week 3 handouts

8/4/2019 Week 3 Handouts

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Nursing informatics

Week 3: Issues in Informatics

TOPICS

Nursing Informatics and Health Care Policy

The Role ofTechnology in the Medication-UseProcess

Health Care Data Standard

Electronic Health Record Systems

Dependable Systems for Quality care

Nursing Minimum Data Set System

Nursing informatics and healthcare policy

Definition of terms

Policy

Defined as a course of action that guides present and future decision, the action is based on

given conditions and selected from among identified alternatives.

Healthcare Policy

Established on local, state, and national levels to guide the implementation of solutions for the

populations health needs.

Nursing informatics as a specialty

criteria

Healthcare policy impact on nursing informatics practice

A higher ratio of older associate degree graduates rather than younger baccalaureate counter

parts.

Schools and colleges of nursing have shortened programs lengths and instituted acceleratedprograms for those who have already baccalaureate degree.

American academy of nursing (AAN) multiphase project in 2002

Definition: project to develop IT that willhelp support nurses in their day-to-day work.

Phase I


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Interdisciplinary, creative thinkers were assembled to determine how technology could be used

to facilitate nurses work.

Example by Bradley: increase access through use of portable and handheld devices.

Phase II

Staff nurses from 3 hospitals in Virginia and California were asked to identify and/or verify the

most difficult aspects of their practice and how technology would improve those tasks.

National informatics initiatives and nursing informatics

Guidelines of the Infrastructure

Appropriate information available at the time needed.

Health quality is improved and evidenced based medical care is delivered.

Health care cost are reduced.

More information is available.

Identified health information is secured and protected.

National Health information infrastructure (NHII)

Intends to improve efficiency and overall quality of health and healthcare

Calls for comprehensive knowledge based network that integrates clinical, public health, and

personal health information to improve decision making by having information available toproviders.

Health insurance portability and ACCOUNTABILITY ACT (hipaa)

Passed in 1996

Intended to improve public and private programs by establishing standards to facilitate

transmission of electronic health information.

Requires health plans, health care clearing houses, and healthcare providers to protect and

guard against misuse of identifiable health information.

National Agenda for Nursing Informatics

Responsible for setting national policy to guide the preparation of the nursing

workforce, including preparation in the area of NI


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1997, National Nursing Informatics Work Group (NNIWG) made recommendations to

the National Advisory Council for Nurse Education and Practice (NACNEP) about the

Nations Nursing Informatics Agenda (NIA)

5 assumptions considered by National advisory council for nurse education and practice (nacnep)

Learners are student, faculty, clinicians

NI must be considered within an interdisciplinary context of partnerships and collaboration.

Efforts target disadvantaged and underserved populations

Initiative should be responsive to other government funding priorities

Collaboration among federal agencies and between federal and private entities.

5 key directions for Nursing education and practice

Educate nursing students and practicing nurses in core informatics content

Prepare nurses with specialized skills in informatics

Enhance nursing practice and education through informatics project

Prepare nursing faculty in informatics

Increase collaborative efforts in NI

telehealth

definition

Use of electronic information and telecommunications technology to support long distance

clinical healthcare, patient and professional health related education, public health, and health

administration.

3 major issues in telehealth

Reimbursement

Licensure

Privacy

Factors advancing telehealth technology innovations

Decreasing cost of telecommunication technologies

Decreasing costs of telehealth devices and application


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Resolution and interoperability issues

Convergence of telehealth and telecommunications technologies, IT, and Internet.

The role of technology in medication-use process

Why change from paper based to computer based system?

Unavailability of information at the time needed specially for large organization.

Illegible handwriting

Records increase to multiple volume over the years.

Use of dangerous abbreviations and dose designations

Verbal and faxed orders

Possible problems that may arise

Delays in treatment

Increased length of stay

Increased risk of medication errors

CPOE (Computerized Prescriber ORDER ENTRY)

definition

System used for direct entry of one or more types of medical orders by prescriber into a system

that transmits those orders electronically to the appropriate department.

CPOE Features

Unique to the acute care settings, ambulatory care settings or both.

Allow for prescribers to access records and enter orders from office or home

Prescriber selectable standardized single orders or order sets

Implementation of organization specific standing orders based on specific situations

Passive feedback (patient specific data: test result charges, progress)

Active feedback (clinical decision making tools: specific assessment/recommendations through

alert)

CPOE advantages


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Improve quality, patient outcomes, safety

Reductions in variation in care.

Drug prescribing and administration

Increased refill compliance through reminders and alerts.

Improved drug dosing

Decreased adverse drug event

Errors of omission will be reduced

Handwriting and interpretation issues will be eliminated

Eliminate need to manually transport orders to pharmacy, radiology, laboratory

Access to pertinent literature and clinical information

Increase efficiency, productivity, cost effectiveness.

Better use of formulary and generic drugs

More time with patients

Reduction in time wasted in transcribing duplicate orders

Orders will be executed faster, medication available more quickly, patient receives prompter

care.

CPOE area of concern

Cost of implementation: training, infrastructure, workstations, high speed internet access.

Lack of integration between CPOE system and pharmacy system.

Error in monitoring patients response to therapy if not interfaced with laboratory system.

Complex and time consuming order entry processes leads to frustration, increase verbal order,

error-prone in communicating orders.

Error messages, frozen screens, slow access of information.

Wrong patient error.

STAT orders

Nurses ability to use computers


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Benefits of cpoe to nurses

Increased time w/ patients

Reduction in time wasted in transcribing/duplicating orders

Improve efficiency in ordering test or procedures

Orders are executed faster

Greater standardization of orders

Bar code enabled point of care (BPOC) technology

definition

Can improve medication safety through several levels of functionality.

Helps to verify that the right dose is being administered to the right patient at the right dose by the right

route and at the right time.

How BPOC Works?

Patient is admitted

BPOC advantages

Greater accuracy in recording the timing of medication administration. (real-time technology)

Increased accountability and capture of charges for items.

Up to date drug reference information

Customizable comments to alerts or reminders (actions that need to be taken)

Monitoring the pharmacy and nurses response to predetermined rules or standards in rules

engine: allergies, duplicate dosing.

Reconciliation for pending STAT orders

Retrospective analysis to monitor trends

Verifying blood transfusion and laboratory specimen collection administration.

Doesnt allow nurse to prepare multiple medications at the same time.

BPOC negative effects

Nurses are caught off guard by programmed automated actions taken by BPOC


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Inhibit coordination of patient information between prescribers and nurses when compared to

traditional paper

Nurses find it difficult to deviate from routine medication administration sequence with BPOC

system.

Nurses felt that their main priority was timeliness of medication administration.

Nurses used strategies to increase efficiency that circumvented the intended use of BPOC.

BPOC related issues

Pharmaceutical industry dont want to use a universal bar code.

Extended lag time between launch of new medications and their availability in unit dose packaging.

Types of error that may occur

Automated dispensing cabinets (ADC)

definition

Computerized point of use medication management system that is designed to replace or support the

traditional unit dose drug delivery system.

Reasons for acceptance of ADcs

Improving pharmacy productivity

Improving nursing productivity

Reducing costs

Improving charge capture

Enhancing patient quality and safety

Tracking, storage, dispensing, and use of controlled substances

Warnings of potential errors from look alike/sound alike drug.

Downside of adcs

Lack of pharmacy screening of medication order prior to administration.

Choosing the wrong medication from an alphabetic list

Reliance on ability to choose the right drug.

High alert medications placed, stored, returned to ADCs (double check)


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Storage of medications with look alike names and or packaging next to each other.

The development of workarounds (not working properly, overriding)

Safe practices for use of adcs

Purchasing system that allow patient profiling so that the pharmacist can enter and screen drug

orders.

Careful selection of drugs that will be stocked in the cabinets

Place drugs that cannot be accessed without pharmacy order entry

Use individual cabinets to separate pediatric from adult medication

Reassess the drugs stocked in each unit based cabinets

Remove only a single dose of medication ordered and return it if not administered.

Develop a check system to ensure accurate stocking of cabinets.

Place allergy reminders.

Routinely run and analyze override reports.

Smart infusion pump delivery system

definition

Infusion pump with dose calculation software that could reduce medication errors, improve

workflow, and provide a new source for continuous quality improvement by identifying and

correcting pump programming errors.

How Smart infusion pump changed the infusion therapy paradigm

Removing reliance on memory and human brain input of calculated values to a software

enabled filter to prevent keystroke errors

Includes comprehensive libraries of drugs, usual concentration, dosing units, institution based

dosage limits.

Additional verification ate point of care including medication delivery.

Integration of bar code technology

Limits: soft (overridden) or hard (will not let nurse go any further)

Access to data obtained through direct cable downloads


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implementation team

definition

Includes key players such as chief information officer (CIO), information technology, risk

managers, medical staff, front line practitioners, and other support groups.

What issues the implementation team will address?

Outlining goals for type of automation to be implemented

Wish list of desired features and determining which one are practical

Investigating systems that are presently available.

Analyzing current workflow and determining what changes are needed.

Identify the required capabilities and configuration of a new system

Sell the benefits and objectives of automation to staff

Development of implementation plan.

Health care data standards

definition

Include the methods, protocols, terminologies, and specifications for the collection, exchange, storage,

and retrieval of information associated with healthcare applications, including medical records,

medications, radiological images, payment and reimbursements, medical devices and monitoringsystems, administrative processes (Washington Publishing Company, 1998)

Reduce level of ambiguity in communication of data so that actions are taken based on the data are

consistent with actual meaning of data.

3 Categories of Data Standards

Health care data interchange standards

definition

Addresses primarily the format messages that are exchanged between computer systems, document

architecture, clinical templates, user interface, and patient data linkage (Committee on Data Standards

for Patient Safety, 2004)

4 broad classes of message format standards

Medical device communications


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Digital imaging communications

Administrative data interchange

Clinical data exchange

National Committee on Vital Health Statistics (NCVHS)

The advisory committee established to make recommendations on health information policy to the

Dept. of Health and Human Services(HHS) and Congress.

Was called on to study the issues related to the adoption of uniform data standards for patient medical

record information (PMRI) and the electronic exchange of such information.

Organizations that develop the standards

Institute ofElectrical and Electronic Engineers (IEEE)

P1073 Medical Information Bus (MIB), which supports real-time, continuous and comprehensive

capture and communication of data from bedside medical devices.

802.11 or Wi-fi

Most widely known standard

Allows anyone with a computer and either a plug-in card or built-in circuit to connect to the Internet

wirelessly through myriad access points

National Electrical Manufacturers Association (NEMA)

In collaboration with the American College Radiologists (ACR), formed the DICOM to develop a generic

digital format and a transfer protocol for biomedical images and image-related information.

DICOM standard

Dominant international data interchange message format in biomedical imaging.

Accredited Standards Committee X12/Insurance

Developed a broad range of electronic data interchange (EDI) standards to facilitate electronic business

transactions

X12

Adopted for administrative transactions as claims, enrolment, and eligibility in health plans and first

report of injury under the requirements of HIPAA

National Council for Prescription Drug Porgrams


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Developed standards for information processing for the pharmacy service sector

Formed the basis of electronic prescription transactions

HL7

Focus on facilitating the interchange of data to support clinical practice both within and across the

institution.

Major areas covered by the standard

Medical orders

Clinical observations

Test results

Admission and discharge

Document architecture

Clinical templates

EHR

Charge and billing information

terminologies

INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASE AND RELATED HEALTH PROBLEMS: 9th

Revision and Clinical Modifications (ICD-9-CM)

Latest version of a mortality and morbidity classification that originated in 1893.

Sole classification used for morbidity reporting in the US since 1979

Uses

Data collection

Quality of care analysis

Resource utilization

Statistical reporting

Basis for diagnostic related groups (DRGs), which are used extensively for hospital

reimbursement

ICD-9 is used internationally for death tabulation


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INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES AND RELATED HEALTH PROBLEMS: 10th

Revision

The most recent revision of ICD classification system for mortality and morbidity, which

is used worldwide

CURRENT PROCEDURAL TERMINOLOGY, 4th

Revision (CPT-4)

descriptive terms and codes for reporting medical services and procedures

Its contains modifiers, notes, and guidelines to facilitate correct usage

SYSTEMIZED NOMENCLATURE OF HUMAN AND VETERINARY MEDICINE INTERNATIONAL, Clinical Terms

(SNOMED)

created for indexing human and veterinary medical vocabulary, including signs and symptoms,

diagnoses and procedures.

LOGICAL OBSERVATION IDENTIFIERS NAMES (LOINC)

Provides a set of names and numeric identifier codes for laboratory and clinical observations and

measurements in a database structure.

Represents laboratory data in terms of names for tests and clinical observations.

RxNorm

Provides standard names for clinical drug (active ingredient+strength+dose form) and for dose forms as

administered.

Unified medical language system

Consists of:

Metathesaurus of terms and concepts from dozens of vocabularies

Network of relationship among concepts recognized in the metathesaurus

Information source map of the various biomedical databases referenced.

Data content standards

Definition of terms

Minimum Data Set

A minimum set of items with uniform definitions and categories concerning a specific aspect or

dimensions of the healthcare system which meets the essential needs of multiple users


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Core Data Element

A standard data element with a uniform definition and coding conversation to collect data on persons

and on events and encounters

The building blocks for a well-formed minimum data set

NATIONAL UNIFORM CLAIM COMMITTEE RECOMMENDED DATA SET FOR A NONINSTITUTIONAL

CLAIM(NUCC)

Organized in 1995 to develop, promote, and maintain a standard data set for use in non-institutional

claims and encounter information

Chaired by American Medical Association

STANDARD GUIDE FOR CONTENT AND STRUCTURE OF THE COMPUTER-BASED PATIENT RECORD (ASTM

E1384-96)

Provides a framework vocabulary for computer-based patient record (CPR) content.

Continuity of Care Record (CCR)

A core data set for more relevant and timely facts about a patients health care.

Includes summary of patients health status (problems, medications, allergies) and basic info about

insurance, advance directives, care documentation, and care plan recommendations.

Standards development process

Patient centered ehr that:

Safeguards personal privacy

Standardized medical terminology

Eliminates the danger of illegible handwriting and missing patient information

Can be transferred as a patients care requires over a secure communications infrastructure for

information exchange.

3 ways in which standards are developed and adopted

Standards coordination efforts

International Organization of Standardization (ISO)

Develops and publishes standards internationally.


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In 1998, ISO Technical Committee(TC)215 in health informatics was formed to coordinate the

development of international health care information standards, including data standards.

EUROPEAN TECHNICAL COMMITTEE FOR STANDARDIZATION

Established TC 251 on medical informatics in 1990

Works to develop wide variety of standards in the area of healthcare data management and interchange

Adopted by its members in Europe and are also submitted for development into ISO standards

AMERICAN NATIONAL STANDARDS INSTITUTE (ANSI)

Serves as the coordinator for voluntary standards activity in the US

US representative to ISO and is responsible for bringing forward US standards to that organization

OBJECT MANAGEMENT GROUP (OMG)

Representatives to different approach to standard development

International consortium of over 800 organizations, primarily for-profit vendors of information systems

technology

The OMG CORBAMed working group is responsible for development of object-based standards in the

health information area.

Framework for strategic action

Done by Dr. David Brailer, MD.PhD

Goal 1: Inform clinical practice

Incentivize EHR adoption

Reduce risk ofEHR investment

Promote EHR diffusion in rural and underserved areas

Goal 2: Interconnect clinicians

Foster regional collaborations

Develop a national health information network

Coordinate federal health information systems

Goal 3: Personalize Care

Enhance informed consumer choice


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Promote use of teletech systems

Goal 4: Improve Population Health

Unify public health surveillance architectures

Streamline quality and health status monitoring

Accelerate research and dissemination of evidence

Electronic health record systems

introduction

Definition of terms

Electronic Health Record (EHR )

a physical or logical(virtual) repository data

Electronic Health record System (EHR-S)

Set of components that for the mechanism by which patient record are created, used, stored, and

received.

Key capabilities of ehr

Immediate electronic access to person-and-population-level information by authorized, and only

authorized users;

Provision of knowledge and decision support that enhances the quality, safety, and efficiency of patient

care; and

Support of efficient processes for healthcare delivery

Other Features ofEHR-S

A checking system that alerts clinicians if an order they are entering could cause a problem

A notification system that immediately alerts clinicians to clinically significant events

A visual posting system that alerts healthcare providers to issues specifically related to thepatient on the opening of the patients electronic chart, including crisis notes, adverse reactions,

and advance directives

A template system that allows the healthcare provider to automatically create reports

A clinical reminder system that electronically alerts clinicians when certain actions such as

examinations, immunizations, patient education, and laboratory tests, need to be performed


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Remote data viewing to allow clinicians to see the patients medical history at all the VA facilities

where the patient was seen.

Federal initiatives

Federal agencies that provide direct care have been early adopters ofEHR-S

DEPARTMENT OF VETERANS AFFAIRS

The Veterans Health Information Systems and Technology Architecture(VistA) supports day-to-

day clinical administrative operations at local VA healthcare facilities.

VistA created a new interface which was easier for clinical use CPRS or the computerized

patient record system

CPRS

Review and update a patients health record and order medications, special procedures,x-rays, nursingorders, diets, and laboratory tests.

All aspects of patients record are integrated: active problems, allergies, current medications, laboratory

results, vital signs, hospitalizations, outpatient clinic history

DEPARTMENT OF DEFENSE (DoD)

January 2004, they began a worldwide rollout of the next generation system, the composite

health care system II (CHCS II), a secure, scalable, patient-centricEHR-S.

DODs Pharmacy Data Transaction Service

Links military treatment facilities, mail order, and network pharmacies.

Enable providers at all military and civilian pharmacies to track nearly 400,000 daily medications

and to check drug allergies and interactions.

INDIAN HEALTH SERVICE

Has long been pioneer in using computer technology to capture clinical and public health data.

OFFICE OF THE NATIONAL COORDINATOR FOR HEALTH INFORMATION TECHNOLOGY (ONCHIT)

The office of the national coordinator is positioned to bring together public and private entities for

accelerating solutions to known problems.

THE NATIONAL COMMITTEE ON VITAL AND HEALTH STATISTICS (NCVHS)


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Encompasses tools such as clinical practice guidelines, educational resources for the public and

professionals, geographic information systems permitting regional analysis and comparisons,

health statistics at all level of governments

AGENCY for HEALTHCARE RESEARCH and QUALITY

o Unveiled a major HIT portfolio, with grants, contracts, and other activities to demonstrate the

role of HIT in improving patient safety and the quality of care

CENTERS for MEDICARE and MEDICAID SERVICES

Has initiated several pilot projects to promote health IT.

2003 Medicare Modernization Act(MMA)

Federal government is authorized to give grants to doctors to help them buy computers,

software, and training to get ready for electronic prescribing.

Chronic Care Improvement Program (CCIP)

Offers self-care guidance and support to chronically ill beneficiaries (end of 2004)

Aim is to help beneficiaries manage their health, adhere to plans of care given by their

physicians, and assure that they seek or obtain medical care that they need to reduce their

health risk.

PUBLIC-PRIVATE PARTNERSHIPS

Collaborative efforts are focused on the use ofEHR-Ss and HIT to improve care.

Among these private sector organizations are those formed specifically to address issues of

connectivity, HIT, and standards development.

Connecting for health

introduction

Is addressing the barriers to development of an interconnected health information

infrastructure.

It brings together several dozen of the leading healthcare provider and payer organizations, HITvendors, and representatives of federal and state agencies.

eHealth Initiative

Is an independent, non-profit affiliated organization established to foster improvement in the

quality, safety, and efficiency of healthcare through information and IT.


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www.ehealthinitiative.org

INSTITUTE OF MEDICINE (IOM)

Has championed the use of IT to improve healthcare since its 1991 foundational work, The

computer-based patient record which was revised and republished in 1997

CERTIFICATION COMMISSION for HEALTH INFORMATION TECHNOLOGY(CCHIT)

Collaboration of Health Information and Mgt Systems (HIMSS), American Health Information

Management Association (AHIMA) and National Alliance for Health Information Technology

(NAHIT)

HEALTH LEVEL SEVEN (HL7)

Is an international, not-for-profit, volunteer standards organization, known for its large body of

work in the production of technical specifications for the transfer of healthcare data.

3 categories of HL7 HER-S

1. Direct care functions

familiar to clinicians; support direct care delivery

2. Supportive functions

- involves secondary use of data captured via the direct care functions; supports enhanced for

direct care and advanced information handling needs for the organizations

3. Information infrastructure

the backend of the system; unfamiliar to many clinicians, this is considered essential

by informaticist and technical staff.

Types of Profile defined by user:

Use profile developed by clinicians to provide care to their patient population

Product profile a list of functions customized to describe a vendor product

Dependable system s for quality care

dependability

definition

Ethical obligations drive requirements for system reliability, availability, confidentiality, data

integrity, responsiveness, and safety attributes.


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Measure of the extent to which system can justifiably be relied on to deliver the services

expected of it.

Six attributes of dependability

dependable systems guidelines

Tolerant systems

- More practical approach to attaining dependability

- Anticipate problems, detect faults, software glitches and intrusion.

1. Architect for dependability

Enterprise system should be developed from bottom up so that no critical component is

dependent on a component less worthy than itself.

Component of Architecture

Bottom - Physical and logical network that provide the pipes that carry data from system to

system.

Top number of software applications

Corollary any vulnerability that exist in the networks, OS, and other services that support the

applications.

Administrative safeguards

Security management

Assigned access management

Information access management

Security awareness and training

Security incident procedures

Contingency planning

Evaluation

Business associate contracts

Physical safeguards

Access control


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Audit controls

Data integrity protection

Person or entity authentication

Transmission security

Nursing minimum data set system

definition

Identifies essential, common, and core data elements to be collected for all patients/clients

receiving nursing care.

Standardized approach that facilitates the abstraction of these minimum, common, essential

core data elements from both paper and electronic records.

Broad categories of elements

Nursing care

Patient/client demographics

Service elements

benefits

Access to comparable, minimum nursing care, and resources data on local, regional, national,

and international levels.

Enhanced documentation of nursing care

Identification of trends related to patient problems and nursing care provided.

Improved costing of nursing service

Improved data for quality assurance

Further development and refinement of NI

Comparative research on nursing care

Contributions on advancing nursing as a research based discipline

Nursing information and data set evaluation center (nidsec)


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Develops and disseminates standards related to nomenclature, clinical associations, clinical data

repositories, and system characteristics/decision support/contextual variables pertaining to

data.

Established NMDs

7 countries

Australia

Canada

Belgium

Iceland

Netherlands

Switzerland

Thailand

Nursing management minimum data set (NMMDS)

Minimum set of items of information with uniform definitions and categories concerning the

specific dimension of the context of patient care delivery

Represents the essential data used to sup[port management and administration of nursing care

delivery across all types of settings.

3 categories ofElements of NMMDS

Environment

Nursing care resources

Financial resources

International nursing minimum data set

(i-NMDS)

definition

Includes core, internationally relevant, essential, minimum data elements to be collected in the

course for providing nursing care.

Provide information to describe, compare, and examine nursing practice around the globe

purposes


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Describe human phenomena, nursing interventions, care outcomes, and resource consumption

Improve the performance of healthcare systems and the nurses working within these systems

Enhancing the capacity of nursing and midwifery services

Addressing nursing shortage, inadequate nursing conditions, poor distribution and inappropriate

utilization of nursing personnel

Testing evidence-based practice improvements

Empowering public internationally

Data elements

Thanks for listening!!!

END OF WEEK 3

week 3 handouts

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