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CHAPTER 2
INFORMATICS AND EVIDENCED BASED PRACTICE
Since the passage of the Affordable Care Act in 2009, and with the opportunity to capture incentive monies from the Centers for Medicare and Medicaid Services (CMS), the use of technology has exploded as healthcare organizations have accepted the challenge to convert their paper records to an electronic health record (EHR) (Duffy, 2015). Gugerty and Delaney (2009) describe how the Technology Informatics Guiding Education Reform (TIGER) initiative addressed this explosion of technology in health care and the need for nurses to be prepared to effectively use technology to provide evidence-based care. TIGER competencies include: basic computer proficiency; the ability to identify a clinical question, find, evaluate, and apply information on the question (information literacy); and the ability to appropriately collect, process, and communicate data (information management). The TIGER report encourages inclusion of all three areas in nursing programs as these are key skills of evidence- based practice (Cheeseman, 2012; Gugerty & Delaney, 2009). Successful use of technology by nurses to implement evidence-based practice and thus to improve patient care requires a basic understanding of computer architecture, computer terminology, and data and file management (Cheeseman, 2012). Developing the skill of finding and appraising current evidence from research, systematic reviews of literature, and clinical practice guidelines may be difficult as the nurse moves from the academic to practice settings. However, evidence-based practice (EBP) is a core skill necessary to improve nursing care and enhance the safety of patients. Introduction to Information and Computer Science Computer Architecture Computers are used to find, manipulate, and store data in an electronic format. In recent years, computers have become more complex and mobile, and they are increasingly essential to individuals in their personal and professional lives. Desktop devices, laptops, tablets, cell or smartphones, and a wide variety of medical and household equipment use computer software to perform their functions (Dainow, 2016). A basic understanding of how computers operate provides the nurse with the first step to exploring the evidence as it relates to clinical practice. A computer system has four main functions: collection, processing, storage, and retrieval of data A computer consists of input devices, the central processing unit (CPU), memory, and output devices. Two main components of a computer are its hardware (physical components) and software (applications). Physical components include the casing (desktop, laptop, or mobile) and the internal mechanisms (CPU, motherboard, power supply, hard disc, and memory). External hardware includes touch screens, keyboards, a mouse to control screen position, and a monitor that displays information on a screen. Additional hardware is available to help the user print information or enhance listening. Computers are further categorized on the basis of size and use. Supercomputers are large and only run a few programs at a high processing speed. Their specific uses range from animations and simulations, or training to weather forecasting. Mainframe computers have large memory capacity, work at a high speed, and have the ability for many users to operate the computer system at the same time. Healthcare and university computer systems are examples of mainframe computers. WHAT ARE MAINFRAME OPERATING SYSTEMS? Mainframe – computer that can support thousands of applications and I/O devices to simultaneously serve thousands of users.
Most mainframe computers are sold by IBM, and the operating systems are also provided by IBM. z/OS, is IBM’s foremost mainframe operating system. The smallest computers, microcomputers or personal computers, are designed for single users, can be connected as a network, and are small and affordable to most individuals. Data Organization, Representation and Structure A computer’s work begins with input of information via an external or touch-screen keyboard to a CPU where a processor chip collects data and makes decisions based on the software’s program code (instructions). The memory of a computer is divided into random-access (RAM) and read-only (ROM). RAM provides temporary storage of data during the creation of work before it is stored in a more permanent location, either in the computer’s hard drive or other storage location. Unless saved to a more permanent location, RAM storage is lost when the program is closed or the computer is turned off. ROM is located in the motherboard (circuit boards) and saves data in a more permanent way after the computer is turned off. During work, data are uploaded in the RAM and, when directed by the user, stored in ROM on the hard drive, on a USB flash drive, or in other external locations. The ability to store information is based on the capacity of the device. The basic (smallest) unit of memory is a bit; a byte consists of eight bits of data. From these small units, storage can be expanded in increments of 1,000 to kilobytes (KB), megabytes (MB), gigabytes (GB), and terabytes (TB). Decisions about the amount of storage needed in a computer system is based on the amount of data to be processed and stored, and on estimated 94 storage time. Data can be collected, organized, and stored in a database where it can be retrieved easily and in a way that is meaningful to the user. Commonly used databases in health care include electronic medical records, databases that support mobile applications. Software applications are internal programs that can be modified without changes to the external hardware of the computer (Dainow, 2016). These applications are categorized as productivity, creative, or communication programs. APPLICATION SOFTWARE Productivity software include a variety of information processing needs. Creative software can be used to create drawings, music, or digital photography/videos. Communication software includes email programs, Internet browsers, instant messaging, and a variety of conferencing programs. Networking and Data Communication Computer networks are formed when two or more computers are linked in a way that allows them to share information. A local area network (LAN) is confined to a single site, a metropolitan area network (MAN) connects regional areas, and a wide area network (WAN) reaches far beyond the single location to connect many LANs together. Connections to the Internet are available through cable or digital subscriber lines (DSL) or through dial-up telephone services (Cheeseman, 2011; Dainow, 2016). To connect to the Internet, the computer has to be connected to an Internet service provider (ISP) through a modem and a unique Internet protocol (IP) address. Each website is identified by a unique uniform resource locator (URL) protocol. Two types of URL addresses are commonly used to reach web resources: hypertext transfer protocol (HTTP) or hypertext transfer protocol— secure (HTTPS). Computer networks allow knowledge to be shared in multiple ways. The World Wide Web (www) is a network program that is familiar to most Internet users. A collection of documents, images, and web pages, the World Wide Web makes it possible to gather information from many resources, as well as to share information around the globe.
INFORMATION NEEDS FOR THE HEALTHCARE
PROFESSIONAL OF THE 21ST CENTURY
CHAPTER OVERVIEW
Clinical Informatics is evident throughout the healthcare system. Nurses are expected to enter the field with baseline knowledge of clinical informatics as well as understanding of its application to clinical guidelines, protocols, and procedures. Moreover, many quality improvement (QI) techniques aimed at preventing medical errors involves informatics and are necessary to achieve cost reduction as well as patient and clinician satisfaction. The role of the nurse in informatics related to interprofessional practice, practice workflow, and leadership in information technology (IT) will be discussed in this chapter. Finally, nursing education curricula and their alignment with the expectations of a complex healthcare system related to clinical informatics will be described. ACCESSIBILITY TO GUIDELINES, PROTOCOLS, AND PROCEDURES Clinical Informatics as it applies to clinical guidelines, protocols, and procedures may be the most easily understood application for nurses. A struggle for clinicians prior to the 21st century was maintaining awareness of current guidelines as many of these groups update their guidelines every few years as new evidence evolves. Through clinical informatics, and the advent of handheld devices, the most up-to-date, clinical guidelines are at every clinician’s fingertips. Handheld devices have become a craze in the new millennium and it is difficult to find anyone today without some or the other handheld gadget in his or her hands. A handheld device is a pocket-sized computing device with a display screen and input/output interface like an external or touch screen keyboard. Going by this definition of handheld devices and gadgets many appliances can qualify to be called handheld, like a mobile phone, PDA, mobile PC, handheld game consoles and so on. Various popular handheld devices include: MOBILE COMPUTERS o Notebook PC - A laptop (also laptop computer), often called a notebook, is a small, portable personal computer(PC) with a clamshell form factor, typically having a thin LCD (LED compute r screen mounted on the inside of the upper lid of the clamshell and an alphanumeric keyboard on the inside of the lower lid. o Ultra-Mobile PC - An ultra-mobile PC (ultramobile personal comp uter or UMPC) is a miniature version of a pen computer, a class of laptop whose specifications were launched by Microsoft and Intel in spring 2006. o Handheld PC - A handheld PC, or H/PC , is a computer built around a form factor which is significantly smaller than any standard laptop computer. It is sometimes referred to as a palmtop computer. o Personal digital assistant/Enterprise digital assistant - Also known as a handheld PC, is a variety mobile device which functions as a personal information manager. PDAs have been mostly displaced by the widespread adoption of highly capable smartphones, in particular those based on iOS and Android. o Graphing calculator - A graphing calculator is a handheld computer that is capable of plotting graphs, solving simultaneous equations, and performing other tasks with variables. o Pocket computer - A pocket computer was a 1980s-era user programmable calculatorsized computer that had fewer screen lines, and often fewer characters per line, than the Pocketsized computers intro duced beginning in 1989. o Tablet Computer - A type of computer that can be carried easily. Unlike a laptop it has no physical keyboard or
trackpad, though users sometimes add those things. Users control a tablet mostly by using its touch screen with multitouch technology similar to a smartphone. HANDHELD GAME CONSOLES o PC Engine GT o Atari Lynx o Pandora o GP2X/GP o Gizmondo o PlayStation Portable o N-Gage MEDIA RECORDERS o Digital still camera(DSC) o Digital video camera (DVC or digital Camcorder) o Digital audio recorders - In digital recording, audio signals picked up by a microphone or other transducer or video signals picked up by a camera or similar device are converted into a stream of discrete numbers, representing the changes over time in air pressure for audio, luminance values for video, then recorded to a storage device. o Media players/displayers o Portable media player o e-book reader - An electronic book, also known as an ebook or eBook, is a book publication made available in digital form, consisting of text, images, or both, readable on the flatpanel display of computers or other electronic devices. COMMUNICATION DEVICES o Mobile Phones o Cordless telephone o Pager Benefits of Handheld Devices and Gadgets: Handheld devices have become as popular as oxygen and their popularity cuts across age, class, sex, nationality, race and ethnicity barriers. Even a roadside tea vendor can be seen merrily chatting away on his handheld mobile device or the busy executive jotting down notes on her handheld PDA. Handheld gadgets like the mobile are steadily replacing the fixed-line telephone and this amazing transition from the wired to the wireless world couldn't have been possible without the numerous benefits offered by handheld devices. Office on the go: Today's handheld devices like smart-phones and PDA's enable you to literally take your office with you. You can send and receive emails, browse the net wirelessly at 3G speeds, access secure office files through VPNs, edit files and much more on your handheld mobiles. Thus, you are no longer limited by either size or mobility to increase your productivity. High Convenience: Today's handheld devices can do all the functions that your traditional computer can do, and more. Today's smartphones like the iPhone have inbuilt GPS navigation services, which was unthinkable just a few years back. New Entertainment forms: As technology has progressed and computing prowess has found its way on small and miniaturised gadgets, new entertainment forms have also emerged. Today people don't just watch movies on television or in theatres, rather their own notebooks and wide display mobile phones offer digital quality experience with Dolby surround sound, entertainment on the move. Similarly the Nintendo's and PSPs have ensured non-stop action to the avid gamer. Breaking the Communication Barrier: Previously snail mail was the only way to keep in touch with your friends, loved ones and in many cases with your business associates too. Not anymore. With umpteen forms of communication devices and tools making appearance almost daily, the communication barrier is well and truly broken. Today you may just ‘tweet' your status on your mobile, or book a railway ticket through your cell while sitting in a bus. Even real time chatting on cool hand held appliances and devices has become possible. No place to hide yourself now. Handheld devices and applications make readily available the most current guidelines and clinical protocols. Guidelines, primarily evidence-based recommendations, are usually generated from an authority group consisting of experts in the field and are publish regularly.
provider. The efficacy of knowledge is directly related to the breadth of the data from which is derived. As time progress and the adoption of technologies such as the electronic health record (EHR) continues, this process will become more important and more efficacious, and the skills required for knowledge creation will become more integral to the nursing practice. The National Academy of Medicine, highlights six main aims of HCPs: (Agency for Healthcare Research and Quality) E – EFFECTIVENESS S – SAFETY E – EFFICIENCY P – PATIENT – CENTERED T – TIMELINESS E – EQUITABILITY Because of the complex and unpredictable nature of health care, measuring quality can be difficult; it is particularly hard to attribute the outcomes of treatment to any one particular cause. Another factor contributing to the complexity of QI is the errors and adverse events should be rare, exceptional events. Several groups have attempted to address this issue by researching, vetting, and endorsing measures of quality that are valid and reliable and more proximal to the actual care provided rather than a long-term measurement. AHRQ is the primary provider of these vetted quality measures, and a breakdown of these measures can be found on its National Quality Measures Clearinghouse website (http://www.qualitymeasures.ahrq.gov). Continuous quality improvement, or CQI, is a management philosophy that organizations use to reduce waste, increase efficiency, and increase internal (meaning, employees) and external (meaning, customer) satisfaction. It is an ongoing process that evaluates how an organization works and ways to improve its processes. CQI is a way of improving our processes to enable us to achieve our strategic goals and attain our vision of becoming THE Model of Service Excellence. It begins with our customers, utilizes proven methods and tools, is data-driven, and implemented by individuals and teams closest to the customer experience. In ongoing, daily ways and through longer-term initiatives, CQI helps us transform the way we do business. A detailed list of QI strategies and tools can be found at the AHRQ’s website: (https://innovations.ahrq.gov/qualitytools/quality - improvement-quality-toolbox) INTERPROFESSIONAL COLLABORATION AND PRACTICE WORKFLOW Clinical informatics impact the ability of professionals to interact and build upon one another’s contribution to patient care. In years past, inter-professional collaboration was limited to verbal encounters, phone calls, and facsimiles. Fax (short for facsimile), sometimes called telecopying or telefax is the telephonic transmission of scanned printed material (both text and images), normally to a telephone number connected to a printer or other output device. With the application of clinical informatics, clinicians now routinely collaborate through portals and electronic medical records (EMR), review and attest one another’s patient notes, and make referrals conveying critical information to other clinicians through informatics.
ELECTRONIC MEDICAL
RECORDS
ELECTRONIC HEALTH
RECORDS
Electronic Medical Records are digital version of a paper chart that contains all of a patient’s medical history from one practice. HER allows a patient’s health record to move with other health care providers, specialist, hospitals and nursing homes. EMR records services that store the entire data of each patient in an electronic format. HER offers more comprehensive view of patient history, thus giving the acting physician a better understanding of the patient’s condition and the past treatment. EMR contains the standard medical ad clinical data gathered in one provider’s office. HER go beyond the data collected in the provider’s office and include a more comprehensive patient history. Online patient’s medical info from one provider Online patient’s medical info from all providers involved in their care. Access to the patient’s data from only one health organization. Access to data from more than one health organization. Has to be printed as it cannot be shared electronically outside the practice. No need to print. Patient’s health record can go across geographical regions. In fact, in 2017, fast healthcare inter-operability resources (FHIR), a standard for electronically sharing healthcare information, released an update and will soon move from a trial version to its final version. Fast Healthcare Interoperability Resources (FHIR, pronounced "fire") is a standard describing data formats and elements (known as "resources") and an application programming interface (API) for exchanging electronic health records. The standard was created by the Health Level Seven International (HL7) health-care standards organization. One of its goals is to facilitate interoperation between legacy health care systems, to make it easy to provide Health care information to health care providers and individuals on a wide variety of devices from computers to tablets to cell phones, and to allow third-party application developers to provide medical applications which can be easily integrated into existing systems. FHIR provides an alternative to documentcentric approaches by directly exposing discrete data elements as services. For example, basic elements of healthcare like patients, admissions, diagnostic reports and medications can each be retrieved and manipulated via their own resource URLs. FHIR was supported at an American Medical Informatics Association meeting by many EHR vendors which value its open and extensible nature. HIEs (health information exchanges) are high level systems that are designed to promote rapid sharing of data across facilities. Although technological factors are certainly essential in the success of an HIE, understanding how the HIE impacts users is also important. Additional positive impacts of HIEs on workflow were noted by participants in other ways, such as how they assist in medical decision making by supplying essential information when laypersons were unable to do so and facilitate referrals and transfers to other facilities. NURSING CURRICULA AND CONTINUING EDUCATION The American Association of Colleges of Nursing, summarizes the need for informatics content in curricula:” Knowledge and skills in information management and patient care technologies are critical in the delivery of quality patient care.” Essentials of Baccalaureate Education for professional Nursing practice: Information Management and Application of Patient Care Technology ✓Demonstrates skills in using patient-care technologies, information systems, and communication devices that support safe nursing practice. ✓Use telecommunication technologies to assist in effective communication in a variety of healthcare settings. ✓Apply safeguards and decision-making support tools embedded in patient-care technologies and information systems to support a safe
