Nursing informatics Week 3: Issues in Informatics TOPICS Nursing Informatics and Health Care Policy The Role of Technology

in the Medication-Use Process 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 population s 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 accelerated programs for those who have already baccalaureate degree.

American academy of nursing (AAN) multiphase project in 2002 Definition: project to develop IT that will help support nurses in their day-to-day work. Phase I

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 to providers. 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

1997, National Nursing Informatics Work Group (NNIWG) made recommendations to the National Advisory Council for Nurse Education and Practice (NACNEP) about the Nation s 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

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

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 patient s 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

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 nurse s 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. Doesn t 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

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 don t 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)

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

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 monitoring systems, 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

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 of Electrical 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

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

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

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 patient s health care. Includes summary of patient s 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 patient s 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.

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 of EHR 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

 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 of EHR-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 the patient on the opening of the patient s 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

Remote data viewing to allow clinicians to see the patient s medical history at all the VA facilities where the patient was seen. Federal initiatives Federal agencies that provide direct care have been early adopters of EHR-S DEPARTMENT OF VETERANS AFFAIRS The Veterans Health Information Systems and Technology Architecture(VistA) supports day-today 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 patient s health record and order medications, special procedures, x-rays, nursing orders, diets, and laboratory tests. All aspects of patient s 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-centric EHR-S. DOD s 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)

 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 of EHR-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, HIT vendors, 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.

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.

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

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)

 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 of Elements 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

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