurs, glows and other effects a well as use visual controls to straighten horizons or remove camera rigs from equirectangular videos. Standard photos and videos can also be added to VR projects.
360-degree videos can then be shared directly to popular websites including YouTube, Facebook and Vimeo.
The update also brings powerful colour grading tools with a unique colour wheel feature built-in to adjust hue, saturation and brightness.
For finer adjustment, editors can use colour curves with multiple control points to target specific colour ranges, as well as eye droppers to let you sample specific colours and apply manual white balance.
For cinematic and custom looks, you can now apply custom lookup tables (LUTs) from popular grading apps like DaVinci Resolve and websites namely PremiumBeat, ColorGraing Central, and more.
The new FCP update also adds support from the most popular HDR formats. Editors can output video to HDR monitors using I/O devices from AJA and Blackmagic with brightness levels up to 10,000 nits.
– Easily import iMovie projects from iPhone and iPad into Final Cut Pro for advanced editing, audio work, motion graphics and colour grading.
– HEVC and HEIF support for importing and editing high efficiency video and photo formats from Apple devices.
– Updated audio effects plug-ins from Logic Pro X with redesigned, resizable interfaces.
– Faster, higher quality optical flow analysis built on Metal, Apple's advanced graphics technology.
This should be a welcome update for the 2 million strong Final Cut Pro user base, with features that will put it at least on par with its biggest rival, Adobe Premiere Pro.
Final Cut Pro X (10.4) is available as a free update for existing users, and MYR1,299.90 as a download from the Mac App Store for new users.
Meanwhile, Motion 5.4 and Compressor 4.4 are also available as a free update for existing users.
Motion and Compressor can be purchased from the Mac App Store for MYR199.90 each.
Education users can purchase the Pro Apps Bundle for Education for MYR899.90.
For more info, head over to apple.com/final-cut-pro.


Room Maker Inc. (Corporation# 11235737) is a federal corporation entity registered with Corporations Canada. The incorporation date is February 5, 2019.
Corporation Name Room Maker Inc.
2019-02-05 - 2019-04-21 Room Maker Inc.


text:
require 'rails_helper'

RSpec.describe CharitiesController, type: :controller do

  render_views

	it 'should get all charities' do
    get :index
    response.status.should eq 200
    response.body.should include('Darity Charity')
	end

end

redpajama_set_name: RedPajamaGithub


Santa Fe Indian Market takes over the downtown Plaza area and comprises 14 square city blocks where it features 1,025 artists representing 160 tribes, nations and pueblos. A reported 125,000 visitors attended this year's Market.
It is a place where I get to meet up with old friends, meet new friends, and be surrounded by thousands of creative minds. So, I like it.
The 'marketyness' aside (remember, people come here to sell and to buy), Indian Market nonetheless is a place where I get inspired, and I get to see, learn and experience new things. And I love seeing what new creative projects everyone is up to.
I ran into fellow Turtle Mountain dude Samuel LaFountain who is a jewelry rockstar. An award-winning artist, LaFountain always comes with new designs forged from some pretty wild materials (he's supposedly working with dinosaur bone and reptile (crocodile?) skins on new/new projects).
Singer's red vest (above right) won Third Place in the Native American Clothing Contest (more info on this competition to come in a future post).
After lunch we had to zip back (yes there was lots of running) to the Sealaska Pavillion and to the Museum of Contemporary Native Arts (more to come on these), and en route we caught the super fresh booth of Navajo artist JT Willie. Throughout his designs, Willie combines Navajo silversmith work with Great Lakes floral beaded motifs with Plains and Plateau 8-band trade cloth wool styles. Willie also won Best of Class at the Native American Clothing Contest (Contemporary fashion) for the green dress pictured in the back of his booth (more to come). Willie is also a Beyond Buckskin artist, and we hope to expand his section on the site in the coming weeks.
I finally made my way over to David Sloan's booth where he was displaying his original 2D work, but also his fashion - including jewelry, tees, and bandanas. Here, I got a picture of Andrea Preston taking a picture of D.Sloan. Cool kids rock.
These are just a small fraction of the amazing artists who participated in the Santa Fe Indian Market this year. Unfortunately, even though I was doing a lot of running to and fro, I didn't make it to all the the booths, and I completely missed an entire row! Besides the hundreds of booths, there are also many gallery shows and other events that I checked out and will be posting about in the days to come, so stay tuned.
Thanks for all the pics, Jessica!


ARTICLE - why do i need business insurance when i Operate my business from home?
Your home is your castle, but it's also where you make your gold. So, when you run your business out of your home, does that mean you need more than a standard home insurance policy?
The short answer is: yes. Running a home-based business requires special considerations—business matters that aren't covered under your personal home insurance coverage.
For instance, your home insurance is not designed to provide sufficient coverage for business-related equipment and goods. This is especially true if the business you operate means you keep valuable stock on the premises of your home, or your company requires you to store and run expensive equipment in your home in relation to your business activities.
Of course, some property coverage is available through your current home insurance policy, but there's usually a limit to how much will be covered under this insurance policy and, typically, it rarely comes close to how much it would cost you to replace all your business items should they be damaged, destroyed or stolen from your home office.
Another reason why you should seriously consider paying for a home-based business insurance policy is that most homeowner insurance policies will not cover business property that leaves the home-based business premises. So, if your laptop and camera are in your car and stolen while you're at a client's house, your home insurance won't cover this loss. A business property policy, however, would provide full coverage for all of the important and valuable property owned by your business.
Another advantage to business insurance is that it can be tailored to your specific needs. For instance, if you anticipate greater risk of being sued—say, for instance, people are constantly trying your product and risking an injury—than you can increase the business liability portion of your business insurance policy. This is particularly important since most home insurance policies won't extend the liability coverage to risks that are associated with operating a business.
Also a business policy can provide coverage to home-based businesses where customers come into your home for goods or services. That's because if a customer were to injure themselves while in your home, your homeowner's insurance would not cover the medical and legal bills associated with this liability. A general liability policy could protect you, but without it you could risk losing your entire business and more.
Does your homeowner's policy limit coverage of business stock and equipment? By reading your home insurance policy carefully you can easily determine whether or not a fire or loss would cap your losses, leaving you to pay out-of-pocket to replace the remaining tools and equipment used for your business. Another good reason to read your homeowner's policy is that some providers actually consider operating a home-based business a violation of the policy terms. To keep your policy coverage in place and with the right amount of coverage, be sure to read the limits and coverage exclusions and then get additional coverage, as needed.
Do you have an office but work from home regularly? Even if your employer's office is locate elsewhere, if you regularly work from home you may need additional coverage to help protect yourself from work-related incidents that can occur in your home.
Do clients, business contacts or other employees visit your home? Many home-based business owners are surprised to learn that their homeowners policies often don't cover third-party injury claims related to their work. If you have people visiting your home for business-related activities, you'll need to pay for additional coverage to protect yourself and your work.
Do you conduct business in other people's homes? Since most homeowners' policies don't cover third-party injury claims when related to work you'll need to get business insurance to protect you from liability claims when working in other people's homes.
Nobody wants to risk losing everything they've worked so hard to build, so it's important to inform your home insurance provider as soon as you consider operating a home-based business. Failure to do so can void your policy, leave you without coverage when you need it most, and even prevent you from being able to renew your home insurance coverage in the future. The good news is that business insurance can be tailored to suit your needs. Let an insurance professional help you find the right coverage at a cost-effective price.


text:
An Encore Voyage
A Journey of Reinvention and Discovery
The Things We've Learned
The Thunderbird Lodge at Lake Tahoe
While visiting the north shore of Lake Tahoe, we had the opportunity to take a guided tour of the Thunderbird Lodge. This property was built in 1936 as the private residence of George Whittell. George Whittell originally purchased 40,000 acres on the east shore of Lake Tahoe and possessed 26 miles of its shoreline. It seems that George was quite a colorful character, and developed a love of wild animals, booze, poker and women. He built a separate enclosure for his pet Sumatran elephant, Mingo, and kept a full grown lion, Bill, as a pet.
Living area in Thunderbird Lodge
His Thunderbird Lodge home is fascinating to tour, primarily because of its situation among enormous granite boulders on the property, along with its 600-foot underground tunnel which connects his boathouse to the residence.
Giant granite boulders surround the lodge
During the home's construction, Whittell hired Native American boys to construct a series of intricate stone paths, which later became known as "the Dragon's Tail."
Dragon's Tail Walk
Private beach, surrounded by huge boulders.
Whittell summered at Thunderbird, and while there commissioned the building of Lake Tahoe's most recognizable speedboat, The Thunderbird. It's mahogany hull and huge twin V-12 engines are currently in restoration in Incline Village, and will be returned to the Lodge in the near future.
This poker room had a door through which he could sneak away when he wanted privacy!
While Whittell's original plan was to build a resort and condominium complex, along with a ski resort, his later lifestyle altered those plans. He became more and more reclusive and his privacy was highly valued. Ultimately, he sold off vast pieces of his property to the Nevada State Parks Department and other agencies. After his death, Wall Street maven Jack Dreyfus purchased the remaining estate and ultimately sold most of it to the U.S Forest service.
It is the result of George Whittell's reclusive nature that the eastern shore of Lake Tahoe remains largely undeveloped today. Hubs and I were fascinated by the careful siting of the original home, and the use of materials to marry the residence to its site. If you happen to visit the Lake Tahoe area, it's worth it to take a tour of this historical home.
This entry was posted in Baby Boomers, Retirement, Wanderings and tagged adventures, baby boomer, Lake Tahoe, Retirement, Retirement travel, travel on June 6, 2016 by Encore Voyage.
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7 thoughts on "The Thunderbird Lodge at Lake Tahoe"
MrFireStation June 6, 2016 at 9:18 am
Very interesting – quite the bachelor pad!
Retirementallychallenged.com June 6, 2016 at 9:28 am
Wow! I had never heard that story before! I love that we have rich eccentrics like that (William Randolph Hearst would be another one) who have the money to build amazing places like that – then we mere mortals get to enjoy them later.
Encore Voyage Post author June 8, 2016 at 2:53 pm
"Eccentric" is pretty much the word for it. But according to the history, he's pretty much responsible for the east side of the lake being undeveloped.
Kate Crimmins June 6, 2016 at 9:45 am
Pretty cool!
Chez Shea June 6, 2016 at 2:52 pm
What an amazing place! Very magical.
Terri Webster Schrandt June 6, 2016 at 4:54 pm
This is so cool, we'll have to check this out soon! Less than 2 hour drive from where I live 🙂
dconnollyislandgmailcom June 6, 2016 at 9:31 pm
Thanks, Lynn! This is now on my bucket list of places to visit!
http://www.retirementreflections.com
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Hi! I'm Lynn
Encore Voyage
In 2011, my husband, Jeremy, and I gave up our lifelong careers and started down the road to reinventing our lifestyle. This is our story.
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redpajama_set_name: RedPajamaCommonCrawl


We are only closed on the public holidays i.e. Christmas Day and Boxing Day etc. so we will be happy to see current or new patients during Christmas. Some patients only come and see us when they are home for holidays. We encourage patients to book an appointment as soon as they know their holiday dates but we always keep a few appointments for those who forget and for those who find themselves with toothache.
At Tewkesbury Dental we are looking forward to Christmas as in the new year we are giving the Practice a makeover! Beginning in January, we are putting in a new reception and a new surgery as well as a new patient bathroom. Following this we will be updating our Facial Treatment Rooms so that patients can receive wrinkle reduction treatments in a non-dental environment i.e. not a drill in sight!
As we develop all our facilities in 2018, we will continue to ask for patient feedback to allow us to keep providing what our patients want and in modern, comfortable and professional surroundings.
We wish all our patients a very Happy Christmas and a pain-free and prosperous 2018!
A recent study in the US (at the New York University of Buffalo) has found that periodontal disease places more mature women at a heightened risk of; oesophageal, breast and gallbladder cancers. The new study confirmed previous findings but also highlighted previously undetected connections, notably between gum disease and gallbladder cancer.
Diagnosed periodontal disease was found to cause a 14% increase in all cancers. It is perhaps surprising that we take home hygiene quite seriously – just look at all the ads for home cleaning products, but the hygiene of our mouth … is often ignored. We wouldn't dream of ignoring an open wound, especially if it was bleeding but guess what, many people believe that bleeding gums is 'normal'!
Your dentist and hygienist will tell you that bleeding gums is not normal and is a sign of gum disease. At Tewkesbury Dental we have our own hygienist and we offer Saturday appointments, so that you don't have to miss work and get some shopping done at the same time. Book early to avoid disappointment.


Ohio Bmv Vehicle Bill Of Sale – Every business has numerous kinds of financial statements which will help a prospective investor gauge the health of a business. Statements such as the stability sheet, income statement and cash flow statement can be a vital step in assessing if the business you are considering investing your cash in is definitely a viable investment. Through the use of these elements of balance sheet accounting, you can ascertain the assets, liabilities and collateral of an ongoing business at a specific point in time, as well as the income and expenses that they are dealing with currently.
Let me describe why the use of a setting goals worksheet might help you to obtain what you need. Imagine for an instant trying to change the wheel on a car if you haven't got a jack or a tyre iron to take action. Without these tools you would have to look elsewhere for assist in carrying out what is actually a reasonably simple task. Similarly without the right kind goal setting worksheets attaining your goal becomes a complete lot harder.
Choosing to hire a specialist to help you keep an eye on your investments and deal with all of the balance sheet accounting concerns is a superb relief for those traders who simply don't have the time to spend obsessing over if they have gained or lost money every day. It could become overwhelming to constantly view your investments for changes and can take over your daily function. You intend to have the ability to enjoy your daily life without wondering in the event that you will be viewing an excellent retirement or not every minute. This is where your professional advisor can do the ongoing work for you and save you your sanity.
With respect to navigating between different worksheets in a workbook, of scrolling over the length of the worksheet instead, one can right click on the 4 triangle navigation buttons, that may then display a pop of all the available worksheet names in the workbook up, out of which the individual can select the required one and head to that worksheet directly. If one really wants to toggle between two adjacent worksheets, then which can be accomplished by using the keyboard strokes Ctrl + Page Down for likely to the next sheet and Ctrl + Web page Up to go to the previous sheet.
Regardless of what you want to achieve, it is suggested that you start with a great goal setting techniques worksheet and abide by it through. You'll be amazed at how effective the simple activity of answering the goal setting questions is just.
20 Photos of "Ohio Bmv Vehicle Bill Of Sale"


text:
Q: Oracle lock issue - ORA-00054: resource busy - while creating a foreign key Initial situation:

*

*A table PARENT_TABLE with a primary key on its column PK_COL.

*A table CHILD_TABLE1 with a foreign key on PARENT_TABLE(PK_COL).

I insert a line into CHILD_TABLE1 in a transaction and do not commit.
Then I try to create a table CHILD_TABLE2 symmetrical to CHILD_TABLE1 in another session.
But an ORA-00054: resource busy and acquire with NOWAIT specified or timeout expired is raised when I create the foreign key, because of the ongoing insertion in CHILD_TABLE1.
I don't understand why Oracle is preventing the foreign key creation: there is no modification performed on PARENT_TABLE.
Please help.
To reproduce under sqlplus:
set autocommit off

create table PARENT_TABLE(PK_COL varchar(10));
alter table PARENT_TABLE add constraint PK_CONSTRAINT primary key (PK_COL);
insert into PARENT_TABLE values ('foo');
commit;

create table CHILD_TABLE1(CHILD_PK_COL varchar(10), FK_COL varchar(10));
alter table CHILD_TABLE1 add constraint CHILD_TABLE1_CONSTRAINT foreign key (FK_COL) references PARENT_TABLE(PK_COL);
create index CHILD_TABLE1_INDEX on CHILD_TABLE1(FK_COL);
insert into CHILD_TABLE1 values ('bar', 'foo');

In another console:
alter session set ddl_lock_timeout=10;
create table CHILD_TABLE2(CHILD_PK_COL varchar(10), FK_COL varchar(10));
alter table CHILD_TABLE2 add constraint CHILD_TABLE2_CONSTRAINT foreign key (FK_COL) references PARENT_TABLE(PK_COL);

Funny: with NOVALIDATE in CHILD_TABLE2_CONSTRAINT creation, the execution is hanging...

A:
You are not modifying something in the parent table. But you're
  actually, trying to refer its primary key in your child table. Before
  establishing a relationship or any DDL with table, it has to be free
  of locks.

So, before creating this constraint, Oracle do check for existing locks over the referred table(PARENT_TABLE). A lock over a table(Table Level Lock,in this context) is actually for a reason to adhere to the ACID properties.
One best example to understand its importance is ON DELETE CASCADE which means if a record in the parent table is deleted, then the corresponding records in the child table will automatically be deleted.
So, when there's a uncommitted insert/update/delete over the child table referring a parent table. No other referential constraint can be created to the parent. Just to avoid a deadlock or chaos.

To be more crisp, when you have an uncommitted insert in your child table.
  There's a lock over your parent table as well. So all other further DDLs referring it will be made wait.

You can use this query to check the same.
SELECT c.owner,
  c.object_name,
  c.object_type,
  b.sid,
  b.serial#,
  b.status,
  b.osuser,
  b.machine
FROM v$locked_object a ,
  v$session b,
  dba_objects c
WHERE b.sid     = a.session_id
AND a.object_id = c.object_id;

A: I added the LOCKED_MODE explanation in you query:
DECODE(a.LOCKED_MODE, 0,'NONE', 1,'NULL', 2,'ROW SHARE (RS/SS)', 3,'ROW EXCLUSIVE (RX/SX)', 4,'SHARE (S)', 5,'SHARE ROW EXCLUSIVE (SRX/SSX)', 6,'EXCLUSIVE (X)', NULL) LOCK_MODE.

Here is the result:
OBJECT_NAME                    OBJECT_TYPE         LOCK_MODE                         SID    SERIAL# STATUS
------------------------------ ------------------- ----------------------------- ---------- ---------- --------
PARENT_TABLE                   TABLE               ROW EXCLUSIVE (RX/SX)              71          8694 INACTIVE
CHILD_TABLE1                   TABLE               ROW EXCLUSIVE (RX/SX)              71          8694 INACTIVE

RX/SX is a table lock so it prevents any DDL operation (That seems to be said in the doc). This lock is used on both parent and child. I suppose that the lock is added on parent to at least prevent it from being deleted so we would lost the pending update on the child table.
That said, I still have no solution. Suppose that the parent table is a manufacturer. There is a child car table and we are inserting plenty of new cars in that table on the fly. There is a foreign key from car to manufacturer. Now there is a new product that we want to manage: "bicycles". So we want to create a bicycle table similar to car. But we cannot create the table as we are performing insertions in car. Seems a very simple use case... How to support it?
=====
Edit:
There might be no solution. Here is a guy with the same issue.

redpajama_set_name: RedPajamaStackExchange


The answer to this economic-environmental challenge is surprisingly simple: Harness the power of the market and create a global, uniform price on carbon.
If we were to impose a revenue-neutral pollution fee on major greenhouse-gas emitters, we could use half of the proceeds to lower the U.S. corporate income tax rate to a more globally competitive level, and return the rest to households. These "carbon-funded tax cuts" eliminate any economic drag that higher energy prices would create, as the government would not be extracting any new revenue from the economy. By targeting half of the revenue to reducing our uncompetitive corporate tax rate, we enhance the competitiveness of U.S. companies in the global economy, stimulating growth and job creation.
Consumers win because a carbon-pollution fee would encourage the manufacture of more fuel-efficient vehicles, homes and appliances. It would provide incentives and certainty to business decision-makers to invest in cleaner energy and energy efficiency. It would reduce the current indirect subsidies for fossil fuel resources: the "social costs" those fuel sources impose on all of us, such as increased health-care costs resulting from burning coal or losses suffered by drought-stricken farmers.
Some U.S. policymakers have ruled out a "carbon tax," on the basis that it would make us less competitive in the global economy and reduce our rate of growth. And standing alone, it would. But, coupled with reducing taxes on business, as Harvard professor Dale Jorgenson points out in his book "Double Dividend, it would enhance economic growth. If engineered to spread globally, it would enhance U.S. competitiveness.
We can internationalize the fee with a two-way, border-adjustment mechanism, applicable to goods imported from or exported to countries without comparable carbon pricing. This would provide incentives to other nations to similarly price emissions or see their exporters pay the United States at our border. No nation wants to watch its exporters pay a fee to our government when it could instead collect that revenue for itself, so such a border adjustment would quickly lead to widespread adoption: a global, uniform price on carbon.
President Barack Obama plans to join other world leaders in Paris this year to pledge to reduce our emissions. But this pledge, combined with pledges other nations can reasonably be expected to make leading to the Paris climate summit Nov. 30, will get us only a fraction of the emissions reductions that scientists say are needed. Worse yet, the Paris meeting will produce only pledges — with no third-party monitoring, no penalty for countries that fall short, and no agreed international framework or incentives to help achieve these pledges.
Carbon-funded tax cuts offer a way to implement our Paris pledge and reduce emissions faster, and far more efficiently, than current Environmental Protection Agency plans to require each state to impose emission reductions on power plants. In addition, a global, uniform price on carbon would enhance the worldwide competitiveness of American manufacturers, thanks to our nation's unparalleled access to cheaper, cleaner energy sources.
Combating climate change is the foremost environmental, geopolitical, and moral challenge of this century. Leading the world to a successful response will require honesty, clear thinking, bipartisan cooperation, and skillful international engagement. As we contemplate the pope's encyclical, let's harness the free-enterprise system to rise to the challenge and protect our planet for generations to come.


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Home » Europe » William 'poised to take' Harry's pivotal Commonwealth role in Megxit review
mediabest 01/13/2021 autoplay_videoctp_videoPrinc
Prince Harry: Experts discuss 'falling out' with Prince William
The Duke of Sussex has reportedly insisted on a face-to-face meeting with senior members of the Royal Family in his upcoming 12-month review of his post-royal life. He and Meghan Markle have settled into their new home in California with their one-year-old son Archie, but may be making a return trip to the UK a year after first announcing their intention to step back as working royals. Just as the initial blueprint for the Sussexes' new life was drawn up by Harry, William, Prince Charles and the Queen, the review is expected to be undertaken by the same senior royals.
The royals ended up agreeing on a 'hard Megxit', meaning the Sussexes ended up with a much harsher deal than they had initially hoped for.
Both of them were stripped of their titles as Commonwealth Youth Ambassadors in the process.
A source told TMZ at the time that the couple were "shocked" they had to lose their platform which they never expected to even be "on the table".
The role carried great responsibility, as 60 percent of the Commonwealth's 2.4 billion citizens are aged 29 or under.
After Harry was awarded the honour in 2018, reports emerged that Prince William was frustrated — he had had an eye on the title himself.
The Sun reported: "Wills' nose was reportedly put out of joint when the Queen gave the plum job to his brother instead of him."
Courtiers also claimed that the Duke of Cambridge had to be cajoled into taking part in any Commonwealth activities after being snubbed in favour of his brother.
However, the Queen could replicate the actions she took over Harry's other royal privileges when the 12-month period lapses, and pass some of his positions to William.
Harry had to give up his ceremonial positions of Captain General of the Royal Marines, Honorary Air Commandant, RAF Honington and Commodore-in-chief Small Ships and Diving, Royal Naval Command during the Megxit negotiations.
The Queen is not expected to reinstate these military titles in the review, according to some royal critics and Palace insiders.
Royal correspondent Roya Nikkah said the Queen believes "either you work for the Royal Family or you don't — you don't make the Royal Family work for you".
She said Princess Anne is expected to replace Harry as Captain-General of the Royal Marines next year, too.
Yet, sources in the Navy told the Sunday Express this was a title William may be granted.
Insiders said: "The decision has been made to invite Prince William to take over this important duty, largely on the basis that the Duke of Sussex has given no reason to believe that he will alter current arrangements.
"Quite the opposite, in fact."
The Queen could then do the same for Harry's former role as Commonwealth Youth Ambassador, and hand it to William.
How Queen 'avoided' Commonwealth officials after 'string of scandals' [INSIGHT]
Queen's 'real reaction' to Harry's Commonwealth criticism [EXPLAINED]
How Queen's Jubilee left Commonwealth in 'bloody outrage' [EXPOSED]
But, as the Megxit agreement states, "no new appointments will be made to fill these roles between the 12-month review of the new arrangements in completed".
The Sussexes still have their HRH titles but cannot use them in a working capacity now they no longer represent the Queen.
However, the Duke and Duchess are still President and Vice-President of the Queen's Commonwealth Trust.
They have taken part in an array of virtual discussions with young leaders since leaving the royal frontline.
It's thought that the Commonwealth means a great deal to the couple, especially as they reportedly fell in love in the Commonwealth nation of Botswana.
Amid mixed reports as to whether Harry has actually requested an extension to discussions over his current post-royal arrangement, some believe he is determined to return this summer.
The Duke and Duchess of Sussex may be looking to return for Prince Philip's 100th birthday this June, along with the Queen's official birthday which is celebrated in the same month.
Harry is likely to want to see the unveiling of the Princess Diana memorial statue on what would have been her 60th birthday in July.
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Dr. Vivek Sama is a qualified Orthopedic and Trauma surgeon, as well as a seasoned and accomplished management professional. His experience extends across India, England, and the U.S., and combines corporate leadership as well as entrepreneurship and investing.
Vivek began his management career at Bain & Co., in their San Francisco office, where he advised senior management of corporations including Varian Medical Systems, Guidant Corporation, Evanston Hospitals, Great West Life, Nike Corporation, Hewlett Packard, and others. As part of Bain's Private Equity Group he also led due diligence and operational transformation projects for healthcare companies on behalf of leading private equity firms in the San Francisco Bay Area.
Following his time at Bain & Co., Vivek led the business team of Opus Medical, a highly successful medical device startup acquired by ArthroCare Corporation, Sunnyvale, California, in 2006. Subsequently, Vivek joined ArthroCare as Director of Marketing & Business Development. At Arthrocare, Vivek led the sports medicine business unit, and also held responsibility for corporate venture capital activities.
Vivek is based in India where he has been an Executive Partner for HealthCare Global Enterprises (HCG), a leader in cancer care and research in India. In 2012, he founded the Indian operation of the American Hospital Management Company, Washington DC, and grew its presence as a hospital management and consulting firm in South Asia.
Vivek has also established Chiranjiv Medical Foundation, a charitable organization that funds medical treatment for BPL (Below Poverty Line) patients.
As a trauma surgeon, Vivek has practiced in the Oxford Radcliffe and the Coventry & Warwickshire Hospitals in the United Kingdom, as well as premier centers in India. He is a graduate of the prestigious Maulana Azad Medical College, University of Delhi, and has an MBA from the Kellogg Graduate School of Management, Northwestern University.


This drawing is an exploration of pastels on suede board. I love how the texture of this support just begs to receive my pastel. It's as if a million little fibers are sitting on the surface with their tiny arms outstretched in anticipation of grabbing my stroke. With that, I love how I am able to approach my subject. This bear is so large and solid. His strength and mass is readily visible. But there is a gentle touch of softness, of warmth and sensitivity that balances his massive nature in a very subtle way. I love how these two themes play off each other in this pastel artwork.
Interested in a custom painting, or maybe have questions about this one? Shoot me a message. I would love to hear from you.


text:
Jepson Family Crest, Coat of Arms and Name History
Erm. three bugle horns stringed gu. Crest —A wyvern vert. Motto—Vincit veritas.
Origin, Meaning, Family History and Jepson Coat of Arms and Family Crest
Jepson Coat of Arms Meaning
The two main devices (symbols) in the Jepson blazon are the buglehorn and wyvern. The two main tinctures (colors) are ermine and gules.
The hunting horn, or bugle horn has a distinctive shape, being curved almost into a semi-circle, it can be decorated with bands of a different colour and typically hangs from a string, also coloured. 7. Apart from its obvious reference to the pursuit of hunting, it has also been used in allusion to the name of the holderr (HUNTER of Hunterston) and Woowward suggests it is also associated with those who have rights or obligations to the forest. 8
Nowadays we might conflate many mythical creatures under the heading of dragon but to the heraldic artists there was a whole menagerie of quite distinct beasts, the wyvern being one of them. 9 Whilst both the dragon and wyvern are winged and scaled, the wyvern stands on two legs rather than four. Wade suggests, somewhat plausibly that both creatures may have arisen through garbled descriptions of the crocodile. 10
7 A Glossary of Terms used in British Heraldry, J.H. Parker, Oxford, 1894, Entry:hunting horn
8 A Treatise on Heraldry, J. Woodward, W & A.K Johnston, Edinburgh & London, 1896, P400
9 A Glossary of Terms used in British Heraldry, J.H. Parker, Oxford, 1894, Entry:Cockatrice
10 The Symbolisms of Heraldry, W. Cecil Wade, George Redway, London, 1898 P26


text:
Research Article|Articles in Press, 101892
An overview and policy implications of national nurse identifier systems: A call for unity and integration
Garrett K. Chan, PhD, APRN, FAAN
Garrett K. Chan
Corresponding author: Garrett Chan, PhD, APRN, FAAN, Associate Adjunct Professor, School of Nursing, University of California, San Francisco, President & CEO, HealthImpact, 2 Koret Way, Box 0610, San Francisco, CA 94143.
Associate Adjunct Professor, School of Nursing, University of California, San Francisco, President & CEO, HealthImpact, San Francisco, CA
Mollie R. Cummins, PhD, RN, FAAN
Mollie R. Cummins
Professor, Jon M. Huntsman Presidential Chair, Associate Dean for Research and the PhD Program, College of Nursing, University of Utah, Salt Lake City, UT
Cheryl S. Taylor, PhD, RN, FAAN
Cheryl S. Taylor
Associate Professor and Chair of the Graduate School Nursing Program, Southern University, Baton Rouge, LA
Betty Rambur, PhD, RN, FAAN
Betty Rambur
Professor and Routhier Endowed Chair for Practice, University of Rhode Island, Kingston, RI
David I. Auerbach, PhD, MS
David I. Auerbach
External Adjunct Faculty, Montana State University, Bozeman, MT
Mikki Meadows-Oliver, PhD, PNP-BC, FAAN
Mikki Meadows-Oliver
Clinical Professor, NYU, New York, NY
Cindy Cooke, DNP, FNP-C, FAANP
Cindy Cooke
Adjunct Faculty, University of Mary, Bismark, ND
Emily A. Turek, BA
Emily A. Turek
Government Affairs and Policy Coordinator, American Association of Colleges of Nursing, Washington, DC
Patricia (Polly) Pittman, PhD
Patricia (Polly) Pittman
Fitzhugh Mullan Professor and Director, Mullan Institute for Health Workforce Equity, George Washington University, Washington, DC
Open AccessPublished:January 12, 2023DOI:https://doi.org/10.1016/j.outlook.2022.10.005
Previous ArticleThe Robert Wood Johnson Foundation Future of Nursing Scholars program: The scholar experience
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Need to track the contributions of nurses to patient care and outcomes.
Need to understand the state of the nursing workforce.
Efforts are underway to advance unique identifiers for these purposes
Need to examine this emerging effort for potential challenges and opportunities.
There is a clear and growing need to be able record and track the contributions of individual registered nurses (RNs) to patient care and patient care outcomes in the US and also understand the state of the nursing workforce. The National Academies of Sciences, Engineering, and Medicine report, The Future of Nursing 2020–2030: Charting a Path to Achieve Health Equity (2021), identified the need to track nurses' collective and individual contributions to patient care outcomes. This capability depends upon the adoption of a unique nurse identifier and its implementation within electronic health records. Additionally, there is a need to understand the nature and characteristics of the overall nursing workforce including supply and demand, turnover, attrition, credentialing, and geographic areas of practice. This need for data to support workforce studies and planning is dependent upon comprehensive databases describing the nursing workforce, with unique nurse identification to support linkage across data sources. There are two existing national nurse identifiers– the National Provider Identifier and the National Council of State Boards of Nursing Identifier. This article provides an overview of these two national nurse identifiers; reviews three databases that are not nurse specific to understand lessons learned in the development of those databases; and discusses the ethical, legal, social, diversity, equity, and inclusion implications of a unique nurse identifier.
Nurse identifier
Nursing workforce
National provider identifier
National council of state boards of nursing identifier
During the past two years, unprecedented demand has been placed on the nursing workforce due to the worldwide COVID-19 pandemic. The focus on healthcare workers during the pandemic made the role of nurses more visible to the public. Yet the increased attention also highlighted the absence of robust data to track the nurse workforce. The absence of nurse data has hindered the ability to understand the factors driving high turnover and professional attrition. This gap has made it impossible to study the outcomes of nursing education in the manner similar to how other health professions have been examined. During a public health emergency, national, state, and local governments have limited data on how many licensed nurses are in a given locality, as well as where or whether they were practicing. The lack of nurse attribution data and a nurse tracking system directly impacts the ability to address a surge in the demand for patient care, such as issuing a call to licensed nurses to help in times of crises. It also impairs the ability of organizations to leverage experienced nurses that have left the bedside to mobilize support for younger nurses in their transition to practice.
As a result, there is a growing call to record and track the individual and collective contributions of registered nurses (RNs) to patient care and patient care outcomes in the US. As
Reed, 2020
Reed S.
National provider identifier: Why every Clinical Nurse Specialist needs one.
Clinical Nurse Specialist. 2020; 34: 231-233
states, "In the current healthcare climate, invisibility in data equals invisibility, period" (p 233). Further, the recent National Academies of Sciences, Engineering, and Medicine report, The Future of Nursing 2020–2030: Charting a Path to Achieve Health Equity (
National Academies of Sciences, Engineering, and Medicine [National Academies] 2021
National Academies of Sciences, Engineering, and Medicine [National Academies]
The future of nursing 2020-2030: Charting a path to achieve health equity.
The National Academies Press, Washington, DC2021
), identified the need to track nurses' collective and individual contributions to patient care outcomes. This capability depends upon the adoption of a unique nurse identifier, its implementation within electronic health records, and linking it to broader publicly available data sets that track the health workforce, health care, and health. Additionally, there is a need to understand the nature and characteristics of the overall nursing workforce including supply and demand, turnover, attrition, credentialing, and geographic areas of practice. This need for data to support workforce studies and planning is dependent upon comprehensive databases describing the nursing workforce, with unique nurse identification to support linkage across data sources.
Currently, the two main reasons for nurse identifiers that are in separate databases are for (a) efficiently and effectively transmitting financial transactions and health information electronically via the National Provider Identifier, and (b) for licensure tracking through the National Council of State Boards of Nursing Identifier. The unique identification of RNs is a critical step in advancing information technology interoperability. As part of Section 4,003 (c) of the 21st Century Cures Act (
21st Century Cures Act, H.R. 34, 114th Congress 2015
21st Century Cures Act, H.R. 34, 114th Congress. (2015). Retrieved from https://www.congress.gov/bill/114th-congress/house-bill/6/text, Accessed February 26, 2022.
); Public Law 114–255: 2016), healthcare systems will be required to create a trusted universal framework as a means of authenticating providers in EHRs for assured exchange of patients' health information.
The passage of the Health Information Technology for Economic and Clinical Health Act (HITECH Act) in 2009 spurred the use of health information technology (HIT) and the scope of the health information environment (
DesRoches et al., 2022
DesRoches C.M.
Painter M.W.
Jha A.K.
(Eds.). (2015, September 18).
Health Information Technology in the United States, 2015: Transition T. 2022; (Health Information Technology in the United States, 2015: Transition to a Post-HITECH World. Retrieved November 8, 2022, from)
https://ideas.repec.org/p/mpr/mprres/88affeeaf97a4893b1f96da5d93afa80.html
). Originally, the goal was broad adoption of EHRs for better data collection and analysis. Since then, EHRs and information technology have become more sophisticated, with secure data exchange within and across health systems for improved coordination of care, efficiency, and health outcomes now being the driver of HIT advances.
For nurses, the critical first step in doing so is the identification and adoption of a nurse identifier.
Unique nurse identification also brings opportunities for clarity of renumeration, either the nurse directly or to the employing agency, reflective of their contribution to care. Currently, in most settings nursing care is bundled into aggregate costs, for example, hospital room rates. As such, the clinical contributions of individual nurses are not discernable. Since the vast majority of nurses in the US are not reimbursed directly for their services, there is little impetus for them to register for a National Provider Identifier (NPI) through the National Plan and Provider Enumeration System (NPPES), or for health care systems to track them as unique providers in electronic health records (EHRs). Participation in both of these data systems would enhance our understanding of the nurse workforce and its contributions to safe, effective, high-quality care. This is particularly critical as the nation increasingly transitions to value-based care in which reimbursement reflects achievement of quality and cost metrics. Nearly 60 percent of all healthcare payments in the U.S. either stem directly from value-based models or linked in some manner to outcomes, quality, and cost, and this proportion is expected to increase (
LaPointe, 2021
LaPointe J.
The state of value-based reimbursement, financial risk in healthcare.
Xtelligent Healthcare Media. 2021; (Retrieved from) (Accessed November 9, 2022)
https://revcycleintelligence.com/features/the-state-of-value-based-reimbursement-financial-risk-in-healthcare
). An empirical link between a nurses' contribution to value and their salary may be particularly critical, given new evidence that among essential workers, RNs are the least satisfied with their salaries and less likely to perceive them as fair relative to other healthcare workers (
DeSilva, 2022
DeSilva H.
RNs among essential workers least satisfied with wage increases.
Becker's Hospital News. 2022; (Available at) (Accessed November 9, 2022)
https://www.beckershospitalreview.com/compensation-issues/rns-among-essential-workers-least-satisfied-with-wage-increases.html?origin=WomensE&utm_source=WomensE&utm_medium=email&utm_content=newsletter&oly_enc_id=9085F7288456J5N
There are two existing systems that uniquely identify individual RNs at the national level: the National Provider Identifier (NPI) and the National Council of State Boards of Nursing identifier (NCSBN ID). This paper examines the advantages and disadvantages each. By way of comparison, we also describe the benefits, challenges, and lessons learned of three other national provider databases that are not specific to nursing.
The National Provider Identifier (NPI)
One of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (Public Law 104–191) required the creation and adoption of a unique identification number for providers, health plans, and healthcare clearinghouses to improve the efficiency and effectiveness of electronic transmission of health information and financial transactions (
Centers for Medicare and Medicaid Services Medicare Learning Network 2021
Centers for Medicare and Medicaid Services Medicare Learning Network. (2021). NPI What you need to know -CMS. Retrieved February from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/NPI-What-You-Need-To-Know.pdf. Accessed February 26, 2022.
). The Administrative Simplification standards, sometimes known as the electronic data interchange (EDI) standards, help save time and costs across different healthcare systems. For example, these standards mandate industry interoperability across EHRs and other electronic healthcare databases and systems to streamline paperwork and exchange of information such as transactions for pharmacy and healthcare administrative information, including healthcare claims (
Centers for Medicare and Medicaid Services n.d
Centers for Medicare and Medicaid Services. (n.d.). About administrative simplification – CMS. HIPAA and Administrative Simplification Overview. Retrieved from https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/HIPAA-ACA/Downloads/AboutAdminSimpFactSheet20171017.pdf. Access November 9, 2022.
). The NPI is one standard included as an EDI standard.
The NPI is a 10-digit number that allows providers to identify themselves in the healthcare system and is associated with an individual provider for the duration of their career (
). NPIs are available for registered nurses, advanced practice registered nurses (APRNs), physicians, dentists, chiropractors, and psychologists, among others. Enrollment for an NPI through the Centers for Medicare and Medicaid Services (CMS) National Plan is free of charge, and the database is the Provider Enumeration System (NPPES). It takes from 1 to 20 days to receive an NPI, once a completed application is received. Data on active and deactivated NPIs are compiled monthly, with incremental updates provided weekly (
Centers for Medicare and Medicaid Services 2021
Centers for Medicare and Medicaid Services. (2021). Data dissemination. Retrieved from https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/DataDissemination. Accessed February 26, 2022.
). The data are stored in the NPPES NPI Registry and disclosed to the public under the Freedom of Information Act. Therefore, the data in the NPPES NPI Registry, which includes the fields noted in Table 1, are available to download free of charge.
Table 1NPI and Nursys Data Fields
NPI (selected fields)
Nursys
NPI number License number(s)
Full name Full name
Practice or business mailing address, telephone
number, country License status
Unencumbered (full unrestricted license to practice)
Cease and desist
Denial of license
Expired license
Other license action
Voluntary agreement to refrain from practice
Voluntary surrender
License(s) type, number(s), state(s)
NPI deactivation reason, date
Healthcare provider taxonomy code(s)
Sole proprietor or Organization
Currently, all healthcare clinicians, including nurses, who conduct electronic transactions and transmit health information, are required to obtain an NPI. Many nurses also use the NPI for direct billing for their services2. Payers and researchers use the NPI in analysis of prescription, screening, and diagnostic trends (
Klein, 2008
Klein, K. A. (2008). Do registered nurses need a National Provider Identifier (NPI)? Retrieved from https://www.medscape.com/viewarticle/579984#vp_2. Accessed February 26, 2022.
highlights specific requirements for nurses to obtain an NPI number, including: (a) nurses who participate in, provide services, and are paid by federally funded programs, such as Medicare, Medicaid, and Community HOME Investment Program; (b) nurses who work in specific settings that bill for nursing services separately, such as home health, long-term care, occupational health, and other areas that bill for nursing services; and (c) nurses participating in research performed in large healthcare systems or health plans, especially as health systems continue to merge.
Nurses can apply for their NPI while still a student and change their status once they pass the licensure test and have obtained employment.
A greater understanding of nurses' roles, work settings, and activities via an NPI would flow from the availability of NPIs for other providers along with RNs, thus allowing for a complete picture of relationships between providers, analyses of care teams, and underlying healthcare workforce issues.
National Council of State Boards of Nursing Identifier (NCSBN ID)
The NCSBN ID has been recognized as an opportunity to enhance the "visibility of nurses' contributions" (
Beale et al., 2021
Beale N.
Carroll W.
Aldrich K.
Alexander S.
Baernholdt M.
Fields W.
What a unique nurse identifier means for the future.
American Nurse Journal. 2021; 16: 21-24
, p 21). The NCBSN ID was designed by the National Council of State Boards of Nursing in response to the long-recognized importance of uniquely identifying individual nurses to gain insight into practice patterns and workforce issues.
The NCSBN ID was initially used as a unique identifier to verify licensure, discipline, and practice privileges for RNs, APRNs, and licensed vocational/practical nurses (LVN/LPNs) in specific jurisdictions. The NCSBN ID can be automatically and universally assigned to nurses when they are initially licensed, and some states boards of nursing have begun to do so. The system and underlying database for updating and maintaining records of individual nurses with a NCSBN ID is called Nursys. This database system is used by state licensing bodies to access and update information on individual nurses. NCSBN has indicated that Nursys also is available to researchers and quality experts to engage in quality, patient outcome, and health services research (
Sensmeier et al., 2019
Sensmeier J.
Androwich I.
Fong V.
Rajwany N.
The value of nursing care through use of a unique nurse identifier.
Online Journal of Nursing Informatics (OJNI). 2019; 23
). Currently, all RNs, APRNs, LVNs, and LPNs with a record of licensure in the United States hold an NCSBN ID. Data fields that are available within Nursys are found in Table 1.
Since its creation, the NCSBN ID has gained favor and support in the nursing community. The Alliance for Nursing Informatics (ANI), a collaboration of more than two dozen professional organizations engaged in nursing informatics whose members include the American Association of Colleges of Nursing, American Nurses Association, American Nursing Informatics Association, and Healthcare Information and Management Systems Society, has endorsed the following policy statement: "The NCSBN ID should be used by key stakeholders as a nurse identifier to demonstrate the value of nursing through research and enhance individual care and health outcomes via more comprehensive documentation in the EHR (electronic health record), ERP (enterprise resource planning) and technologies and systems" (
Alliance for Nursing Informatics 2020
Alliance for Nursing Informatics. (2020). Demonstrating the value of nursing care through the use of a unique nurse identifier. Retrieved from https://www.allianceni.org/sites/allianceni/files/wysiwyg/inline-documents/ANI_Unique_Nurse_Identifier_Policy_Statement_FINAL4_Approved_071620.pdf. Accessed November 9, 2022.
Currently, efforts to advance the adoption of the NCSBN ID as a unique nurse identifier in electronic health records continue to be led by the Nursing Knowledge: Big Data Science Initiative (BDSI), facilitated by the Alliance for Nursing Informatics. Though recognizing the importance of the NPI for payment to advanced practice registered nurses, BDSI also acknowledges the opportunity for widespread implementation provided by the NCSBN ID, which can be automatically assigned to new nurses when they pass their licensure exam (
). BDSI has moved forward with the development of an action plan aimed at achieving widespread adoption and implementation of the NCSBN ID as a consensus standard for uniquely identifying nurses in electronic health records and health information exchanges, as well as to support health services research. Additionally, several pilot projects are in progress entailing the implementation of the NCSBN ID as a unique nurse identifier within EHRs within HCA Healthcare, the University of Alabama in Huntsville, and at the Center for Medical Interoperability (
Alliance for Nursing Informatics. (2021). Nurse unique identifier (NCSBN ID) ongoing proof of concept. Retrieved from https://www.allianceni.org/sites/allianceni/files/wysiwyg/inline-documents/Proof_of_concept_Nurse_Unique_Identifier_Jan_2021.pdf. I accessed it on November 9, 2022.
Lessons From Other National Databases
An analysis of other national or widely used databases is crucial to learn about the issues and challenges of those identification databases to avoid pitfalls in the development of the nursing system or network of systems to fully account for and attribute work to the nursing workforce. An overview of functions, issues, and challenges of three databases will be reviewed: the American Medical Association (AMA) Physician Masterfile, the National Practitioner Data Bank (NPDB), and the Acute Physiology and Chronic Health Evaluation (APACHE) database.
AMA Physician Masterfile
The AMA Physician Masterfile is the most well-established health profession database and its success and some of the controversies surrounding it may provide insights. Given that academic and licensing agency data are entered directly into the database, the physician Masterfile is considered a primary resource for verification of credentials and other activity by third-party organizations such as employers. Unlike the NCSBN ID, the Masterfile uses the NPI as the primary identification system.
The Masterfile was created in 1906, initially as a record keeping method supporting membership and mailing activities of physicians within the United States (
American Medical Association n.d.a
American Medical Association. (n.d.a.). American Medical Association Physician Masterfile. Retrieved from https://www.ama-assn.org/about/masterfile/ama-physician-masterfile. Accessed February 26, 2022.
). Today, a record within this database is generated when an individual enters a medical school accredited by the Liaison Committee on Medical Education (LCME) or if the physician was educated in a foreign country and is considered an international medical graduate (IMG). The IMG record is generated upon entry into a post-graduate residency training program accredited by the Accreditation Council for Graduate Medical Education (ACGME) or if the IMG is licensed in one of the 68 US licensing jurisdictions. The database collects a wide range of data on each individual physician or trainee such as, but not limited to, name, professional mailing address and telephone number, birthplace and date, medical and/or osteopathic education and year of graduation, graduate medical education specialty/subspecialty and the sponsoring institution with training dates, state license numbers, Drug Enforcement Agency registration status, NPI registration information, licensure or other federal sanctions, major professional activity, and practice specialty (
American Medical Association n.d.b
American Medical Association. (n.d.b.). Data services & publications. Retrieved from https://www.ama-assn.org/about/masterfile/data-services-publications, Accessed February 26, 2022.
Third-party organizations can access the physician Masterfile for a fee, including research institutions, governmental agencies, professional medical organizations, universities and medical schools, and other health-related groups (
). The AMA has mechanisms for database licensing, contracts, and royalties, although details of these mechanisms are not publicly available (
American Medical Association n.d.c
American Medical Association. (n.d.c.). Contracts & royalties. Retrieved from https://www.ama-assn.org/about/masterfile/contracts-royalties. Accessed February 26, 2022.
American Medical Association n.d.d
American Medical Association (n.d.d.). About database licensing. Retrieved from https://www.ama-assn.org/about/masterfile/about-database-licensing-dbl. Accessed February 26, 2022.
Prior to 2006, the AMA Physician Masterfile data were available for sale to pharmaceutical companies for direct marketing purposes regardless of physicians' privacy or other objections (
Wolfe, 2012
Wolfe S.M.
The American Medical Association and Its Dubious Revenue Streams.
Public Citizen Health Letter. 2012; 28
https://www.citizen.org/wp-content/uploads/hl_201211.pdf
). In 2004, the AMA commissioned a Gallup poll of physicians to understand physician preferences about privacy as it relates to pharmaceutical companies, and the poll found that two-thirds of physicians were opposed to the release of data, and 77% felt that an opt-out program would alleviate concerns about release of the data (
Saul, 2006
Saul S.
Doctors Object to Gathering of Drug Data.
The New York Times. 2006; 5
). As a result of the objections, the AMA included new functionality to prohibit a physician's information from being shared with industry for marketing purposes or any other reason (
). This privacy function is an opt-out system rather than an opt-in system (
), meaning that the physician needs to be proactive and take action to prohibit release of data to industry. Today, while the AMA does not collect, license, sell, or have access to physician prescribing data, pharmaceutical companies and pharmaceutical representatives can license the AMA Physician Masterfile and match physicians with data collected by Health Information Organizations (HIOs) to understand prescribing patterns of individual physicians (
American Medical Association n.d.e
American Medical Association. (n.d.e.). AMA physician data restriction program. Retrieved from https://www.ama-assn.org/about/masterfile/ama-physician-data-restriction-program. Accessed February 26, 2022.
). HIOs are organizations that serve as a local or regional health information exchange (HIE) network (
Adler-Milstein et al., 2021
Adler-Milstein J.
Garg A.
Zhao W.
Patel V.
A survey of health information exchange organizations in advance of a nationwide connectivity framework.
Health affairs (Project Hope). 2021; 40: 736-744https://doi.org/10.1377/hlthaff.2020.01497
Licensing, contracts, and royalties from the AMA Physician Masterfile are major sources of revenue. According to the AMA 2020 Annual Report (
American Medical Association n.d.f
American Medical Association. (n.d.f.). 2020 AMA Annual Report. Retrieved from https://www.ama-assn.org/system/files/2021-04/2020-annual-report.pdf. Accessed February 26, 2022.
), revenue from publishing, health solutions, and insurance (the umbrella term that includes database products including royalties) brought in $376 million in revenue.
Though the AMA database meets many informational needs, there are limitations. In particular, the field of "active" may be delayed in its updates, as it takes time to identify retired and deceased physicians.
Similarly, practice settings may lag in updates. Still, the benefits of having a central source for data on the education and training of physicians allows for longitudinal studies that are impossible to do for nurses.
The decades of research using the AMA Masterfile to track the physician workforce underscore the importance of this resource to advancing scholarship. One innovative effort to link educational curricula and learner outcomes to clinical outcomes led the University of Minnesota Medical School to create a Medical Education Outcomes Center (MEOC) (
Rosenberg et al., 2019
Rosenberg M.E.
Gauer J.L.
Smith B.
Calhoun A.
Olson A.
Melcher E.
Building a medical education outcomes center: development study.
JMIR medical education. 2019; 5: e14651https://doi.org/10.2196/14651
). The MEOC was linked to the Masterfile data of UMMS graduates and the NPI registry to connect alumni practice data to education data. In another example, researchers at George Washington University used the NPPES and the AMA Masterfile to create interactive maps at the county level to track workforce shortages during the COVID-19 pandemic (
Fitzhugh Mullan Institute for Health Workforce Equity n.d
Fitzhugh Mullan Institute for Health Workforce Equity. (n.d.). Covid-19 county workforce deficit estimator. Retrieved from https://www.gwhwi.org/tracker-county-workforce.html. Accessed February 26, 2022.
National Practitioner Data Bank
The National Practitioner Data Bank (NPDB) is a web-based repository of reports related to medical malpractice payments and certain adverse acts involving healthcare practitioners, providers, and suppliers (
National Practitioner Data Bank n.d.a
National Practitioner Data Bank. (n.d.a.). National Practitioner Data Bank About Us. Retrieved from https://www.npdb.hrsa.gov/topNavigation/aboutUs.jsp. Accessed February 26, 2022.
). Over time, the NPDB has served as an important repository to ensure the quality and safe patient care through disclosure of important information about incompetent or unprofessional behavior, fraud, and abuse by healthcare professionals, providers, and suppliers. The NPDB is a national database that is free of charge, easily accessible by anyone, and demonstrates the feasibility of such a resource.
NPDB was created as a result of the passage of the Health Care Quality Improvement Act (HCQIA) of 1986 to protect the health and safety of the public by informing actual or potential employers and medical staffs of incompetent or unprofessional behavior of physicians. Initially, the law offered qualified immunity from liability for peer review of physicians, dentists, and other healthcare providers; mandated the creation of a national practitioner data bank to track incompetent, inept, or unprofessional physicians; and enacted procedural rules for due process, privilege restrictions, and reporting and disbursement of information (
Horner, 1990
Horner S.L.
The Health Care Quality Improvement Act of 1986: Its history, provisions, applications and implications.
American journal of law & medicine. 1990; 16: 455-498
). In the HIPAA of 1996, provisions of the law mandated the creation of the Healthcare Integrity and Protection Data Bank (HIPDB) to combat fraud and abuse in health insurance and healthcare delivery (
National Practitioner Data Bank n.d.b
National Practitioner Data Bank. (n.d.b.). HIPDB Archive. Retrieved from https://www.npdb.hrsa.gov/resources/hipdbArchive.jsp. Accessed February 26, 2022.
). The HIPDB housed information regarding civil judgments, criminal convictions, or actions by a federal or state licensing agency against a healthcare provider, supplier, or practitioner related to the delivery of a healthcare item or service (
Scott, 1999
Scott R.L.
(rep.). Fighting Fraud: Healthcare Integrity and Protection Data Bank.
University of Huston Law Center, 1999
https://www.law.uh.edu/healthlaw/perspectives/Fraud/991210Fighting.html
). In 2013, due to many overlaps of data that HIPDB and NPDB collected and to reduce redundancy and duplication, pursuant to the Affordable Care Act of 2010, all data from HIPDB are now part of the NPDB database and collection system (
The NPDB is housed within the Health Resources and Services Administration (HRSA) and is a public- private partnership. The system was designed to be self-supporting through query fees (
National Practitioner Data Bank n.d.c
National Practitioner Data Bank. (n.d.c.). NPDB History. Retrieved from https://www.npdb.hrsa.gov/topNavigation/timeline.jsp. Accessed February 26, 2022.
). The first private company to create and manage the NPDB was Unisys in 1988, and in 1995, the contract was given to SRA International to develop and manage the second generation of NPBD (
Berkshire Hathaway 2012
Berkshire Hathaway. (2012). SRA Awarded $78.5 Million Contract from National Practitioner Data Bank. Business Wire. Retrieved from https://www.businesswire.com/news/home/20120109006718/en/SRA-Awarded-78.5-Million-Contract-from-National-Practitioner-Data-Bank. Accessed February 26, 2022.
). In 2012, SRA International did receive a $78.5 million contract for the Fifth Generation NPDB and the HIPDB (
The NPDB was not created immediately after the passage of HCQIA of 1986 and was unveiled in 1990. Between 1986 and 1990, the rules and regulations needed to be promulgated. Early publications analyzing the NPDB identified issues to consider: disparate reporting requirements, resolving data bank disputes, the effect of terminating physician privileges as a result of data in the NPDB, corporate liability for malpractice, clinical agency liability for failure to report, increased risk for litigation and access by plaintiff lawyers for malpractice suits, when to purge information out of the NPDB, appeal rights, physician statements regarding information found in the NPDB file, education of physicians related to the implications of the NPDB, confidentiality, third-party access to the NPDB file, and the costs of establishing and operating the NPDB (
Anderson, 1990
Anderson B.J.
Problems of the National Practitioner Data Bank.
The Medical staff counselor. 1990; 4: 21-30
Passin and Haberek, 1990
Passin P.
Haberek J.
National practitioner data bank: How to exercise your rights.
Health policy week: HPW. 1990; 19: 1-5
). Many of these issues were resolved over the course of the life of the NPDB. These are potential issues for consideration in designing access to a comprehensive nurse identifier system for nationwide utilization. According to the NPDB Guidebook, only authorized entities are allowed to access the NPDB, which is not a publicly available database (
National Practitioner Data Bank n.d.d
National Practitioner Data Bank (n.d.d.). NPDB Guidebook. Retrieved from https://www.npdb.hrsa.gov/guidebook/APreface.jsp. Accessed February 26, 2022.
). Also, the practitioners, providers, or suppliers are able to enter a statement, and there is a dispute process.
Acute Physiology and Chronic Health Evaluation (APACHE)
There have been examples of health professions' databases dissolving as a result of conflict regarding funding and access issues. These risks should be duly considered in relation to the NCSBN ID and its governance.
One example is the Acute Physiology and Chronic Health Evaluation (APACHE) tool. The APACHE II system was a free database intended to be used as a quality improvement tool (
Knaus, 2002
Knaus W.A.
APACHE 1978-2001: The development of a quality assurance system based on prognosis.
Arch Surg. 2002; 137: 37-41
). It became the "gold standard" for quality for medical and surgical care monitoring and was widely accepted and used in clinical care. In over 20 years, more than 2,000 peer-reviewed scientific research studies used APACHE (
). APACHE and APACHE II were managed and further refined by APACHE Medical Systems, Inc. (AMSI). AMSI was funded by the National Institutes of Health and private foundations.
When the AMSI decided to create the next version of APACHE – APACHE III – AMSI decided to seek venture capital and have APACHE III become the new commercial version of APACHE. The APACHE III public offering in 1996 raised $25 million to help with further research, development, and distribution (
). Subsequently, questions were raised that federal monies were spent inappropriately to promote APACHE's commercial operations; yet AMSI was cleared of these allegations after a prolonged legal review by the Agency for Healthcare Quality and Research (formerly the National Center for Health Services Research). Even so, clinical colleagues were critical of the commercialization and demanded that the APACHE software be free. Ultimately, because of the commercial controversy, the field of risk scoring and prognostication in critical care became confused and fragmented. Instead of a single tool being the standard for illness severity and prognosis, other systems that were free to use such as the Simplified Acute Physiology Score (SAPS), the Mortality Probability Model (MPM), and the Society for Critical Care Medicine's Project IMPACT tool, among others proliferated and entered the field.
There are some lessons to be learned from the APACHE example. If databases are privatized and access to the data are not free or are not available for a nominal fee, then the potential for finding alternatives to the centralized database that allow for free access to data can splinter the centralized database and create many other databases. As a result, there is no unified and reliable single source of information. This disunity of prognostication and quality improvement tools has led to confusion among the various tools. Choosing the incorrect tool among all of the available tools can lead to wastage of time, increased cost, unwarranted clinical extrapolations, and poor science (
Rapsang and Shyam, 2014
Rapsang A.G.
Shyam D.C.
Scoring systems in the intensive care unit: A compendium.
Indian journal of critical care medicine: Peer-reviewed, official publication of Indian Society of Critical Care Medicine. 2014; 18: 220-228
There is an urgent need for a reliable and comprehensive healthcare workforce database to support workforce planning and evaluation at the national, state, and local level and to ensure that the contributions of nurses are fully taken into account as value-based payment evolves (
). The pandemic has shown how important it is for the government and large employers to have data on the current supply of licensed nurses, as well as where and whether they are working. There is also evidence that hospitals known for nursing excellence perform better in value-based payment arrangements such as Hospital Value-Based Purchasing (
Lasater et al., 2016
Lasater K.B.
Germack H.D.
Small D.S.
McHugh M.D.
Hospitals known for nursing excellence perform better on value based purchasing measures.
Policy, politics & nursing practice. 2016; 17: 177-186https://doi.org/10.1177/1527154417698144
). This program, as well as the Hospital Acquired Condition (HAC) Reduction Program, and the Hospital Readmission Reduction Program all rely on nurse sensitive or fully nurse-driven performance measures. Yet, to the authors' knowledge, the enhanced reimbursement stemming from value-based payments has not flowed to the nurses who shape these outcomes. If reimbursement is based on value metrics and measurement of nurses' contributions to outcomes is absent, then nurses' contributions are excluded from the financial analysis and are therefore viewed as only a labor expense.
Dimond, 2019
Dimond V.
Value based care should include caring for our nurses.
Healthcare Purchasing. 2019; (Retrieved October 4, 2022 from) (Accessed November 9, 2022)
https://www.hpnonline.com/blog/article/21089283/value-based-care-should-include-caring-for-our-nurses
underscores the existing absence of nurse/value-based payment "profit-sharing" (para 3) and suggests that nurses only receive negative feedback when performance metrics linked to payment are not achieved. Unique identifiers may offer one strategy whereby the nurses who create the value can be more directly compensated for it. Such efforts may also offer corrective action to address the findings of
Yang & Anderson, 2022
Yang W.
Anderson G.
Hospital resource allocation decisions when market prices exceed Medicare prices.
Health services research. 2022; 57: 237-247https://doi.org/10.1111/1475-6773.13914
. This study of 8,862 hospital-year observations found that non-profit hospitals with more revenue largely did not allocate those resources to expenditures that impact patients, service offerings, or the workplace environment, but instead to administrative expenses and revenue surpluses. Having a unique nurse identifier has the potential to more accurately determine the relationship between revenue and nurses' contributions. However, more discussions about the impact of a unique identifier on health care finance is essential.
Conversely, is there the potential for unintended negative consequences? Would individual nurses be targeted for poor performance on metrics for reasons that are beyond their control, such as inadequate staffing, system failures, or legal controversies? The RaDonda Vaught criminal charge offers a chilling view into a specter where an individual nurse is blamed for a broader system failure.
See the letter from the American Nurses Association and Tennessee Nurses Association to the Judge Jennifer Smith regarding the sentencing of RaDonda Vaught at https://www.nursingworld.org/∼49a0c0/globalassets/practiceandpolicy/ethics/vaught-judge-letter-05092022.pdf
The tenets of a Just Culture take in consideration the quality of one's choices, risk, systems design, human behavior, and patient safety (
Boysen P. G
Boysen P. G., 2nd (2013). Just culture: a foundation for balanced accountability and patient safety. The Ochsner journal, 13(3), 400–406.
U.S. Department of Health and Human Services, 2022
Marx, D. (2022, April 5). Radonda Vaught found guilty of negligent homicide. LinkedIn. Retrieved November 9, 2022, from https://www.linkedin.com/pulse/reckless-homicide-vanderbilt-just-culture-analysis-david-marx/?utm_source=Outcome%2BEngenuity%2B2017&utm_campaign=bec0fe1b64-VANDERBILT_2019_03_02_03_39&utm_medium=email&utm_term=0_d9af1bc6e6-bec0fe1b64-87912065
). The attribution of an error and the subsequent criminalization of that error through a unique nurse identifier are a topics for much more discussion in the nursing profession. Additionally, the HIPAA Privacy Rule ensures that protected health information (PHI) including information related to abortion and other sexual and reproductive health care will be kept private (
U.S. Department of Health and Human Services. (n.d.). HIPAA privacy rule and disclosures of information relating to reproductive health care. Retrieved from https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/phi-reproductive-health/index.html, Washington, D.C. Accessed July 24, 2022.
). While HIPAA does afford privacy of PHI, privacy advocates are concerned that search engines could be used to prosecute abortion seekers (
Allyn, 2022
Allyn B.
Privacy advocates fear Google will be used to prosecute abortion seekers.
NPR, 2022
https://www.npr.org/2022/07/11/1110391316/google-data-abortion-prosecutions
) and some abortion clinic providers are only using paper charts to ensure the maximum privacy of patients (
Collier, 2022
Collier, K. (2022). Looming abortion law changes prompt digital privacy worries for Clinics. Looming abortion law changes are pushing clinics to take a look at digital privacy. Retrieved from https://www.nbcnews.com/tech/security/abortion-clinics-providers-digital-privacy-roe-overturn-rcna30654. Accessed July 24, 2022.
). Considerations regarding the ethical, legal, and social implications as it relates to privacy and how law enforcement may try to access PHI and provider practices needs to be discussed before any implementation is enacted.
Unique nurse identifiers, if included in the EHR, would allow for clearer understanding of the value of nurses' work in various practice settings that use the EHR. For example, it could also help identify and distinguish RN roles and the roles of unlicensed healthcare workers with the aim of ensuring a safe and effective healthcare system with all nurses practicing to the full extent of their education and licensure or certification. It could also allow for real- time implementation research to assess the contribution of nurses to value-based performance and payment metrics that go beyond the traditional nurse-sensitive measures (e.g., hospital acquired infections, patient falls, pressure ulcer, and patient satisfaction). As new measures are added to reporting requirements, such as those related to severe hypoglycemia and hyperglycemia within the Hospital Inpatient Quality-Reporting Program, nurses who understand quality and payment measures are in an optimal position to deploy identifiers to maximize not only the quality of care, but also their professional practice (
). Moreover, the unique identification of nurses is essential for robust systems of interoperability and health information exchange needed to support patient care across settings.
As summarized in Table 2, the attributes and foci of the NPI and NCSBN ID differ, and each has advantages and disadvantages, when considered in light of the lessons learned through the three other databases reviewed above. At the same time, the increased visibility of individual nurses' performance could have unintended consequences to the nursing workforce and individual nurses. For example, nurses who contribute to poor outcomes for which hospitals are penalized under the HAC Reduction Program could be unfairly targeted (
), even when organizational factors, such as overall staffing levels and skill mix, were the primary drivers of poor outcomes. Critical strengths of NCSBN ID are its comprehensive coverage, automatic re-enrollment, and automatic updating. The NSCBN ID could be feasibly implemented in EHRs. The major challenge, as suggested by the AMA and the APACHE cases, is a lack of certainty around how future public access and fee structures could affect the viability of its long-term use as a unique nurse identifier. As such, it will be important for NCSBN to engage with state boards of nursing and stakeholders with an interest is using the NCSBN ID to ensure appropriate governance and access.
Table 2Comparison of the NPI and NCSBN ID
NCSBN ID
Owner Centers for Medicare and Medicaid Services National Council of State Boards of Nursing
Database NPPES NPI Registry Nursys
Enrollment Voluntary; RN/APRN must apply Automatically enrolled and an identifier is assigned upon initial licensure
Coverage Most APRNs, low percentage of RNs All RNs, APRNs, and LVN/LPNs with a record of licensure
Fee for identifier number for nurses Free Free
Database access Publicly available
Accessible for matching, via API or web interface, at no cost
Data not available for download in its entirety as a database; it is owned by the individual state boards of nursing.
Fee for accessing database No Yes
How the identifier is updated RN/APRN must submit updates. Automatically upon licensure Changes
Current use case
All clinicians who conduct electronic transactions and transmit health information are required to have an associated NPI.
Payers and researchers use the NPI in the analysis of prescription, screening, and diagnostic trends.
An NPI is used for billing purposes with payers.
Unique identifier for the purposes of licensure, discipline, and practice privileges for RNs, APRNs, and LVN/LPNs.
Track nurses electronically across state licensures
Pilot projects in progress or completed by HCA Healthcare, University of Alabama in Huntsville, and the Center for Medical Interoperability (
Planned use CMS' call for interoperability includes requirement that all providers be included in NPPES
Ongoing effort to endorse and promote use in EHRs by the Alliance for Nursing Informatics
Use in EHRs for the purposes of health information exchange
Health services and workforce research
Summary of Limitations
Only RNs that bill or are in certain federal-funded programs are required to register. Others have no incentive to sign up.
NPI holders must submit changes, including when an RN/APRN leaves the profession. As with other professions in NPPES, there are instances when this does not happen.
When health professionals change jobs, their new employer should upload new work address, but sometimes this does not happen.
Only a small percentage of the nursing workforce holds an NPI.
Although virtually all of the nursing workforce holds an NCSBN ID, it has not been widely adopted within EHRs.
Functions as a free unique nurse identifier, and Nursys® can be used to look up or match identities, but the data cannot be downloaded in its entirety, which could be a limitation in some types of workforce studies.
APRN, advanced practice registered nurse; HER, electronic health record; LVN, licensed vocational nurse; LPN, licensed practical nurse; NPPES, National Plan and Provider Enumeration System; NPI, National Provider Identifier; RN, registered nurse.
The NPI also has advantages and disadvantages. As a federal database subject to the Freedom of Information Act, the prospective issues of access and fee structures do not represent a barrier to nurses or researchers. The NPI would also provide a number that could be used in studies of teams and other cross- professional research questions. The system would allow for local, state, and federal level planning and evaluation of the nursing workforce, which is critical during public health emergencies, as well as for long- term estimations of needs and allocative efficiencies. Currently, registration is not necessary for practice as an RN. Consequently, the overwhelming majority of RNs do not register for NPIs.
While NPIs could be a powerful complement to the NCSBN ID in advancing nursing workforce data, policy action addressing barriers to registration are necessary for the NPI to evolve into a robust workforce database for nurses. Further, the US Congress would likely need to authorize additional funding for CMS to modernize the NPPES NPI Registry to accommodate millions of additional records and new user interaction with the system. Both funding and policy investments would be necessary for its use as a unique nurse identifier.
As the development of a system or network of systems are developed to create a unified national nurse identifier system, it is important to keep in the national discourse and understanding regarding the desired needs and the intended and unintended impact or outcomes on the ethical, legal, and social factors of the unique nurse identifier. For example, when the Human Genome Project was being established, the healthcare and scientific community was concerned about how the new genetic information was going to be used, how the genetic data would be housed, and how individuals and society should be protected from possible harm. As a result, the Ethical, Legal, and Social Implications (ELSI) program of Human Genetics Research was created to examine and address those issues and assist in the development of policy recommendations and guidelines to protect individuals and society (
National Institutes of Health 2012
National Institutes of Health. (2012). Review of the ethical, legal and Social Implications Research Program and Related Activities (1990-1995). Genome.gov. Retrieved from https://www.genome.gov/10001747/elsi-program-review-19901995. Accessed February 26, 2022.
). Examples of possible use case scenarios are listed in Table 3. Ethicists, thought leaders, and business leaders should engage in the discourse about the issues and controversies that confronted the AMA Physician Masterfile, NPDB, and APACHE in addition to how to ensure that any organization provides equitable access while remaining financially solvent. Further deep discussions should also include topics such as how minority nurses can be hurt or helped by a unique nurse identifier and what the intended and unintended consequences are of a nurse identifier. A nurse identifier is yet another label that is attached to someone. While there are no databases that currently collect personal demographic data such as race and ethnicity, future iterations of a national unique nurse identifier could include those data, especially for workforce studies. Both the National Academy of Medicine's report, The Future of Nursing 2020 to 2030: Charting a Path to Achieve Health Equity (2021) and the
National Commission to Address Racism in Nursing 2022
National Commission to Address Racism in Nursing. (2022). Racism in Nursing. Retrieved from https://www.nursingworld.org/∼49c4d0/globalassets/practiceandpolicy/workforce/commission-to-address-racism/racism-in-nursing-report-series.pdf. Accessed August 22, 2022.
report call upon the nursing profession to dismantle structural and cultural racism. In discussing the racial, ethical, legal, and social implications of a unique national nurse identifier before the identifier is linked to demographics can potentially avoid the need to dismantle structural and cultural racism. Additionally, determining the types of information that current and potential users want and for what purposes is a critical component of the national dialogue among nursing leadership. Learning from past examples will help the nursing profession plan for a smooth, equitable, fair, and just development of a nurse identifier system or network of systems. Some key questions are listed in Table 4 and are intended to engage nursing and healthcare leaders to proactively address the ethical, legal, and social implications of a national nurse identifier.
Table 3Possible Use Case Scenarios
Identified Need for an Integrated Nurse Identifier System
Understanding and analyzing workforce issues, such as supply, demand, shortage areas, migration of the workforce, specialty, and subspecialty practice. Designation of shortage areas could include nurses, and it would be possible at a highly localized level, using a valid and reliable public data source. Health Professional Shortage Areas (HPSAs) currently include only physicians, for example, but if data were available for nurses in the NPPES, it would be possible for the US Department of Health and Human Services to add them, or create a new designation regarding the nurse workforce.
Attribution of work to understand quality of care, the value and contributions of nursing, and reimbursement models. Any of the services nurses can provide in ambulatory, community, and primary care settings are billable if nurses have an NPI (
Flinter et al., 2017
Flinter M.
Hsu C.
Cromp D.
Ladden M.D.
Wagner E.H.
Registered nurses in primary care: emerging new roles and contributions to team-based care in high-performing practices.
The Journal of ambulatory care management. 2017; 40: 287-296https://doi.org/10.1097/JAC.0000000000000193
). There is a growing body of evidence highlighting the potential roles of RNs in primary care, including preventive care, chronic illness management, practice operations, care management, and hospital transition care (
Bodenheimer & Mason, 2017
Bodenheimer T
Mason D
Registered Nurses: Partners in Transforming Primary Care. Proceedings of a conference on Preparing Registered Nurses for Enhanced Roles in Primary Care.
in: Josiah Macy, Jr. Foundation, New York2017
Needleman, 2017
Needleman J.
Expanding the role of registered nurses in primary care: A business case analysis.
The Journal of Medical Practice Management. 2017; 32: 343-351
points out that RNs practicing in primary care can bring significant income into this practice setting, far above the cost of RN employment. Further, RNs in the outpatient community, and primary care settings are practicing more autonomously, leading case management, managing patient panels, and coordinating complex care (
Another example is a nurse identifier would allow the nursing profession to expand its impact in the context of interdisciplinary teams in various types of practice settings. Using common, consistent, and accessible identifiers across provider types allows employers, researchers, and policymakers to understand specific team configurations in relation to specific types of population needs and could lead to greater efficiency and effectiveness. The NPI allows nursing to join an interprofessional identifier system, one that would enhance visibility in healthcare and health services research and increase the likelihood of future models of interprofessional care optimizing the scope of nursing practice.
Credentials and privileges to understand scope of services and scope of practice. Attribution data cross-referenced with workforce data can help articulate the scope of services and
scope of practice of nurses and advanced practice registered nurses to inform policy and education in various types of practice settings.
Evaluating nursing educational outcomes on quality of care. The Medical Education Outcomes Center (MEOC) (
) is a good example of how new innovations can help evaluate the effectiveness of curricula and andragogies can have an impact on graduates and the quality of care.
Evaluation of the impact of federal dollars, grants, scholarships, and loans on the nursing workforce to support future funding. The Health Resources and Services Administration (HRSA) is supportive of the expansion of NPIs to nurses because it would allow them to track clinicians over time and assess the impact of grants/loan/scholarship programs. This would help them build links between education, training, and healthcare service in various types of practice settings. Such linkages would empower HRSA and the nursing community to demonstrate the value and reach of these workforce programs and support future funding.
Table 4Key Questions for Policy Development Related to a National Nurse Identifier System
How can we leverage the relative strengths of the NCSBN ID and NPI to optimize nursing workforce data for knowledge development and decision making?
Should nurses with additional license types be required to register in the National Provider Index?
What would it mean for a nurse to be potentially identified and tracked with risk of harm based on surveillance and access to their personal data or a negative incident report associated with their identifier?
In the current and proposed systems, could data (gender, race, etc.) be used to discriminate, exclude,
or control nurses who are perceived as undesirables or expendable?
Design and use of data to pick and choose preferences based on bias is well documented in the technology and artificial intelligence literature (
Hoffman, 2021
Hoffman S.
The Emerging Hazard of AI-Related Health Care Discrimination.
The Hastings Center report. 2021; 51: 8-9https://doi.org/10.1002/hast.1203
Panch et al., 2019
Panch T.
Mattie H.
Atun R.
Artificial intelligence and algorithmic bias: Implications for health systems.
Journal of global health. 2019; 9010318https://doi.org/10.7189/jogh.09.020318
). How can this be prevented in the new system or network of systems? What laws should be considered to protect nurses' privacy and protect them from bias, discrimination, and false attribution of adverse events and discipline?
What are other ethical, legal, and social implications of creating a system or network of systems for a national nurse identifier?
How will nurses be educated and informed about a national nurse identifier system or network of systems? How will their support and concerns be collected and incorporated into the development of a system or network of systems?
What modifications to the NPI would be required to support the large-scale registration of other nursing license types in the NPI?
What type of coordination between the NCSBN ID system and the NPI would best optimize nursing workforce data?
What types of policy changes would promote the adoption of unique nurse identifiers within electronic health records?
Collaborative development and adoption of an accessible national nurse identifier system to improve the value-based purchasing dimension of nursing and health care is imperative. Collaboration and mandating that frontline nurses, especially nurses of color and other minority nursing groups, who will be affected by a national nurse identifier must be involved in the policy discussions; we know that whoever controls the power also controls the narrative about nursing and the nursing workforce. Ensuring that the frontline nurses be involved can proactively help address and possibly resolve the ethical, legal, and social implications of the unique nurse identifier. A unified system or network of systems needs to be a functional, unbiased repository of nurse data controlled by nursing.
In summary, the NPI and NCSBN ID systems for identifying nurses have complementary advantages and disadvantages, and both systems hold value. Thanks to the efforts of nursing leaders and many years of hard work, there has been substantial progress in advancing the implementation of the NCSBN ID as a unique identifier for nurses within the EHR. Moreover, as states respond to the requirements of Section 4003 of the Cures Act (Public Law 114–255: 2016), we have a new opportunity to advance the NPI as a parallel effort, recognizing (a) the complementary nature of the systems, and (b) the fact that some actors may opt to use NPIs as a means of authenticating providers in EHRs for assured exchange of patients' health information.
The passage of the Health Information Technology for Economic and Clinical Health Act (HITECH Act) in 2009 spurred the use of HIT and the scope of the health information environment (Mathematica Policy Research, 2015). Originally, the goal was broad adoption of EHRs for better data collection and analysis. Since then, EHRs and information technology have become more sophisticated, with secure data exchange within and across health systems for improved coordination of care, efficiency, and health outcomes now being the driver of HIT advances.
Given this evolution and the new opportunities at hand, it is important to understand ways that both systems can be enhanced simultaneously. Even if the NCSBN ID becomes a resource as important as the AMA Physician Masterfile in the future, the need for NPIs will continue so long as RNs and APRNs bill for services. Further, the usefulness of the NCSBN ID will be substantially enhanced through linkage to the NPI, and advancement in the comprehensiveness of the NPI, as well as the widespread adoption within EHR systems. Advancing the co-development of the two systems is, therefore, an important next step in meeting nursing workforce needs while attending to the intended and unintended consequences of creating a national nurse identifier system.
GKC: Conceptualization, writing-original draft, writing- review & editing; MR C: Conceptualization, writing-original draft, writing- review & editing; CST: Conceptualization, writing-original draft, writing- review & editing; BR: Writing-original draft, writing-review & editing; DIA: Writing-review & editing; MM-O: Writing-original draft, writing-review & editing; CC: Writing-original draft, writing-review & editing; ET: Project administration, writing-review & editing; P(Polly)P: Conceptualization, writing-original draft, writing-reviewing & editing.
The authors thank Colleen Leners, DNP, ARPN, FAANP, FAAN, Director of Policy at the American Association of Colleges of Nursing (AACN) and the 2017-2019, 2019-2021, and 2021-2023 AACN Health Policy Advisory Councils (HPAC) under the leadership of 2019-2021 HPAC Chair Dr. Patricia Pittman for the paper's origination, background research, committee discussion, and verbal contributions. The authors also acknowledge Nur Rajwany, MS, Chief Information Officer at the National Council of State Boards of Nursing, for his kind assistance in providing information related to the NCSBN ID and Nursys.
NPR, 2022 (Retrieved from)
(Accessed July 24, 2022)
University of Huston Law Center, 1999 (Retrieved from)
(Acccessed November 9, 2022)
Received in revised form: October 12, 2022
Publication stage
In Press Journal Pre-Proof
DOI: https://doi.org/10.1016/j.outlook.2022.10.005
© 2022 The Author(s). Published by Elsevier Inc.