chapter 11 issues in informatics

7/28/2019 Chapter 11 Issues in Informatics

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ISSUES IN INFORMATICS

Nursing Informatics and Healthcare Policy

The Role of Technology in the Medication-Use

ProcessHealthcare Data Standards

Electronic Health Record Systems


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Nursing Informatics and

Healthcare Policy

Informatics nurses have strong clinicalbackgrounds but cease to deliver care directlyto patients.

They refocus their careers on the informaticsdomain of interest to provide indirecthealthcare services.

E.g. informatics nurses working in acute caresettings might focus on system selection andimplementation.


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Healthcare Policy

Informatics nurses should assist with the

development and implementation of

technology tools for clinical practice,evaluation of the effectiveness of

technological tools on nurses work, and

help prepare nurses to use information

technologies.


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Healthcare Policy

NI- a well established as a specialty withinnursing

NI- needs to broaden its educational andpractice perspectives to include moreinterdisciplinary focus

Certification as a generalist in NI is currently

available, but a specialist level of certification isneeded to acknowledge more advancedinformatics skills


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Healthcare Policy

There is a tremendous need to improve the general

informatics skills of nursing faculty, students and

clinicians

Informatics nurses need to embrace telehealth as

part of informatics practice and work to educate

barriers imposed by licensure and reimbursement

issues NI community needs to become aware of health

policies that have been established or are under

consideration to determine their effect on

informatics practice


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Healthcare Policy

Preparation for Specialty Practice

Educational programs are available to prepare

nurses to practice in the field. Certification examination currently available

through the American Nurses Credentialing Center

is for a generalist NI.

Final requirement for specialty is representation byat least one organization. (AMIA, Health Information

Management System Society)


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April 27, 2004- President George W. Bush

issued an Executive order Incentives for the

Use of Health Information Technology andEstablishing the Position of the National Health

Information Technology Coordinatorthat has

the potential to impact every healthcare

entity, provider and NI professionals in the

US.


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1. Established a national health information

technology coordinator position

2. Work to develop a nationwide interoperablehealth IT infrastructure

3. Develop, maintain & direct implementation

of a strategic plan to guide implementationof interoperable health IT in both public &

private sectors

Components of Executive

Order 2004


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Interoperable health IT

- should reduce medical errors

- Improve quality & produce greatervalue for healthcare expenditures


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1. Appropriate information is available at the

time & place needed for medical decisions

2. Health quality is improved & evidence-based

medical care is delivered

3. Healthcare costs are reduced

4. More information is available to promote

greater competition

5. Health information is exchanged

6. Identifiable health information is secure &

protected

Guidelines for the

Infrastructure


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Was passed in 1996

Intended to improve public & private heath

programs by establishing standards to

facilitate the efficient transmission ofelectronic health information

Law also designates financial penalties for

noncompliance with standards related tospecific transactions

Health Insurance Portability

and Accountability Act (HIPAA)


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Enhanced doctor-patient

communication

Only minimal risks in increasing accessof patients to their records

Benefits of HIPAA


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1. To include core informatics knowledge and skill inall undergraduate, graduate and continuing

education programs

2. To increase the number of nurses with specializedskills in informatics

3. To enhance nursing practice and education through

informatics projects

4. To improve faculty skills in NI so that they in turn

can promote the development of informatics

competency in students

5. To increase collaborative efforts in NI

Strategic Directions for NI


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Is the use of electronic information andtelecommunications technologies to support

long distance clinical healthcare, patient and

professional health-related education, publichealth and health education.

With its introduction, ten of thousands of

patients are accessing healthcare remotelyfrom Arctic villages, rural communities and

prisons.

Telehealth


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Factors advancing telehealth technologyinnovations are decreasing cost of

telecommunication technologies, decreasing

cost of telehealth devices and applications,resolutions of interoperability issues, and

convergence of telehealth and

telecommunication technologies, IT and theInternet.

Telehealth


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The Role of Technology in the

Medication-Use Process


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IMPORTANT FACTS:

In fact, less than 10% of health care organizations

have yet to incorporate any type of medication

safety technology indicating that they have

allocated their limited financial and humanresources in other directions.

1995 television and newspaper accounts that

reported the tragic death of a patient from apreventable adverse drug event (ADE) due to an

inadvertent administration of a massive overdose

of a chemotherapy agent over 4 days at the Dana

Farber Cancer Institute


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How do we solve the problemswith regard to medication

usage and administration?

S l ti t th bl


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Solutions to the problem:

IT INNOVATIONS IN MEDICATION

USE PROCESS

Computerized Prescriber Order

Entry (CPOE) Bar Code-enabled point-of-care

technology

Automated Dispensing Cabinets

Smart Infusion Pump Delivery

Systems


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The Spoonful of Sugar: medicine management in NHS

hospitals (Audit Commission 2001) report concluded:

Complications arising from medicines treatment arethe most common cause of adverse events in hospital

patients.

Errors may occur from the initial decision to prescribe

to the final administration of the medicine, and theseinclude choice of the wrong medicine, dose, route,

form, and frequency.

Prescription sheets themselves may also be

tem oraril unavailable or lost.


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In the outpatient setting that indecipherable or unclear

orders resulted in more than 150 million telephone

calls from pharmacists and nurses to prescribersrequiring clarification.

Handwritten prescriptions are used 99% of the time to

communicate orders. Studies have shown that as a result of poor

handwriting, 50% of all written physician orders require

extra time to interpret.

Illegible handwriting on medication orders has beenshown to be a common cause of prescribing errors and

patient injury and death have actually resulted from

such errors


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COMPUTERIZED PRESCRIBERORDER ENTRY (CPOE)

The Leapfrog Project advocated the use ofCPOE technology to prevent errors.


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Computerized Prescriber

Order Entry (CPOE)

Use of CPOE has the potential to alleviate

many problems

Defined as system used for direct entry ofone or more types of medical orders by a

prescriber into a system that transmits

those orders electronically to theappropriate department


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Order Entry (CPOE)

is a process of electronic entry of medical

practitioner instructions for the treatment of

patients (particularly hospitalized patients)under his or her care.

These orders are communicated over

a computer network to the medical staff or tothe departments (pharmacy, laboratory,

or radiology) responsible for fulfilling the

order.
http://en.wikipedia.org/wiki/Hospitalhttp://en.wikipedia.org/wiki/Computer_networkhttp://en.wikipedia.org/wiki/Pharmacyhttp://en.wikipedia.org/wiki/Radiologyhttp://en.wikipedia.org/wiki/Radiologyhttp://en.wikipedia.org/wiki/Pharmacyhttp://en.wikipedia.org/wiki/Computer_networkhttp://en.wikipedia.org/wiki/Hospital


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Order Entry (CPOE)

CPOE decreases delay in order completion,

reduces errors related to handwriting

or transcription, allows order entry at point-of-care or off-site, provides error-checking for

duplicate or incorrect doses or tests, and

simplifies inventory and posting of charges.

Comp teri ed Prescriber
http://en.wikipedia.org/wiki/Transcription_(linguistics)http://en.wikipedia.org/wiki/Transcription_(linguistics)


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Features: Ordering

Physician orders are standardized across the

organization, yet may be individualized for eachdoctor or specialty by using order sets. Orders are

communicated to all departments and involved

caregivers, improving response time and avoidingscheduling problems and conflict with existing

orders.


Order Entry (CPOE)



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Features: Patient-centered decision support

The ordering process includes a display of the

patient's medical history and current results andevidence-based clinical guidelines to support

treatment decisions.


Order Entry (CPOE)

http://en.wikipedia.org/wiki/Decision_supporthttp://en.wikipedia.org/wiki/Guideline_(medical)http://en.wikipedia.org/wiki/Guideline_(medical)http://en.wikipedia.org/wiki/Decision_support


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Features: Patient safety features

The CPOE system allows real-time patient

identification, drug doserecommendations, adverse drug

reaction reviews, and checks on allergies and test

or treatment conflicts. Physicians and nurses canreview orders immediately for confirmation.


Order Entry (CPOE)

http://en.wikipedia.org/wiki/Patient_safetyhttp://en.wikipedia.org/wiki/Adverse_drug_reactionhttp://en.wikipedia.org/wiki/Adverse_drug_reactionhttp://en.wikipedia.org/wiki/Adverse_drug_reactionhttp://en.wikipedia.org/wiki/Adverse_drug_reactionhttp://en.wikipedia.org/wiki/Patient_safety


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Features: Intuitive Human interface

The order entry workflow corresponds to familiar

"paper-based" ordering to allow efficient use bynew or infrequent users.


Order Entry (CPOE)

http://en.wikipedia.org/wiki/Human_interfacehttp://en.wikipedia.org/wiki/Human_interface


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Features: Regulatory compliance and security

Access is secure, and a permanent record is

created, with electronic signature.

Portability

The system accepts and manages orders for all

departments at the point-of-care, from anylocation in the health system (physician's office,

hospital or home) through a variety of devices,

including wireless PCs and tablet computers.


Order Entry (CPOE)

http://en.wikipedia.org/wiki/Electronic_signaturehttp://en.wikipedia.org/wiki/Computerhttp://en.wikipedia.org/wiki/Tablet_computerhttp://en.wikipedia.org/wiki/Tablet_computerhttp://en.wikipedia.org/wiki/Computerhttp://en.wikipedia.org/wiki/Electronic_signature


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Features: Management

The system delivers statistical reports online so

that managers can analyze patient census andmake changes in staffing, replace inventory and

audit utilization and productivity throughout the

organization. Data is collected for training,planning, and root cause analysis for patient

safety events.


Order Entry (CPOE)

http://en.wikipedia.org/wiki/Root_cause_analysishttp://en.wikipedia.org/wiki/Patient_safetyhttp://en.wikipedia.org/wiki/Patient_safetyhttp://en.wikipedia.org/wiki/Patient_safetyhttp://en.wikipedia.org/wiki/Patient_safetyhttp://en.wikipedia.org/wiki/Root_cause_analysis


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Features: Billing

Documentation is improved by linking diagnoses

(ICD-9-CM or ICD-10-CM codes) to orders at thetime of order entry to support appropriate

charges.


Order Entry (CPOE)
http://en.wikipedia.org/wiki/ICD-9-CMhttp://en.wikipedia.org/wiki/ICD-10-CMhttp://en.wikipedia.org/wiki/ICD-10-CMhttp://en.wikipedia.org/wiki/ICD-10-CMhttp://en.wikipedia.org/wiki/ICD-10-CMhttp://en.wikipedia.org/wiki/ICD-10-CMhttp://en.wikipedia.org/wiki/ICD-10-CMhttp://en.wikipedia.org/wiki/ICD-9-CMhttp://en.wikipedia.org/wiki/ICD-9-CMhttp://en.wikipedia.org/wiki/ICD-9-CMhttp://en.wikipedia.org/wiki/ICD-9-CMhttp://en.wikipedia.org/wiki/ICD-9-CM


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Advantages:Can improve quality, patient outcomes

& safety by a variety of factors such asincreasing preventive health guideline

compliance by exposing prescribers to

reminder messages to providepreventive care by encouraging

compliance with recommended

guidelines, identifying patients

needing updated immunizations orvaccinations and suggesting cancer

screening & diagnosis reminders &

prompts


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Advantages:Reductions in the variation in care to

improve disease management byimproving follow-up of newly

diagnosed conditions, reminder

systems to improve patientmanagement, automating evidence-

based protocols, adhering to clinical

guidelines or providing screening

instruments to help diagnosisdisorders


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Advantages:Order entry system can improve drug

prescribing & administration byimproving antibiotic usage, suggesting

whether certain antibiotics or their

dosages are appropriate for useMedication refill compliance can be

increased using reminder systems to

increase adherence to therapies

Drug dosing could be improved


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Advantages: Reduction of non-missed-dose

medication errors from 142/1000patient days to 26.6/1000 patient

days

Reduction of nonintercepted seriousmedication errors from 7.6/1000

patient days 1.1/1000 patient days

Errors of omissions reduced- such as

failure to act on results or carry out

indicated tests


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Advantages: Handwriting & interpretation issues

would be eliminated Eliminate the need for staff members to

manually transport orders to the

pharmacy, radiology department and

labs, resulting in fewer lost or misplaced

orders and faster delivery time

Eliminated the need for staff members in

those departments to manually enter theorders into their information systems,

reducing the potential for transcription

errors


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Advantages: More comprehensive and accurate

documentation by prescribers and nurses Enable ready access to updated drug

information

Reductions in hospitalizations &decreased lengths of stay can be obtained

from automated scheduling of follow-up

appointments to reducing unnecessary

diagnostic tests Patient user satisfaction


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Disadvantages: Concern about the costs of

implementation- software package, time,space, manpower, staff education &

development, workstations & high speed

Internet access

Difficult to prove or demonstrate any

quantifiable benefits or returns on

investment because it is hard to

accurately measure the actual costs ofusing paper-based records

System require nurses to possess basic

computer skills


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Benefits; Nurses have more time with patients due

to enhanced productivity due to areduced frequency in contracting

prescribers to clarify orders

Reduction in time wastedin transcribing

duplicate orders for the same medication

or test

Greater standardization of orders

Lessening the need to understand andadhere to diverse regimens and schedules

Improve efficiencywhen ordering

tests/procedures


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Benefits; Reducing time devoted to carrying

out redundant orders

Less need to enter voice orders into

system as prescriber gain access to

the system from other units &remote locations

Orders would be executed faster

Medication would be available morequickly

Patients receive prompter care

B C de E bled P i t


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Bar Code-Enabled Point-of-Care Technology

Demonstrated its power to greatly improve

productivity & accuracy in the identification

of products in a variety of business settings,such as supermarkets & department stores

Proven to be an effective technology, it

quickly spread to virtually all otherindustries

B C de E bled P i t


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Bar Code-Enabled Point-of-Care Technology

1435 Hospitals showed that only:

43% of hospitals had even discussedthe

possibility of bar code drug administration 2.5% used this technology in some areas of the

hospital

Less than 1% hadfully implementeditthroughout the organization

Reasons for few implementation of


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Reasons for few implementation of

Bar Code-Enabled point-of-care

technology

Cost of implementation

Inadequate systems

Lack of the number of medications thatare packaged with bar codes


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Bar Code Technology

Improve safe administration of

medications

10-fold reduction in error over 8 years

The system helps to verify thatright

drug is being administered to the rightpatientat the right dose by the right

route at the right time


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BPOCOn admission, patients are issued an

individualized bar code wristband thatuniquely identifies their identity

When the patient is to receive a

medication, nurses scans their bar

coded employee identifier and the

patients bar code wristband to confirm

their identity.

Prior to medication administration,each bar coded packaged of medication

to be administered at the bedside is

scanned


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Bar code Scanner

Enable nurses to have greater

accuracy in recording the timing of

medication administration, as

computer generates an actualreal-time log medication

administration


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Features:Increased accountability and capture

of charges for items such as unit-stock medications

Up-to-date drug reference

information from online medicationreference libraries. This could

include pictures of tablets or

capsules, usual dosages,

contraindications, adverse reactions

and other safety warnings,

pregnancy risk factors and

administration details


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Features:

Customizable comments/alerts (e.g. look-

alike/sound-alike drug names) and

reminders of important clinical actions thatneed to be taken when administering certain

medications (e.g. respiratory intubation is

required for neuromuscular agent)

Monitoring the pharmacy and nursesresponse to predetermined rules/standards

in the rules engine such as alerts or

reminders for the pharmacist or nurse.

Includes allergies, duplicate dosing,

over/under dosing, checking for cumulative

dosing for medications with established

maximum doses


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Reconciliation for pending or

STAT orders (i.e. a prescriber

order not yet verified by apharmacist). The ability of the

nurse to enter a STAT order

into the system onadministration that is linked

directly to the pharmacy

profile and prevents theduplicate administration of the

same medication.

Features:


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Capturing data for the purpose of

retrospective analysis of aggregate

data to monitor trends (e.g.percent of doses administered late

& errors of omission). However,

this analysis should notbe used toassess employee performance,

especially if it could lead to

punitive action

Verifying blood transfusion &

laboratory specimen collection

identification

Features:

Negative Effects:


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Negative Effects:Nurses were sometimes caught off guard

by the programmed automated actionstaken by the BPOC software. Ex. The BPOC

would remove medications from a patient

drug profile list for 4hrs. After the

scheduled administration time, even if themedication were never administered.

Therefore if the patient returned from a

procedure more than 4hrs after a

scheduled medication administrationtime, the nurse would have no way of

viewing if the ordered medication

had/had not been administered

Negative Effects:


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Negative Effects:

The BPOC seemed to restrain the

coordination of patient information

between prescribers and nurses

when compared to traditional paper

based system. Before, the prescribercould quickly review the handwritten

MAR at the patients bedside or in

the units medication room

Negative Effects:


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Negative Effects:The nurse found it more difficult to

deviate from the routineadministration sequence with the

BPOC system.

Ex. If a patient refused a medication,the nurse had to manually document

the change in a time-consuming

process since the medication hadalready been documented as given

when it was originally scanned.

Negative Effects:


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Negative Effects:The nurse felt that their main

priority was the timeliness ofmedication administration because

BPOC required nurse to type in an

explanation when medications weregiven even a few minutes late.

Nurses used strategies to increase

efficiency that circumvented theintended use of BPOC

IMPORTANT NOTE


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IMPORTANT NOTE

Interaction between nurses and technology at

the bedside is important & must be continually

evaluated for SAFETY. Ex. Nurses circumventing the normal

procedures by removing/duplicating patients

barcode wristbands & scanning all of the

patients bar code wristbands & then scanning

the medications for each patient while in the

medication room prior to or after medication

administration

Type of Errors could occur


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Type of Errors could occurOmissions: After a patients bar

code armband & medication havebeen scanned, the dose is

inadequately dropped onto the

floor. This results in a time lapsebetween the documentation that

the medication was supposedly

administered and the actualadministration after obtaining of a

new dose


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Extra Dose: An extra dose may be

given when there are orders for the

same drug to be administered by adifferent route. Ex. If one nurse gives

oral dose is called away & the

covering nurse administers the doseintravenous (IV). The problem arises

when there is no alert between

profiled routes of administration

indicating that the medication was

previously administered by one route

that is different than the second route


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Wrong drug: in situations when the

nurse administers a medication,

which has not been labeled with a barcode

Wrong dose: In situations when thenurse has difficulty in scanning

medication & proceeds to scan the

medication twice. This results in adouble dose when only one tablet

is to be administered.


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AutomatedDispensing Cabinets A computerized point-of-use medication

management system that is designed to

replace or support the traditional unit-dose drug delivery system.


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AutomatedDispensing Cabinets is a computerized drug storage device or

cabinet designed for hospitals. ADCs

allow medications to be stored anddispensed near the point of care while

controlling and tracking drug distribution.


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AutomatedDispensing Cabinets incorporate sophisticated software and

electronic interfaces to synthesize high-

risk steps in the medication use process.

provide computer controlled storage,

dispensation, tracking, and

documentation of medication

distribution on the resident care unit.

a ona es e n e w e


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a ona es e n e w eacceptance of ADC

technology Improving pharmacy productivity

Improving nursing productivity Reducing costs

Improving charge capture

Enhancing patient quality and safety


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Errors:Look-alike/sound-alike medication names

Lack of pharmacy screening of medication

order prior to administration

Choosing the wrong medication from an

alphabet pick list

High-alert medications placed, stored and

returned to ADCs

Storage of medications with look-alike names

and/or packaging


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ADC issues to ensure safemedication practicesConsider purchasing a system that allow for patient

profiling so pharmacist can enter & screen drug

orders prior to their removal & administered. Also

consider purchasing a system that utilizes bar-code

technology during the stocking, retrieval and drug

administration

Carefully select the drugs that will be stocked in thecabinets. Consider the needs of each patient care

unit as well as the age and diagnoses of patients

being treated on the units.


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ADC issues to ensure safemedication practicesPlace drugs that cannot be accessed without

pharmacy order entry and screening in

individual matrix binUse individual cabinets to separate pediatric

and adult medications

Periodically reassess the drugs stocked in eachunit-based cabinet.

Remove only a single dose of the medication

ordered


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ADC issues to ensure safemedication practicesDevelop a check system to assure

accurate stocking of the cabinets.

Place allergy reminders for specificdrugs, such as antibiotics, NSAIDs on the

cabinets

Routinely run and analyze override

reports to help track and identify

problems

Smart Infusion Pump


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Smart Infusion Pump

Delivery Systems

Infusion Pump- primarily used to

deliver parenteral medications through

IV or epidural lines and can be found invariety of clinical settings ranging from

acute care and long term facilities,

patients homes and physicians office


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ERRORS: due to incorrect, inappropriate or

miscalculation of an order for the medication

Smart Pump-

infusion pumps with dosecalculation software

Could reduce:

Medication errors

Improve workflow

Provide a new source of data for continuous quality

improvement by identifying and correcting pump-

programming errors


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are designed to offer extra bedside protection

against mistakes.

The pumps' software can hold an extensive

drug library that includes pre-

established maximum and minimum range doses

for each medication.

SMART PUMPS


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A warning sounds if a staff tries to exceed these

doses.

The pump may give a "soft alert," which asks

users to reconsider whether they want to

program that particular dose.

A "hard alert" will not allow users to override

the machine and administer a dose outside of

the librarys limit.

SMART PUMPS

Smart Infusion Pump


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Smart Infusion Pump

Delivery Systems

Can also integrate bar code technology toprovide

additional checks and balances in the drug

administration process

Ensure correct medication, correct patient, at right

dose

Enables the infusion system toprovide an additional

verification of the programming of medication delivery

Nurse receives an alert when the dose is below/above

the organizations preestablished limits

f


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The fact is paper records

kill. And the tragic is the

deaths are avoidable.

As patient advocates,

nurses have a

responsibility to discuss

their patient safety concern

and speak up about thedangers associated with the

current paper-based

medication use process.

N h


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Nurses have a

responsibility to become

familiar with the availabilityofsafety technology, the

advantages and

disadvantages and to work

in collaboration with other

healthcare stakeholders in

the search for new and

innovative technologic

solutions to improve patient


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Dependable Systems forQuality Care

Th h lth i d t i


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The healthcare industry is

undergoing a dramatic

transformation from todaysinefficient, costly, manually

intensive, crises-driven

model of care delivery to a

more efficient, consumer-

centric, science based,

model that proactively

focuses on health

management.

C d f Ethi f N


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Code of Ethics for Nurses

affirms that the nurse

holds in confidencepersonal information and

ensures that the use of

technology is compatible

with the safety, dignity and

rights of people.

IT i k bl f thi


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IT is a key enabler for this

transformation

As provider organizations

become increasingly

dependent on IT in the

delivery of care, new risks

emerge, & system

dependability becomesessential for business

success, quality care, and

patient safety.

Dependable systems are


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Dependable systems are:

Reliable- the system consistently behaves

in the same way.

They are available when they are needed

Confidentiality-sensitive information is

disclosed only to those authorized to seeit.

Dependable systems are


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Dependable systems are:

They assure the integrity of data-data are

not corrupted or destroyed.

They are responsive-system responds to

user input within an expected and

acceptable time period.

They are safe-does not cause harm

Five guidelines for achieving


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Dependable systems are: Architect for dependability

Anticipate failures

Anticipate success

Hire meticulous managers

Dont be adventurous


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As business operations and priorities

change, the role and status of IT within

the provider organizations will increase. The healthcare provider of tomorrow

undoubtedly will consider IT a core

business asset and system dependability abusiness imperative


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An enterprise system architecture should be

developed from the bottom up so that no

critical component is dependent on a

component less trustworthy than itself.

Single-point dependencies should be avoided

or eliminated.

No single component should be capable of

bringing the system down should that

component fail.

Guideline 1: Architect for Dependability


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At the infrastructure level, features that are

transparent to software applications should be

implemented to detect faults, to fail over to

redundant components when faults are

detected, and to recover from failures before

they become catastrophic.

Guideline 2: Anticipate Failures


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Security features to detect, disable and recover

from malicious attacks, while preservingsystem stability and security should be

implemented

Guideline 2: Anticipate Failures


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The system planning process should

anticipate business success and the

consequential need for larger networks, more

systems, new applications, and additional

integration.

Guideline 3: Anticipate Success


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Anticipate hospital and clinic mergers,

growing patient/customer base will enable the

system designer to visualize the data flow,

system loading and network impact resulting

from business growth and success.

Guideline 3: Anticipate Success


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Managing and keeping complex networks and

integrated systems available and responsive

requires meticulous overseers individuals

who know that failures will occur and accept

that failures are most likely to occur when they

are least expected.

Guideline 4: Hire Meticulous Managers


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Good system administrators meticulously

monitor and manage system and network

performance, using out-of-band tools that do

not themselves affect performance.

They take emergency and disaster planning

seriously; they develop, maintain, and

judiciously exercise plans and procedures for

managing emergencies and recovering from

disaster.

Guideline 4: Hire Meticulous Managers


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For dependability, one should use only proven

methods, tools, technologies and products that

have been in production, under conditions, and

at a scale similar to the intended environment.

Guideline 5: Dont Be Adventurous

chapter 11 issues in informatics

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