Ch. 20 Readings
System Development Lifecycle
Fundamental area of practice for nurse informaticists in any care setting Very similar to the concepts of the nursing process: Focuses on the areas of Analyze and Plan, Design and Build, Test, Train, Implement, Maintain, & Evaluate (NP focuses on Assess, Plan, Implement, & Evaluate)
Emerging Areas in the Field of Informatics
Health care IT is seeing the emergence of numerous innovations that nurses will need to be familiar with as the pervasiveness of health care technologies grows Nurses need to be able to adapt & have a basic understanding of it to use these tools
Designing Technology
A basic tenet for informatics success is that nurses & other care providers using the clinical information system must be involved in the design for successful outcomes to be achieved What should the screen display look like? How should it be laid out to be consistent with other screen layouts? Can the design support improve the nurse's workflow as mapped out during the analysis & planning phase? Is there evidence supporting the effectiveness of the new technology and if so, does it provide recommendations for the design?
Standard Terminology
A common language designed to be shared among users Nurses typically select items from a drop-down lists or check boxes that represent an assessment parameter, an intervention, or a patient outcome Allows development of reports & data that can help to make assignments based on patient care needs Nursing terminologies identify, define, & code care delivery concepts in an organized structure to represent nursing knowledge ANA recognizes 12 (__) Office of the National Coordinator for Health Information Technology (ONC)
Clinical Information System
A computer based system designed for collecting, storing, manipulating, & making available clinical information important to the health care delivery process
Electronic Health Record (EHR)
A digital version of a patient's chart or medical history More formalized role of informatics Core of informatics practice Many areas within the scope of informatics deal with technologies peripheral to EHR ex) telehealth, mobile devices, patient portals, data analytics, etc.
The IN
A registered nurse with an interest or experience in an informatics field Usually a nurse who is considered a "superuser" (someone who has become a system expert & can navigate the EHR at ease when they access a patient's data Type of nurse informatics
Informatics Nurse Specialist
A registered nurse with formal graduate-level education in the field of informatics Often responsible for strategy development, implementation, & maintenance & evaluation of clinical systems requiring collaboration w/ mult. Disciplines Type of nurse informatics
Patient Portal Enables Patients To:
Access medical history & other health information Complete various forms & questionnaires online Communicate securely & conveniently w/ providers Request prescription refills Pay bills Review lab results Schedule appointments
Telehealth
Also called: "Broadband-enabled health care-related interactions", telehealth, telemedicine, & telecare The use of electronic information & telecommunications technologies to support & promote long-distance clinical health care, patient & professional health-related education, public health, & health administration Technologies include: videoconferencing, long distance imaging review, streaming media, & terrestrial & wireless communications Can also include remote nonclinical services (along w/ clinical services): Provider training, administrative meetings, & continuing education Advantage: Allowing patients to remain in their communities while being seen by a HCP at a remote site Benefits: Saves time & $$$ Telepsychiatry can help evaluate a patient's mental health Apps are providing communication platform that allows discussion amongst key stakeholders (peers, patients w/ similar conditions, or care providers)
Genomics
An emerging discipline that involves using genomic information about a person as part of their clinical care (for diagnostic or therapeutic decision-making) and the other implications of that clinical use Can be used to make a diagnosis to assist in treatment decisions or to screen for risks for the development of certain diseases -Used on people who may be at risk to passing it on to their children -Child must inherit 2 abnormal alleles (1 from each parent) in order for symptoms to appear This research changed the "one size fits all" approach for prescribing drug doses -Depending on a person's genes, a medication may work better/worse for them EHR vendors are developing the ability to capture a patient's genetic information in the medical record
Health Care Analytics
Anytime a nurse enters something into the EHR, it becomes a piece of data ex) Patient's temperature, heart rate, respiratory rate, lung sounds, wound appearance, etc. Tools to extract the data in order to identify trends & opportunities for improvement are becoming more mainstream & easier to use If it is entered or stored in a database, then it can be pulled into a report 3 areas of this for which nurses should have a high level of understanding: data visualization, predictive analytics, & big data
Benefits to Patient Engagement
Better health outcomes Chronic condition management Timely access to care Patient retention Patient-Centered Medical Home recognition
Examples Questions of Data Being Asked (Health Care Anaytics)
Clinical: How many patients currently have had an indwelling urinary catheter in place for longer than 24 hours Populations: Can we get a listing of all patients from our ACO organization who are diabetic & have not had a hemoglobin A 1c drawn in the last year? Administrative: What nursing staff ratios are recommended based on patient acuity? Financial: Has revenue increased since implementing a new electronic bill pay system?
Big Data
Compromises the accumulation of health-care related data from various sources, combined with new technologies that allow for the transformation of data to information, to knowledge, & wisdom Will help health care organizations answer questions & make predictions never before possible as clinical systems advance, data entered into systems becomes increasingly interoperable, & analytical technology evolves to allow easier use Sources of available data includes: EHR, Medical devices (physiologic/hemodynamic monitors), Radiology, laboratory, & pathology systems, Ventilators, Wearable devices, Financial databases, Genomics information
Informatics
Drives innovation that is defining future approaches to information and knowledge management in biomedical research, clinical care, & public health First report of this is from Florence Nightingale: Compiled & processed data to improve sanitation conditions in military hospitals during the Crimean War in 1850s ANA recognizes nursing (__) as a specialty & developed board certification in 1992 Electronic Health Record (EHR), Meaningful Use Many areas within the scope of this deal with technologies peripheral to EHR Need for this increase has increased since the signing of the American Reinvestment and Recovery Act (ARRA) in 2009
Predictive Analytics
Encompasses a variety of statistical techniques that analyze current & historical facts to make predictions about future or otherwise unknown events Used as an attempt to ID patients who are at a risk for readmission so case managers can intervene Can also be used for screening for patients who may be at risk for deterioration based on a # of clinical factors so that preemptive rapid response can be called
Testing Technology
Ideally developed in collaboration with nurses who will be using the technology, ensure that all components of the system are working as designed & will support workflow during interaction w/ the system Usually created by informatics specialists, but nurses using the system should provide input into the testing scripts & participate in user acceptance testing Phases: Unit, Function, Integration, Performance, & User Acceptance
System Optimization
Includes strategies to improve processes, maximize effective use, reduce errors, reduce costs, eliminate workflow inefficiencies, improve clinical decision support, & improve end-user skills & satisfaction w/ the system Often lumped into post-live maintenance & support, but it should be treated separately from routine maintenance Nurses quickly become system experts & provide the richest source of ideas for strategies to improve this Helps reduce errors & adds to patient care delivery Ex: Updating a nursing care plan to support an update to a procedure based on new evidence Adding a patient's code status & allergies to the header of the patient's main screen
Evaluate New Technology/EHR
Is the EHR helping us realize our organizational goals? Is it reducing medication errors? Is it eliminating duplicate ordering of diagnostic testing? Is it allowing more time for our care providers to spend with the patients? Is it improving the overall health of our patients? Last phase of the SDLC
Maintaining New Technology/EHR
Keeping a system up & running requires resources & attention to detail Types of tasks that occur during this phase for EHR: -Ongoing updates to hospital & ambulatory orders preference lists -Ongoing updates to hospital & ambulatory medication preference lists -Ongoing updates to provider patient lists -Ongoing updates to scheduling blocks (ambulatory, radiology, & procedure areas) -Monthly first data bank loads (new medications, medication pricing, & clinical alerts) -Error work queue maintenance (billing errors, sure script errors, many types of interface errors)
Pen & Paper Charts Security/Privacy
Limited # of people had access to the chart & had to fill out a request form to access it from Medical Records for review
American Reinvestment and Recovery Act (ARRA) in 2009
Need for informatics increase has increased since the signing of this Included the authorization of the Health Information Technology for Economic and Clinical Health Act (funded billions of $$ to improve quality information technology systems or EHRs that demonstrate meaningful use)
Nursing Informatics Definition
Need nurses trained in informatics to ensure optimized & evidence-based use of these devices & clinical information systems continues to grow Nurses understand clinical workflows & how care is delivered, giving them the knowledge needed to help design technologic tools & clinical information systems to support & transform health care
Analyze and Plan Technology
Need to do this to any type of new technology/ update to any system What is the purpose of this new technology or change to the current technology? What problem do we hope to solve? What data do we have to indicate the current state of the issue (How bad is the problem?) How will its use be incorporated into the current workflow of the nurse? Will it streamline nursing documentation, or will it increase the burden of documentation? Imperative to understand the organizational need & provide the supporting baseline data to justify the effort Tools & Resources used: Assessment tools, data analytics programs, or workflow diagrams Nurses can help clarify the need & provide expertise in the current workflow
Training w/ Technology
Need to have effective end-user training Poor training can decrease efficiency staff turnover, patient care errors, & poor-quality documentation followed by decreased billing revenue Type of training depends on the implementation project ex) New system = classroom model of education Should use principles of ADDIE (analysis, design, development, implementation, & evaluation) in this process Needs nursing input to ensure that the technology supports nursing processes & workflows that will enable nurses to navigate the system as easily as possible
Nursing Informatics Practice
Nurses practicing in direct care roles should have general knowledge of those areas of informatics practice at a conceptual level to ensure efficient, effective, & safe use of clinical information systems & other technologies A basic understanding of these concepts will also help nurses participate & collaborate in the required & evolving interdisciplinary work of embedding technology into care delivery to drive improvement
Electronic Records Security/Privacy
Patient's data is accessible almost everywhere with an Internet connection by many more people: some w/o a justified need
Implementing New Technology
Planning for this phase includes ensuring all testing has been completed, end users have been educated, & support resources are ready for any questions that arise Refers to the activities surrounding the activation of the new technology Nurse superusers are often employed during this phase to assist if help is needed
Example: Using Analytics and Big Data to Support Population Health
Population health addresses the health status & health issues of aggregate populations Brings significant health concerns into focus & addresses ways in which communities, health care providers, & public health organizations can allocate resources to overcome the problems that drive poor health conditions in the pop. Can help organizations ID patients at risk of needing additional assistance to manage their health Pulling data together from Medicare & other payor claims and data in the EHR can help predict which patients are at risk for readmission as well as locate patients who are receiving care outside of an organization's network
Office of the National Coordinator for Health Information Technology (ONC)
Sharing data & information across nonaffiliated organizations Type of standard terminology
Telecare
Technology that allows consumers to stay safe & independent in their own homes Can include consumer-oriented health & fitness apps, sensors, and tools that connect consumers w/ family members or other caregivers, etc.
Nursing Informatics
The ANA's Nursing Informatics Scope of Practice & Standards of Practice contains standards of professional practice & competencies for INs in 16 categories of informatics practice (including criteria that describe the expected knowledge, skills, & abilities necessary to meet each standard) Supports nursing care delivery & evaluation of care using technology & associated analytics "The specialty that integrates nursing science w/ mult. Info management and analytical sciences to identify, define, manage, & communicate data, info, knowledge, & wisdom in nursing practice" (ANA) Graves & Corcoran described the concepts of data (discrete entities that are described without interpretation), Information (Data that have been interpreted, organized, or structured), Knowledge (Info that is synthesized so that relationships are identified), & Wisdom (Appropriate use of knowledge to manage & solve human problems)
2 different types of nurse informatics (ANA)
The IN & the informatics nurse specialist (INS)
Interoperability
The ability of a system to exchange electronic health information with & use electronic health information from other systems without special effort on the part of the user (ONC) Means all individuals, their families & HCPs should be able to send, receive, find & use electronic health information in a manner that is appropriate, secure, timely, & reliable to support the health & wellness of individuals through informed, shared decision making The patient's data should be easily available to caregivers no matter where they were treated
System Usability
The extent to which a product can be used by specified users to achieve specified goals w/ effectiveness, efficiency, & satisfaction in a specified context of use HIMSS report cited that usability is the most important factor that hindered the widespread adoption of EHRs prior to the signing of the HITECH Act -Makes clinical systems easy to use, intuitive, & supportive of nurses' workflow System with this saves time, reduce errors, & improve end user satisfaction Tools for usability evaluation can be found through a # of sources both internal & external to the health care IT industry May seem like common sense but it's essential
Important Informatics Concepts to Understand
Usability, optimization, standard terminologies, interoperability, & security and privacy Intended to heighten awareness among practicing nurses so they can ask questions & use systems safely and allow improvements to be made to all technologies
Data Visualization
The presentation of data in a pictorial or graphical format Enables decision-makers to see analytics presented visually: can grasp difficult concepts or ID new patterns Ex) Bar charts, pie charts, maps, bubble graphics, or infographics, etc
Telemedicine
The use of telecommunications technologies to support the delivery of all types of medical, diagnostic, & treatment-related services (Usually by physicians or nurse practitioners) ex) Conducting diagnostic tests, monitoring a patient's progress after treatment/therapy Involves only remote clinical services
Pharmacogenomics
Uses information about a person's genetic makeup, or genome to choose the drugs & drug doses that are likely to work best for that particular person Combines the science for how drugs work (pharmacology) w/ the science of the human genome This research changed the "one size fits all" approach for prescribing drug doses -Depending on a person's genes, a medication may work better/worse for them
Meaningful Use
Using certified EHR technology to: Improve quality, safety, efficiency, & reduce health disparities Engage patients & family Improve care coordination & population and public health Maintain privacy & security of patient health information Hopes that using this will result in: Better clinical outcomes Improved population health outcomes Increased transparency & efficiency Empowered people More robust research data on health systems Sets specific objectives that eligible professionals & hospitals must achieve to quality for Centers for Medicare & Medicaid Services Incentive Programs
Patient Portal
Web-Based tool that can be securely accessed & provides several functions to increase engagement, a primary patient engagement tool Can be accessible via home computer or smartphone
