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Introduction to Nursing Informatics

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The world has witnessed an unprecedented number of technological advances during the last 100 years. Cars, airplanes Entertainment world - radio and television.

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The computer

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altered the way data and information were viewed and utilized and changed the way business was conducted. changing nursing and health care.

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The internet

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has changed communication drastically.

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What Is Nursing Informatics?

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The Health Information and Management Systems Society (HIMSS) defines informatics as "the discipline concerned with the study of information and manipulation of information via computer-based tools" (2006, p. 44)

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History of Informatics

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Health care began to use computers in the 1950s. Computers, in this era, were typically used in the business office to track financial aspects of health care (Saba & McCormick, 2006). In the 1970s, nursing began to realize the importance of computers to the nursing profession and became involved in the design, purchase, and implementation of information systems (Saba & McCormick, 2006). In the 1980s, medical and nursing informatics specialties emerged. The personal computer was introduced, which allowed for flexibility in how these clinical systems were used The first certification exam for NI was taken in 1995 (Saba & McCormick). The post-2000 era saw an unprecedented explosion hardware and software. Electronic patient records became an integral part of clinical information systems. Telemedicine became possible and was recognized as a specialty in the late 1990s (Saba & McCormick,2006).

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Goal of Nursing Informatics

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In 2008, ANA updated the Scope and Standards of Nursing Informatics Practice. ANA lists the goal of NI as: "The goal of NI is to improve the health of populations, communities, families, and individuals by optimizing information management and communication (p.1)".

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Data

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Collected information used to answer questions

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Information

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Data that are interpreted, organized, or structured in a clinical context

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Knowledge

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Information that is synthesized to identify and formalize relationships - how it is used

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Wisdom

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The appropriate application of knowledge to solve real-world problems

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Metastructures of NI- DIKW

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...

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An Example of DIKW

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Data - vital signs for an individual's heart rate, respiration, temperature, and blood pressure Information - serial set of vital signs taken over time, placed into a context, and used for longitudinal comparisons Knowledge - recognition of a pattern and identification of interventions reflects information synthesis (knowledge) based on nursing knowledge and experience. Wisdom - accuracy of the synthesis of information and appropriate selection of interventions

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Importance of Nursing Wisdom

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A new CVA pt arrived on a med surg unit. For the person's first 3 days a GCS (Glascow Coma Scale) was never performed. The MD had ordered it "as needed" and therefore it was not "mandatory" that the nurse complete it. When the patient had a second stroke who is accountable?

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Glascow Coma Scale

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The most widely used system to grade the arousal and functional capacity of the cerebral cortex consisting of eye opening, motor responses, and verbal responses.

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Nursing Decisions

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The decisions that nurses make can be characterized by both the quality of decisions and the impact of the actions resulting from those decisions. The process of decision-making in nursing is guided by the concept of critical thinking. Critical thinking is the intellectually disciplined process of actively and skillfully using knowledge.

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Informatics in Nursing Practice

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Role of 21st century nurses is complex Requires interaction with multiple medical devices and health IT Increasingly likely to be involved in the design of new clinical systems Technology is integral to all parts of healthcare delivery for healthcare providers (HCPs), patients, and healthcare settings

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Health Care in the United States and the Need for Health Information Management

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Burden of fragmentation

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Burden of fragmentation

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Fragmentation of care places patients at greater risk for poor outcomes, especially in regard to: Patients with multiple or chronic conditions Childhood immunizations Inaccurate or incomplete transfer of information related to patients transitions from inpatient to home care

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Decision Support Systems

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Decision support systems are typically rule-based, using a specified knowledge base and a set of rules to analyze data and information and provide recommendations. Support the transition from information to knowledge

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Expert Decision Support Systems

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applies knowledge through wisdom. It is a type of decision support system that implements the knowledge of one or more human experts.

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Wisdom in Informatics

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Rule 1- never automate a broken process Computerization will not fix process issues- instead it highlights them Prior to any design there needs to be workflow review and redesign Caregivers must come together and "process flow" their work and identify what is not working Allow the decisions for redesign to be implemented and tested prior to automating

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The Nurse as a Knowledge Worker

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Knowledge can be defined as "the distillation of information that has been collected, classified, organized, integrated, abstracted, and value added" (HIMSS, 2006, p. 49). Knowledge work is defined as nonrepetitive, nonroutine work that entails a significant amount of cognitive activity (Sorrells-Jones & Weaver, 1999a). Drucker (1994) describes a knowledge worker as one who has advanced formal education and is able to apply theoretical and analytical knowledge.

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Nursing Informatics Roles

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Most health facilities have come to recognize the importance of having nurses intricately involved in development and support teams No silos - health care workers must work as a team

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Global Definition of Nursing Informatics

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Nursing informatics science and practice integrates nursing, its information and knowledge and their management with information and communication technologies to promote the health of people, families and communities world wide.

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Informatics Needs

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More timely access to data and information, clinical and financial, has been identified as a necessity in the climate of 21st century healthcare Health service organizations, societies, and governments throughout the industrialized world are charged with assuring that healthcare delivery is: safer knowledge-based cost-effective seamless timely

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Informatics to engage consumers

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With the evolving emphasis on issues such as chronic disease management and aging at home informatics can encompass the use of technologies to empower citizens to more effectively manage their own health and wellness. Good- more informed patients Bad- more informed patients *Knowing what material is accurate and relevant

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Informatics and Creating Clinical Knowledge

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New technologies have made the capture of multi-faceted data and information possible through the use of technologies like digital imaging (e.g., photography to support wound management).

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Using Clinical Knowledge

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Evidence-based practice (EBP) and research utilization (RU) are concepts which have been widely addressed in the nursing literature

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Clinical Decision Tools (CDS)

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Computerized alerts and reminders (e.g., medication due, patient has an allergy, potassium level abnormal); Online medication administration/scanning Clinical guidelines (e.g., best practice for prevention of skin breakdown); Online information retrieval (e.g., CINAHL, Micromedics) Clinical order sets and protocols; and Online access to organizational policies and procedures. Many applications now have embedded case-based reasoning.

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CIS Data Input Devices

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Biometrics (facial recognition, security) Voice and video recordings (client interviews and observations, diagnostic procedures, ultrasounds) Voice-to-text files (voice recognition-documentation/ordering) Medical devices (infusion pumps, ventilators, hemodynamic monitors) Bar-code technologies (for medication administration, patient tracking) Telehomecare monitoring (for use in diabetes and other chronic disease management) "Medical Homes" where pts are monitored remotely

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Clinical Practice Challenge

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There are still many organizations with limited online functionality available to nurses. Over the years, nurses have been on the receiving end of systems which either did not add value to their work or created additional work. Nurses must be engaged in the acquisition, design, implementation and evaluation of CIS

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A View of the Future

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The future of healthcare will be highly dependent upon the use of CIS and CDS to achieve the systems' global aspirations of safer, quality care for all citizens. The core concepts and competencies associated with informatics will be embedded in the practice of every nurse, whether administrator, researcher, educator, or practitioner.

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Informatics Tools to Promote Patient Safety

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Nursing professionals have an ethical duty to ensure patient safety. Increasing demands on professionals in complex and fast paced health care environments May cut corners or develop workarounds that deviate from accepted and expected practice protocols.

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Medical Errors

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can be defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.

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Safety Initiatives

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1999 Institute of Medicine (IOM) report: To Err is Human 2001 IOM Quality Chasm report Agency for Healthcare Research and Quality (AHRQ) launched initiatives focused on safety research for patients 2002 Joint Commission National Patient Safety Goals 2002 National Quality Forum (NQF) adverse events and 'never events' list, Creation in 2004 of the Office of National Coordinator for Health IT to computerize health care, 2004 World health Organization's (WHO) Alliance for patient safety, 2005 Institute for Healthcare Improvement (IHI) 100,000 Lives campaign and 2008 5 Million Lives Campaign 2005 congressional authorization of Patient Safety Organizations (PSOs) created by the Patient Safety and Quality Improvement Act to promote blameless error reporting and shared learning, 2008 "no pay for errors" Medicare initiative $19 billion congressional appropriation to support electronic health records and patient safety

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Key Features of a Safety Culture

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acknowledgment of the high-risk nature of an organization's activities and the determination to achieve consistently safe operations a blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems organizational commitment of resources to address safety concerns (AHRQ, n.d., para. 1)

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What is a Just Culture?

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blame free environment to encourage error reporting system or process issues that lead to unsafe behaviors and errors are addressed by changing practices or work-flows processes clear message is communicated that reckless behaviors are not tolerated

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Human Errors

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(unintentional mistakes) perform FMEA to understand error

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Risky Behaviors

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work arounds or cutting corners) examine workflow; educate

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Reckless Behavior

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(total disregard for established policies and procedures) Enact zero tolerance policy; disciplinary measures

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Alarm Fatigue

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Medical equipment alarms frequently and inappropriately May be related to the sensitivity of alarm parameters Alarms/alerts in Information systems can have the same effect Strategies to improve alarm response improving the nurse call system by adding Voice Over Internet Protocol (VOIP) phones Minimizing alerts to must have from the nice to know feeding alarm data into a reporting database for further analysis encouraging nurses to round with physicians to provide input into alarm parameters

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Informatics Technologies and Safety

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Improve communication Reduce errors and adverse events Increase the rapidity of response to adverse events Make knowledge more accessible to clinicians Assist with decisions technology based forcing functions that direct or restrict actions or orders implemented by computer technologies. Provide feedback on performance

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Quality Improvement Techniques and Nursing Informatics

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Aims of the organization must be understood Institute of Medicine highlights six main aims Effectiveness Safety Efficiency Patient-centeredness Timeliness Equitability QI system must develop measures of quality that reflect these aims

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Measuring quality can be difficult

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Hard to attribute outcomes of treatment to any one particular cause Question of whether an error or adverse event is likely to occur or is a rare, exceptional event

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Internal benchmarking

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Compares current and past performance

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External benchmarking

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Compares performance against other HCPs

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Continuous quality improvement (CQI) systems

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Belief that there is always room for improvement in every aspect of the process Constant re-evaluation and assessment of changes made in the past

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Holistic Systems

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Focus on every aspect of an organization Strive to make improvement the primary purpose of the organization

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Medication Administration cycle

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Assessment of need Ordering Dispensing Distribution Administration Evaluation Human Error Factors: Distractions, unclear thinking, lack of knowledge, short staffing, and fatigue

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Six Rights of Medication Administration

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the right patient the right time and frequency of administration the right dose the right route the right drug The right DOCUMENTATION

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Technology Integration into Cycle

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Reduces the potential for human errors by: performing electronic checks providing alerts to draw attention to potential errors Tracks performance

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Computerized Physician Order Entry (CPOE) Benefits

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Prompts warn against the possibility of drug interaction, allergy or overdose; Accurate, current information that helps physicians keep up with new drugs as they are introduced into the market Drug-specific information that eliminates confusion among drug names that sound alike* Improved communication between physicians and pharmacists* Reduced healthcare costs due to improved efficiencies

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Technology in the Pharmacy

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Verifying function is computer based, and the medication order is electronically checked via the knowledge database (E.D. exception) Allergy verification and medication reconciliation with other drugs already in use Automated reports- medication reconcilliation; Medication useage

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Barcode Medication labeling or RFID Technology

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Assists with dispensing and administration

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Automated dispensing machines

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storage, dispensing, controlling, and tracking

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Barcode Medication Administration (BCMA)

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Provides a system of checks and balances to ensure medication safety Nurse scans name badge thus logging in as the person responsible for medication administration. patient's barcode on the patient's ID bracelet is scanned prompting the electronic system to pull up the medication orders. the bar code on each of the medications to be administered is scanned. This technology checks to ensure that the 6 rights of medication administration—right patient, right med, right dose, right route and right time, right documentation—are met.

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Barcoding medications

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Required by a 2004 FDA rule Barcoded medication administration can be implemented from the bedside

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Barcoding Medications - Safety Levels

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Level 1 serves as the foundation to the automated double check of the prescribed order Level 2 incorporates educational tools Level 3 presents alerts and warning specific to the medication regimen and patient condition

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Smart IV pumps

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House a library of medications with corresponding concentrations and safe dose ranges Issues soft-stop or hard-stop alerts if a dose exceeding programmed limits is entered Library can be tailored to a specific location Provide data on care process and provider behavior Must be updated to stay smart Subject to programming errors

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Clinical Decision Support (CDS)

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Help a clinician select an appropriate medication Will ensure that the order is complete (checks for drug interactions, duplications, or allergy contraindications, the right dose and right route Provides double checks for interactions, allergies and appropriate dose orders during verification and dispensing. Assists with infusion pump programming issues such as incompatibilities during infusion and proper notation and dispensing when portions of a dose must be wasted.

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CDS

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Assists with patient identification and current assessment parameters (i.e. blood pressure, glucose level) that may contraindicate the use of the medication at that point in time. Checks for interactions with foods or other medications Provides patient education guidelines and printable handouts The monitoring functions of the CDS provide a structured data reporting system to track side-effects and adverse events across the population

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Technologies for Home Medication Compliance

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eMedonline SIMpill Medication Adherence System Caps of pill bottles may contain RFID tags that monitor and collect data on when the bottle is opened, or contain flashing time reminders when a dose is due (Blankenhorn, 2010). Smart inhalers track asthma medication compliance using a microprocessor that records and stores medication compliance.

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eMedonline

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collects patient medication compliance data by scanning package barcodes or RFID medication tags and using PDA or smart phone technology to send compliance data to the server

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SIMpill® Medication Adherence System

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uses web based technology to monitor patient compliance and provide reminders about taking medications or to refill prescriptions by sending text messages to the patient or caregivers

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Other CDS Patient Safety Benefits

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Data collection and data management functions help to ensure quality approaches to patient health challenges based on research evidence and clinical guidelines. Improves cost-effectiveness- alerting clinicians to "duplicate testing" orders (can put time frames into system), or suggesting the most cost effective diagnostic test based on specific patient data

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Expanded RFID Uses

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patient tracking during procedures and testing, or function as part of the EHR communicating pertinent information to clinicians at the bedside (lab testing) track medical supplies and equipment imbedded into surgical supplies to automate supply counting procedures reduce the likelihood of wrong patient, wrong site surgical procedures reducing the potential that a incorrect medication is inadvertently introduced into the supply, and providing for efficient medication recalls specialized tags can detect temperature fluctuations and thus ensure that the blood or blood product was stored at the optimum temperature for safe administration

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Smart Room Technology

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RFID tag on employee name badge announces to the patient on a monitor exactly who has entered the room and triggers 'need to know' data by caregiver status to be displayed on the monitor in the room Clinicians review patient data in real time and chart at the bedside using touch screen technology Alert clinicians as they enter the room about procedures that need to be implemented for the patient and can track individual clinician efficiency and effectiveness by aggregating data over time

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Patient Monitoring Technologies

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Body Area Networks or Patient Area Networks provide the ability to wear a small unobtrusive monitor that collects and transmits physiologic data via a cell phone to a server for clinician review Wireless chip on a disposable band-aid with a 5-7 day battery promises to be able to monitor the patient's heart rate and electrocardiogram, blood glucose, blood pH, and blood pressure, allowing for the collection of important clinical data outside the hospital

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