NUR 302 Week Five

Introduction to Nursing Informatics
The world has witnessed an unprecedented number of technological advances during the last 100 years.
Cars, airplanes
Entertainment world – radio and television.

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

The internet
has changed communication drastically.

What Is Nursing Informatics?
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)

History of Informatics
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).

Goal of Nursing Informatics
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)”.

Collected information used to answer questions

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

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

The appropriate application of knowledge to solve real-world problems

Metastructures of NI- DIKW

An Example of DIKW
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

Importance of Nursing Wisdom
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?

Glascow Coma Scale
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.

Nursing Decisions
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.

Informatics in Nursing Practice
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

Health Care in the United States and the Need for Health Information Management
Burden of fragmentation

Burden of fragmentation
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

Decision Support Systems
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

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

Wisdom in Informatics
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

The Nurse as a Knowledge Worker
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.

Nursing Informatics Roles
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

Global Definition of Nursing Informatics
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.

Informatics Needs
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:

Informatics to engage consumers
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

Informatics and Creating Clinical Knowledge
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).

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

Clinical Decision Tools (CDS)
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.

CIS Data Input Devices
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

Clinical Practice Challenge
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

A View of the Future
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.

Informatics Tools to Promote Patient Safety
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.

Medical Errors
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.

Safety Initiatives
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

Key Features of a Safety Culture
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)

What is a Just Culture?
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

Human Errors
(unintentional mistakes)
perform FMEA to understand error

Risky Behaviors
work arounds or cutting corners)
examine workflow; educate

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

Alarm Fatigue
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

Informatics Technologies and Safety
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

Quality Improvement Techniques and Nursing Informatics
Aims of the organization must be understood
Institute of Medicine highlights six main aims
QI system must develop measures of quality that reflect these aims

Measuring quality can be difficult
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

Internal benchmarking
Compares current and past performance

External benchmarking
Compares performance against other HCPs

Continuous quality improvement (CQI) systems
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

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

Medication Administration cycle
Assessment of need
Human Error Factors: Distractions, unclear thinking, lack of knowledge, short staffing, and fatigue

Six Rights of Medication Administration
the right patient
the right time and frequency of administration
the right dose
the right route
the right drug

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

Computerized Physician Order Entry (CPOE) Benefits
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

Technology in the Pharmacy
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

Barcode Medication labeling or RFID Technology
Assists with dispensing and administration

Automated dispensing machines
storage, dispensing, controlling, and tracking

Barcode Medication Administration (BCMA)
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.

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

Barcoding Medications – Safety Levels
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

Smart IV pumps
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

Clinical Decision Support (CDS)
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.

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

Technologies for Home Medication Compliance
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.

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

SIMpill® Medication Adherence System
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

Other CDS Patient Safety Benefits
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

Expanded RFID Uses
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

Smart Room Technology
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

Patient Monitoring Technologies
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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