1. Nursing Informatics: Week 6 Review Prepared by Thomas Holton, Stephen Nesbitt, Elizabeth Paling, and Amy Studer December 2010 INFO 648 Healthcare Informatics Dr. Michelle Rogers Drexel University 1
2. Nursing Informatics Profession What is Nursing Informatics? American Nurses Association (ANA) Integrates other sciences Integrates data and information Expanding Nursing Roles and Opportunities New roles for nurses with advanced education in informatics. The role of the American Medical Informatics Association (AMIA) – Nursing Informatics Work Group (NIWG) Need to identify the diverse existing graduate content. Reach consensus on the necessary requirements of a masters level informatics program. (McCormick et al., 2007; Staggers & Thompson, 2002)
3. Why NursingInformatics? Taxonomy and Definitions Relies of Taxonomy and Definitions Distinctiveness of Nursing Informatics Nursing knowledge is different Knowledge Center at Creighton University Physicians do not understand nursing Nursing Data Issues The whole patient concept One thing affects another Creates questions regarding data elements (Graves, 1989)
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5. Coordination of care for each patient and workload management for each provider. “The quality of clinical decisions depends in part on the quality of information available to the decision-maker” (Ozbolt & Bakken, 2006, p. 564) 4
6. Process of Nursing Care Nursing care is an iterative process that includes the following steps: collection and analysis of data synthesis of nursing diagnoses formulation of objectives and priorities selection and implementation of interventions, evaluation of the results of interventions (Ozbolt & Bakken, 2006) 5
7. Information System Processes Patient-care information system processes include: data acquisition data storage data transformation or processing presentation These processes occur at three levels: patient-specific agency-specific nursing domain-specific (Ozbolt & Bakken, 2006) 6
22. Alarms from bedside monitors are now much “smarter” (Gardner & Shabot, 2006)
23. Importance of Information Accessibility through Computers for Patient Monitoring High quality continuity of care in ICU Need improvement over paper records Easier Communication Eliminate duplication of work Decision Support Systems HELP Interpretation of data Alerts Diagnoses Treatment suggestions (Evans et al., 1998, Gardner & Shabot, 2006)
24. Other Issues Related to Patient Monitoring Integration of patient monitoring systems Different manufacturers Medical Information Bus (MIB) “plug & play” interfaces Cost-effectiveness Future of patient monitoring Genomic markers Keep efficiency high, cut unnecessary costs (Gardner & Shabot, 2006)
25. Current Informatics Patient-Care System Research Formulation of Models Development of Innovative Systems Implementation of Systems Study of Effects of Systems (Ozbolt & Bakken, 2006) 11
26. References Evans, R.S., Pestotnik, S.L., Classen, D.C., Clemmer, T.P., Weaver, L.K., Orme Jr., J.F., Lloyd, J.F., Burke, J.P. (1998). A computer-assisted management program for antibiotics and other antiinfective agents. New England Journal of Medicine, 338(4):232-238. In E. H. Shortliffe and J. J. Cimino (Eds.), Biomedical Informatics: Computer applications in health care and biomedicine (3rd ed.) (pp. 603-623). New York: Springer. Gardner, R. M., & Shabot, M. M. (2006). Patient-monitoring systems. In E. H. Shortliffe and J. J. Cimino (Eds.), Biomedical Informatics: Computer applications in health care and biomedicine (3rd ed.) (pp. 585-625). New York: Springer. McCormick, K. A., Delaney, C. J., Brennan, P. F., Effken, J. A., Kendrick, K., Murphy, J. et al. (2007). Guideposts to the future: An agenda for nursing informatics. Journal of the American Medical Informatics Association, 14(1), 19-24. 12
27. References Ozbolt, J. G., & Bakken, S. (2006). Patient-care systems. In E. H. Shortliffe and J. J. Cimino (Eds.), Biomedical Informatics: Computer applications in health care and biomedicine (3rd ed.) (pp. 654-584). New York: Springer. Staggers, N., & Thompson, C. B. (2002). The evolution of definitions for nursing informatics. Journal of the American Medical Informatics Association, 9(3), 255-261.
Editor's Notes
While nurses have many different roles (administration & management, education, public health), much of the nursing informatics effort is aimed at the largest focus of nursing: Patient Care.One trend in healthcare since the 1990’s has been a switch to patient-focused and interdisciplinary care. So, let’s detour a moment to discuss Collaborative Patient Care. Nursing is one of the disciplines that contribute to the multidisciplinary process of patient care: Other clinical disciplines may include: Physicians, pharmacists, dieticians, physical therapists, respiratory therapists, occupational therapists. Social work, health educators, physicians assistants.Each discipline has its own focus, knowledge, language, and processes that it brings to the collaborative process of patient care.Important issues:Communication and collaboration within and between the disciplines Because each of the disciplines have their own focus, knowledge, language, and processes, work has often taken place in silos (for example, historically, nursing notes have been kept in a separate place in the paper record from other disciplines and information not well communicated with others; now the question becomes what level of detail is useful to other providers and should be shared? )**** The effect of collaboration is greater than the mere sum of each discipline’s contribution.****Coordination of care for each patient and workload management for each provider: challenging—as care grows more complex, this becomes more important. The case manager role has become important nursing role, responsible for coordinating patient care activities. In addition, nurses and other providers must balance the needs of all the patients in their caseload…”set priorities, organize, and delegate” (Ozbolt & Bakken, 2006, p. 567).According to Ozbolt and Bakken (2006), “The quality of clinical decisions depends in part on the quality of information available to the decision-maker” (2006, p. 564). This is why we are so interested in informatics approaches…to improve care for patients.Using informatics approaches, we have begun to evaluate the flows of information for the disciplines and design systems that can support the complex process of patient care. Hopefully these systems will be transformative.
It is fundamental when thinking about systems approaches to understand the issues of each discipline involved.Nursing care is an iterative process that includes the following steps:collection and analysis of datasynthesis of nursing diagnosesformulation of objectives and prioritiesselection and implementation of nursing interventionsevaluation of the results of nursing interventionsTypical nursing activities not only include carrying out the steps involved in the process of nursing care, but also documenting the process. In addition, activities include carrying out and documenting treatment plans established by other disciplines. All of these nursing functions generate a lot of data and require communication with others.
In order to develop informatics processes, each discipline’s processes, knowledge and language must be understood. These basic questions are the foundation to understanding information system processes that support patient care:What information does each professional require to make decisions? From where, when, and in what form does the information come?What information does each professional generate? Where, when, and in what form is it needed? (Ozbolt & Bakken, 2006, p. 568)Patient-care information system processes include:data acquisition: How does the data become available for the information system? Does the nurse perform manual entry or acquisition from a medical device or another computer.data storage: Methods, programs, structures used to organize data for later use. This includes the standardized languages that are used to represent nursing patient care concepts. data transformation or processing: The data is acted upon in a way that is useful to the end user. For example, it may be summarized or entered automatically into a risk assessment scoring tool.presentation : Which is required at point of care; Example: report generation, such as trends in vital signs over an entire shiftThese processes occur at three levels: (examples are of presentation)Patient-specific: Displaying reminders or alertsAgency-specific: Generating management reports. Entity might request quality report, for example insurance companiesNursing domain-specific: Displaying relevant literature or guidelines.Ultimately we are hoping to move into an even bigger picture--looking at the aggregation of data from many patients to integrate into outcomes research, perhaps at a larger public health or broader research level.
Now that we have an understanding of the nursing process and patient care information systems, we can look at how computers assist health care professionals at the bedside.Acquire physiological dataMicrocomputers at the patient bedside can obtain temperature, pulse, blood pressure, respiratory rates, oxygen saturation levels, and heart rhythms at predetermined time intervals or continuously.Communicate information to remote locationsThey can also transmit patient information to providers in a different location for the purposes of expert consult or to obtain treatment in a remote location, such as the systems NASA uses to keep it’s Astronauts healthy.Store, organize and report dataThe computer system becomes the patient chart. It maintains neat, legible, chronological documentation of the patients healthIntegrate and correlate data from multiple sourcesA well designed computer system brings the clinical, diagnostic, laboratory, and billing information into a cohesive unitProvide clinical alerts and advisoriesBased upon information that is input into the computer, it can alert and advise health care providers to changes in the patient’s status or interactions between medications and/or therapies.A decision-making tool that health care providers may useBedside computers can have a clinical decision support system which can be an aid to clinicians, which encourages the use of evidence-based medicine at the bedside.Measure the severity of illness for patient classification purposesPatient acuity levels can be determined based upon data input throughout the day to aid in staffing decisions.Analyze the outcomes of Intensive Care Units (ICUs) care in terms of clinical effectiveness and cost effectivenessAnd data can be easily retrieved to determine clinical outcomes, effective treatments, and trends.
It permits pattern recognition and feature extractionThe digital computers ability to store EKG waveforms allows modern bedside computers to use multiple EKG channels and pattern recognitions schemes to identify abnormal waveform patterns and then to classify EKG arrhythmias. Signal quality can be monitored and interference noise monitoredThe computer can monitor for the integrity of the contact between the electrodes and the patient and alert the nurse to the problemPhysiological signals can be acquired more efficientlyWhen physiological signals are digitalized early in the processing cycle the waveform processing can be done by the computer.Transmission of digitalized physiological waveform signals is easier and more reliableDigital transmission of data is inherently noise-free, newer monitoring systems allow health care professionals to review a patients waveform pattern from various locations inside and outside of the hospital.Selected data can be retained easily if they are digitalizedEKG recordings can be more easily stored for later review. Today’s monitors can store a minimum of 24 hours worth of waveform data from multiple leads of EKG and blood pressure transducersMeasured variables can be graphed Things like blood pressure and pulse can be graphed which aids in the detection of life threatening trendsAlarms from bedside monitors are now much “smarter”There are fewer “false” alarms than with analog alarm systems of the past, Today bedside monitors can often distinguish between artifact and real alarm situations by using the information derived from one signal to verify anotherSystems can be upgraded easilyOnly the software programs in read-only memory need to be changed, older analog systems require hardware replacement
High Quality Continuity of Care in the ICUIt is especially important for patient monitoring in the intensive care unit (ICU) to involve high quality continuity of care as these patients are often very ill and need extra attention. (Continuity of care refers to coordinating care for the patient over time through multiple healthcare providers)The issue is that because there is so much transformation of patient information between different providers, there is a significant creation of room for error. Paper records do not allow for easy access of patient information to all these providers.Easier CommunicationThe computer-based record makes it much easier to communicate between departments in the hospital. Access can be granted from the office or home to clinical and administrative information which is essential for the convenience of physiciansElimination Duplication of WorkAnother important aspect of using computers for patient records is that it allows nurses to not have to redo work that was already done or recorded. There is an accumulation of day-to-day reports for a given patient in which nurses verify and initial next to. Weekly reports can be prepared for patients in the ICU and they are logged into a computer so no additional data entry is required for report generationDecision Support SystemsYet another important function of computers for patient monitoring is decision support systems. Computers are now used to provide recommendations for specific antibiotics to be given to the patient. The HELP computer system at the LDS hospital in Salt Lake City assists with antibiotic decision making in the ICU (Evans et al., 1998). Examples of use of the help system include:-interpretation of data (ex. interpretation of breathing status based on blood reports)-alerts (ex. notifications against patient receiving drug)-diagnoses-treatment suggestions -Using this program, relevant patient data for antibiotics can be obtained in roughly 5 seconds, whereas using patient records for the data could take 15 minutes or more to obtain.-This program has also shown to reduce costs and improve quality of care.
Integration of Patient Monitoring Systems There are many different manufacturers of bedside patient-support devices as each of them is designed as a standalone unit. As a result of this, it is common for a nurse to retrieve information from one of these devices and have to record this information on to a different workstation because there is no standard communication between the different devices. Integration of these systems in patient monitoring is extremely important. Fortunately, because of the Medical Information Bus (MIB) standards committee, integration of patient monitoring devices is possible. With these new standards, it is possible for vendors and hospitals to implement “plug & play” interfaces to a variety of bedside medical devices such as bedside monitors, IV pumps, and ventilators.Cost- Effectiveness Presently there are bedside terminals at some ICUs for nurses to create nursing care plans and to chart ICU data. Continuous monitoring of these patients in the units for intensive care is very important. If there is only intermittent monitoring being done with heart rate, for example, the patient could die without anyone knowing about it until it is too late. Although this is without a doubt important, it is unclear to what extent the monitoring needs to be done. Shortcliffe & Cimino, 2006, bring up the pertinent questions, “must second-by-second waveform data be archived permanently? Will it improve the quality of patient care?” These questions need to be answered to find out if money is being efficiently allocated to the right places.The Future of Patient MonitoringThe goal before with monitoring patients was to measure the degree of injury and prevent further injury. This was opposed to measuring the “repair” of the injury. In the future, with the ability to detect bacterial DNA, we may be able to measure repair with genomic markers which would allow clinicians and nurses to better monitor repair by controlling the healing environment. Patient monitoring has been vastly improved with the abundance of microcomputers. There is still much work to be done in this field however. The most appropriate use of, and integration of computers in the ICU for nurses and clinicians is still transforming and in the process of improving. Focus will need to be kept on how to get patients the most efficient, high quality care without unnecessary costs.
Formulation of Models:Standards development organizations (SDOs) and professional groups have formulated models to describe patient care processes and the formal structures that support management and documentation of patient care (for example, agreement from the Nursing Terminology Summit to develop terminology models for nursing diagnoses and interventions, and integrating selected content into the LOINC semantic structure) Development of Innovative SystemsPatient-care systems taking advantage of information entered once for multiple uses (for example, clinical nursing data also used in calculating nursing workload; entered information used to generate a draft nursing discharge abstract that nursing staff then review and edit as needed)Attempts to improve quality of care and patient safety (for example, the use of evidence-based physician order sets that have improved compliance with quality indicators.)Implementation of Systems:Implementation is complex, transforming work and organizational relationships. Administrative buy-in and involving clinicians in the design and modification of systems is essential.Study of Effects of Systems:Focus is on effects that directly impact patients, although other impacts such as cost effectiveness or savings are also of interest.Impact on process of care: Systems support for nursing documentation will decrease the time required for documentation, improve the quality of the record and communication with others, and increase the amount of nursing time spent in direct patient care activities.Patient systems are designed with improving patient safety and outcomes in mind. Improvements can be achieved through improved information access, communication and coordination of care; improved adherence to evidence based clinical guidelines; Great hope is that aggregation of patient data will inform nursing research in terms of what is effective care.
