APPLICATIONS OF NURSING INFORMATICS (CLINICAL) Introduction ■ The evolution of information and communication technology use in health care is transforming care delivery and communication between health professionals and between nurses and patients. ■ Information of different forms may be communicated to multiple providers and patients across settings, in real time over short and long distances. ■ Innovations in ICTs are creating more opportunities to deliver care virtually. ■ Virtual health care delivery establishes opportunities for communicating health information between patients/clients and health care providers. Objectives ■ At the end of this unit, the students should be able to: 1. Describe the application of nursing informatics in a clinical settings 2. Understand and apply how nursing informatics improves patient care APPLICATION OF NURSING INFORMATICS IN CLINICAL SETTINGS Assessment ■ Digitalization helps in gathering and storing data about each patient. ■ Assessment data can be physiological measures automatically documented through a patient monitoring system ■ Other assessment data can be added to the electronic patient record by departments in the healthcare facility such as the laboratory and radiology. ■ The largest source of assessment data is the ongoing nursing assessment. Patient Monitoring ■ Patient monitors measure, record, distribute and display information of vital signs such as heart rate, SPO2, blood pressure, temperature and more. ■ This was originally built for coronary care. ■ In coronary care units, intensive care units and other cradiovascular clinics handling pacemakers, computers were initially used to monitor electrocardiograms, analyze the information, and reduce former volumes of data to manageable proportions, generally some type of graphs. Patient Monitoring ■ High-capability, multi-function monitors are typically used in hospitals and clinics to ensure a high level quality of care ■ Portable patient monitors are designed to be compact and power efficient. ■ It is also programmed to recognize deviation by some indication either an alarm, a light alert or any like. ■ This allows them to be used in remote areas or by paramedics to aid diagnosis in the field, enable monitoring and transmitting data to health care providers in other locations Patient Monitoring ■ Digital devices in acute care areas, such as emergency departments and intensive care unit (ICU), coronary care unit (CCU) and neonatal intensive care unit (NICU), are now widely used for hemodynamic and vital signs monitoring, calculation of physiological indices such as peripheral vascular resistance, respiratory patterns and cardiac output and environmental regulation of isolets. ■ Modern and sophisticated computerized ICU monitoring systems for management of patient data including patients’ temperature, heart rate, respiratory rate, arterial blood pressure, central venous pressure, intracranial pressure and pulmonary artery pressures, are used around the world (Hannah, K.J.,2015 on Varon and Marik, 2002; Wong et al, 2003) Patient Monitoring ■ Automated approaches to patient monitoring made the nurses free from the technician role of watching machinery and allow them to focus on patient care, the family and the nursing process. ■ It is now widely accepted that computerized cardiac monitoring of patients dramatically increases the early detection of arrhythmias and contributes to decreased mortality of CCU patients. Additionally, many of these monitoring systems are already integrated into decision support systems (Hannah, K.J.,2015 on Staggers, 2003) Nursing Generated Assessment Data ■ Source data capture is essential in generation of patient data. ■ Source data capture means gathering data and information about patients where it originates, that is, with the patient. ■ By entering data wherever the patient is, the reliability of the data is increased. (Hannah, K.J, 2015) ■ Assessing research data directly from Electronic Health Records known as electronic source data capture (eSource), can create efficiencies in the clinical research process while improving data quality, reducing cost, maintaining integrity and preserving audit trails. Nursing Generated Assessment Data ■ A significant portion of the growing costs of clinical trials, and hence drug development, relates to source data verification, a process by which data from clinical trial collection systems are compared to the source information. ■ The use of Electronic Health Records in clinical research has potential to eliminate the need for this comparison, and for this reason, electronic source data capture from EHRs has been a priority for the US Food and Drug Administration and the subject of a guidance published in 2018. Nursing Generated Assessment Data ■ According to Hannah (2015), for source data capture to be feasible, nurses must be able to encode patient data remotely or outside of the nursing station. ■ This need has required a revolution digital hardware and software. ■ The local area network nursing station terminal of the hospital mainframe computer is no longer adequate as it increases time needed for nurses to document care rather than focusing those time needed to the patient care whichever nursing setting it might be. ■ Computer data entry must occur wherever patients are found. This is called a “point of care” information system Nursing Generated Assessment Data Goals for moving to point care systems are identified as follows: ■ To minimize the time spent documenting patient information ■ To eliminate redundancies and inaccuracies of charted information ■ To improve the timeliness of data communication ■ To optimize access to information ■ To provide information required by the clinician to make the best possible patient care decisions Nursing Generated Assessment Data ■ Source data capture is the first step in reducing the time nurses spend on documentation of care and eliminating redundancies and inaccuracies (Hannah, 2015) ■ When information can be entered directly into the patient’s electronic health record at the point of care by the healthcare professional or a medical device such as hemodynamic monitors, infusion pumps, or ventilators and it is made immediately available to others involved in the patient’s care, time is saved and data have been accurately transformed into usable information. ■ Point of care systems use a wide array of digital hardware and software. ■ Mobile, portable, real-time, and remotely accessible communication device with many input options that has the ability to display patient information as needed, including graphics, an easy documentation method, and long battery life, is ideally preferred. Nursing Generated Assessment Data According to Hannah (2015), when considering the adoption of point of care systems, the following points should be evaluated: 1. Point of care systems must allow the nurse to interact with the main information system. Systems that do not allow information to be extracted, as well as entered, are not useful to the nurses. 2. Point of care systems must interface with hospital information system. The nurse at the patient’s bedside must be able to access data that has been generated by the laboratory, radiology or pharmacy. 3. The open systems concept is valuable to nurses considering point of care systems. This concept allows machines from all vendors to communicate. Open systems allow the most appropriate type of machine to be selected for each nursing environment. Nursing Generated Assessment Data 4. Point of care systems must have a small footprint. Not all hospitals have the opportunity to configure a new building from the ground up. Most hospitals are trying to fit new technology into “old skin”. Early examples of bedside terminals took up a large amount of space in patient rooms. With limited electrical outlets and no piped-in oxygen or suction, a patient room that had all the equipment necessary to care for seriously ill patients left no room for the nurse. 5. Point of care systems must be easy to use and must adapt a wide variety of nursing environments. Patient contact occurs 24 hours a day. For example, bedside terminals must allow the nurse to access and input data without turning on the lights or disturbing the patient. 6. Point of care systems must be easily disinfected and cleaned between patients. Bedside keyboard should have membrane keyboard or a protective “skin” over the keyboard to protect it from liquids. Nursing Generated Assessment Data 7. For source data capture to be easily accomplished, nurses require a variety of ways for entering data. Keyboards require some typing skills. Other devices include bar code readers for scanning identification bands and medications, physiological probes, microphones for voice input, light pens and touch screens, digital cameras, and natural speech input devices. 8. For effective source data capture, the nurse must go wherever the patient is. Notebook technology and pen based portable systems offer the best choice for mobility. 9. Information to be retrieved using the point of care system must be represented in ways that can be quickly used and easily understood by nurses. Documentation ■ An ideal nurses’ notes are generally lengthy, problem-focused narrative, handwritten and unbiased observations. ■ At their worst, they are inaccurate, inconsistent, incomplete or trivial as some statements are routinely placed such as “endorsed, for continuity of care, kept warm” that are times are irrelevant to the actual patient scenario. Documentation ■ Hannah (2015) stated that automated methods for recording nursing observations are some of the most readily available nursing informatics applications. ■ Two approaches: ■ ■ A digital library of frequently used phrases is arranged in subject categories. The nurse chooses the phrase or combination of phrases that best describes the patient’s condition. – For example, by selecting a primary subject such as “sleeping habits”, a screen menu of standard descriptions appear, allowing for additionally selected comments such as “slept through breakfast – voluntarily” or “awoke early at a.m.” – When completed, the nursing station printer immediately prints a standard, easy to read, complete narrative that could then be attached to the patient’s chart. Develop a “branching questionnaire”. The terminal displays a list of choices, and the nurse selects her choice and indicates it by pressing the corresponding number on the keyboard or touching the terminal with a light sensitive input device (called a light pen). The terminal then displays a further list of choices appropriate to the original selection. Thus, the nurse is led through a series of questions that can be customized for each patient. Documentation Advantages for automated documentation of nursing observations: ■ Content standardization: increased charting competencies including increased numbers of observations because of prompting or forced recall and increased standardization, accuracy, and reliability of observations. ■ Improved standards compliance ■ Increased efficiency: legible notes, which decrease reading time and increase accuracy of interpretation and elimination of repetitive data recording and resulting transcription errors ■ Enhanced timeliness: less time spent writing notes, specifically end of shift charting ■ Expanded accessibility: data available online immediately and access not limited to one person at a time as with proper record. ■ Augmented data archive: ready statistical analysis and easier nursing audit because of the use of standard terminology Clinical Documentation Management ■ The introduction of EHR systems presents both opportunities and challenges for health care professionals. ■ Nurses need to utilize EHR systems to improve interdisciplinary communication and ultimately, patient/client safety. ■ EHRs are considered to be patient/client-centered. Clinical Documentation Management ■ Potential benefits for patients/clients include: (Canada Health Infoway, 2012) ■ Quick access to health information during medical emergencies ■ Improved management of chronic disease through trending of information and improved communication between multiple health care professionals ■ Shorter waiting times through improved communication about wait lists for diagnostic testing and interventions ■ Reduction of unnecessary repetition of diagnostic tests by improved flow of information between health care professionals and health sites ■ Better diagnsostic and treatment capabilities due to quick access and sharing of health information ■ Improved health care access for rural and remote groups via telehealth Clinical Documentation Management ■ EHRs are fundamental to the success of the retail clinics model of care. ■ Those developed for retail clinics support the assessment, diagnosis and treatment workflows of the provider. ■ The goal of the retail EMR is to help providers practice autonomously, streamlining administrative functions, while suggesting clinically appropriate actions generated from evidence based practice guidelines and clinical documentation. (Hannah, 2015 on Ryan, 2009) Data Issues ■ Nurses spend a great deal of time and energy gathering data. ■ Considering the data privacy confounding issues, many of these data are might be used for multiple purposes such as administrative or government statistics in order to determine the eligibility to avail certain services or healthcare premiums. ■ Often the same data are duplicated by the data gathering activities of other healthcare professionals for quality improvement, training purposes and the like for healthcare institutions. ■ Nurses should only be gathering data that are essential for nursing decisions about patient care ■ The principles involved is to gather essential information while avoiding replication and duplication of data that waste resources such as manpower, storage space and memory. The Shift to Electronic Documentation ■ Traditionally health care professionals documented on paper medical records. Papers records are episode oriented, with a separate record for each patient visit to a health care agency. ■ Key informationsuch as patient allergies, current medications and complications from treatment are sometimes lost from one episode of care (e.g., hospitalization or clinic visit) to the next, jeopardizing a patient’s safety. (Hebda and Czar, 2013) ■ An EHR (Electronic Health Record) is a digital version of patient data that is found in traditional paper records. The term EHR is used increasingly to refer a longitudinal (lifetime) record for all health care encounters for an individual patient. ■ An EMR (Electronic Medical Record) is the legal record that describes as a single encounter or visit created in hospitals and out patient health care settings that is the source of data for the EHR. The Shift to Electronic Documentation ■ The promise of EHR is twofold: 1. Making a positive impact on the quality of patient care through interprofessional collaboration with improved data aavilability and information synthesis 2. Improving patient safety through the use of clinical decision support. The Shift to Electronic Documentation ■ The EHR provides access to a patient’s health record information at the time and place that clinicians need it. ■ A unique feature of an EHR is its ability to integrate all patient information into one record, regardless of the number of times a patient enters a health care system ■ The key advantages of an EHR for nursing include a means for nurses to compare current clinical data about a patient with data from previous health care encounters and to maintain an ongoing record of health education provided to a patient and the patient’s response to that information ■ Example of how an EHR works: ■ A patient with complex medical history sees multiple specialists (endocrinologist, cardiologist, nephrologist) to manage his or her health. Each of these providers is able to access patient data from the EHR at the same time. Risks and Benefits of Electronic Health Records ■ Electronic health record systems are used in various hospitals, community health settings and doctor’s offices to enter and view client information. ■ Unique client identifiers are used to ensure that information about the client is linked with the correct health care provider, the client’s most recent results of laboratory and diagnostic tests, and an updated list of currently prescribed medications. ■ Information about the client’s vaccination history, allergies, consults, operative reports, and discharge information is also provided. Risks and Benefits of Electronic Health Records ■ A benefit of using electronic health records is that health care providers have quick access to medical information. ■ Clients benefit as they receive imroved managemet of chronic diseases, such as when health care professionals can receive reminders of follow up tests. ■ Electronic health records also reduce unnecessary repetition of laboratory and diagnostic testing, which ultimately saves money. Risks and Benefits of Electronic Health Records ■ A risk of electronic health records is that people not within the circle of care may access confidential information. ■ Regional health aurthorities have taken measures to monitor for such risks. ■ These measures include providing limited access and monitoring who is viewing any confidential health information. Risks and Benefits of Electronic Health Records ■ Electronic health records may also include the use of standardized evidenced-based protocols for nursing care. ■ Nurses can access the most current evidenced-based protocol to see potential nursing interventions, which can serve to improve documentation of assessments and interventions by providing reminders to chart specific symptoms or to chart the administration of PRN medications. Privacy, Confidentiality and Security Mechanism ■ Electronic documentation has legal risks. It is possible for anyone to access a computer station witjin a healthcare agency and gain information about any patient. Therefore, protection of information and computer system is a top priority. ■ Ensuring appropriate access to and confidentiality of personal health information is the responsibility of all people working in health care. ■ Most security mechanisms for computerized information system use a combination of logical and physical restrictions to protect information. For example, an automatic sign off is a safety mechanism that logs a user off a computer system after a specified period of inactivity ■ Other security measures include firewall and the installation of antivirus and spywaredetection software. A firewall is a combination of hardware and software that protects private network reesources (e.g. The information system pf the hospital) from outside hackers, network damage, and the theft or misuse of information. Privacy, Confidentiality and Security Mechanism ■ Physical security measures include placing computers or file servers in restricted areas or using privacy fillers for computer screens visible to visitors or others without access. This form of security has limited benefit, especially if an organization uses mobile wireless devices such as notebooks, tablets, personal computers, and personal digital assistants. These devices are easily misplaced or lost, falling into the wrong hands. Some organizations use motion detectors or alarm with these devices to help prevent theft. ■ Access or log in codes along with passwords a re frequently used for authenticating autjorized access to electronic records. A password is a collection of alphanumeric characters that a user types into a computer before accessing a program after the entry and acceptance of an access code or user name ■ When using a health care agency computer system, it is essential that nurses do not share computer password with anyone under any circumstances ■ To protect patient privacy, health care agencies track who accesses patient records and when they access them. Disciplinary action, including loss of employment, occurs when nurses or other health care personnel inappropriately access patient information. Handling and Disposing of Information ■ Maintaining the confidentiality of medical records is an essential responsibility of all members of the care team. ■ It is equally important to safeguard any information that is printed from the record or extracted for report purposes. ■ Destroy anything that is printed when the information is no longer needed. Nursing students must write patient data needed for clinical paperwork directly from a patient’s medical record on the computer screen or the physical chart. ■ De-identify all personal health information, keep the documents secure and destroy documents by shredding or dosposing of them in a locked receptacle as soon as possible. ■ Destroy all papers containing personal health information (e.g. Social Security number, date of birth or age, patient’s name or address) immediately after you use or fax them. Most agencies have shredders or locked receptacles for shredding and incineration. Planning: Automated Care Planning ■ Majority of the health care settings uses the Kardex to serve repositiry of nursing care plans. This tool is being used to handoff or endorse patient care between one nurse to another, but has drawbacks similar to those encountered with nursing notes as well as other drawbacks that are unique to the Kardex. ■ Nursing care plans, if they are entered in the Kardex form at all is usually outdated, illegible, irrelevant, inconsistent and incomplete. It is only during the quality care audits that these documents get precised and updated. ■ Notations are made by all levels of nursing personnel from nursing aides to head nurses. ■ Written patient care assignments are usually accompanied by verbal explanations that are often forgotten. This approach is often one source of faulty communication between nurses caring for the patient. Kardex Automated Care Planning ■ Alternative approaches to the automation of nursing care plan is to design care maps or pathways for meeting patient needs, store them in a computer memory banks and then adapt them to individual patients. ■ The resulting output is unique for each patient’s assessed needs for daily care. ■ In all cases, it is the nurse who assess, plans, and evaluates the paln for care, and auxiliary personnel might also be involved in the implemenation of the plan. ■ The evolving and redesigning approach to care planning is the development of the decision support systems for nursing practice. Automated Care Planning Advantages of automated nursing care plans over traditional nursing care plans: ■ Time is saved by eliminating the need for daily hnadwriting of patient assignments and by decreasing the amount of verbal explanation required. ■ Accountability is increased because personnel have printouts of care plans for each of their patients ■ Errors and omissions are decreased ■ Consistency of care from shift to shift and day to day is increased; quality of patient care improves ■ Judgments for nursing care are no longer delegated to whoever walks into a room to care for the patient; they are the responsibility of the professional nurse who now has tools available to help make nursing judgements Automated Care Planning Implications of these advantages for nursing practice: ■ Time saved during the preparation and communication of care plans means more time available for the nursing process. ■ Increased accountability for care improves nursing practice because documentation is available to evaluate the quality of care and thus the quality of practice ■ Benefits to patient care of decreased errors and omissions and increased consistency of care include more rapid diagnosis, more valid assessment and more rapid recovery ■ These factors all reduce the cost of health care for the patient and open the system to more patients, with the over all goal of promoting patient safety ■ The responsibility for nursing judgments is clearly placed on the professional nurse, which helps in defining nursing practice Decision Support System ■ Decision support system helps nurses maintain and maximize their decision making responsibilities and focus on the highest priority aspects of patient care. ■ Standardized care plans, whether manual or computer-based, provide care only for standardized patients ■ Standardized care plans do not enhance nursing decision making Decision Support System ■ A true decision support system allows nurses to encode their assessments at the bedside using source data capture technology and then use the computer to analyze those assessments and recommend nursing diagnosis. ■ The nurse then accepts or rejects the recommendations. ■ After accepting a particular diagnosis, the range of interventions acceptable in that institution can be retrieved and presented by the digital device ■ The nurse can choose the nursing interventions appropriate for the patient Decision Support System ■ Decision support systems are useful because each nurse’s collection of interventions is based solely on professional experience ■ The nurse’s collection of interventions is also influenced by a “forgetting” curve ■ If the nurse has not encountered a specific nursing diagnosis for a long time, the remembered interventions may not reflect the whole collection ■ The advisory or expert system not only accumulates the experience of all nurses in the organization but also serves as a “reminding” function. ■ Decision support systems have been developed for a variety of settings, including critical care, cancer pain management and pediatric fever. Decision Support System ■ Decision support systems may not be appropriate for all patient care settings or at all times. ■ Emergencies such as cardiac arrest do not allow time for the nurse to scroll through suggested actions. ■ High complex patient problems may also prove a great challenge for the current types Decision Support System ■ Decision support systems can never replace the need for nurses with expert clinical and decision making skills. ■ The nurse is still required to exercise clinical judgment, regardless of whether a decision-modeling or expert system has been used. ■ The fundamental idea that must be stressed is that decision support tools should add to the nurse’s decision-making capacity, not attempt to replace it. Implementation ■ Digital devices rarely help the nurse in the giving of care or nursing service. ■ Generally, computers are used more in other phases of the nursing process ■ One example of how computers are used in intervention is the program administration of preloaded drugs in the ICU Evaluation ■ Digital devices can be used to evaluate nursing care through real time auditing and quality improvement and management activities. HOW NURSING INFORMATICS IMPROVES PATIENTS CARE How Nursing Informatics Improves Patient Care ■ The healthcare information revolution is upon us. Clinicians have more access than ever to electronic health records, diagnostics, and treatment plans. ■ Clinical communication and collaboration platforms are making it easier to manage healthcare workflows, improve coordination, and enhance patient outcomes. Systems integration and data access mean that information and analysis are more vital than ever. ■ The secret to using this data to provide better care comes down to nursing informatics — integrating nursing science with other areas to identify, define, manage, and communicate data, information, knowledge, and wisdom to provide better care. ■ As the Healthcare Information and Management Systems Society says, “The informatics nurse is part of the delivery of care, the building of knowledge, skills, and experience in the use of information technology. They often lead clinical informatics committee meetings that have a major influence for nurses in assisting them to coordinate all the multifaceted technology activities in regards to patient care, documentation, and safety.” Aligning Nursing Best Practice with Clinical Workflows and Care ■ Nursing informatics is focused on the best ways to achieve good patient outcomes — it is about applying the overall process and best practice to maximize patient care wherever possible. ■ As a result, nurse informaticists are often involved in process design, clinical workflow reviews, and new diagnostics and treatment plans. ■ They take into account the various options for providing care and use objective facts and analysis to determine the actions that will lead to the most patientcentered, value-based care. Improving Clinical Policies, Protocols, Processes, and Procedures ■ Data is the lifeblood of nursing informatics. That data and information can be used to measure the success of the various protocols, processes, and procedures used in a healthcare organization. ■ A nurse informaticist will measure and analyze how specific parts of the organization are performing, with a focus on the resulting patient outcomes. ■ They can then make changes to specific parts of the process to streamline activities, avoid bottlenecks, and improve care. ■ Informaticists will see what the results are and continue making changes to enhance every part of the clinical care process. Providing Training and Learning Based on Objective Data ■ One of the most valuable ways a nursing informaticist can enhance patient outcomes is through providing training to clinical staff. ■ They can use data to identify endemic issues in a healthcare organization and consult on the best way to resolve these problems. ■ These learnings can be integrated with onboarding new staff, ongoing in-house training, or external education and certification. ■ Nursing informaticists can help to create highly-targeted educational programs to deal with specific gaps between ability and provider expectations. Selecting and Testing New Medical Devices ■ Connected medical devices can provide vast amounts of health data on patients. ■ Nursing informaticists are ideally positioned to understand the true value of that data and provide recommendations on how it can be recorded, accessed, and used. ■ Involving informaticists in the selection of medical devices will ensure you have additional criteria for understanding how device data can inform diagnostics, treatment plans, and ultimately patient outcomes. Reducing Medical Errors and Costs ■ Nursing informaticists can reduce the chance of medical errors in a healthcare organization, together with associated costs. A combination of staff training, process improvement, and best practice will enhance the quality of care and limit patient risks. ■ Four main areas that drive medical errors: ■ ■ ■ ■ Communication doesn’t take place when it should Incorrect or incomplete information is communicated Information is shared with the wrong recipient or third party The message lacks critical facts or is unclear, meaning it isn’t understood correctly ■ Informaticists can look at how your organization communicates and collaborates around patient information. They can audit individual cases, identify gaps, and provide recommendations for avoiding errors in the future. Enhancing End-to-End Treatment and Continuity of Care ■ A patient’s care may involve several areas, many teams, and dozens of individuals. ■ Nursing informaticists can create protocols and processes to ensure proper communications and interactions between departments, teams, individuals, and patients. ■ They can help healthcare employees to seek out “one view of the truth” through electronic health records, so everyone has the context and insight they need to ensure excellent continuity of care.
