Evidence-Based Evidence-Based Nursing (EBN) and Nursing (EBN) and

Diagnostic Accuracy Diagnostic Accuracy in Electronic Health in Electronic Health

RecordsRecords (EHR)(EHR)

Margaret Lunney, RN, PhDMargaret Lunney, RN, PhD

College of Staten Island, The College of Staten Island, The City University of New YorkCity University of New York

margell@si.rr.com

The purposes of this paperThe purposes of this paperare to:are to:1) describe the research 1) describe the research evidence related to diagnostic evidence related to diagnostic accuracy;accuracy;2) explain the impact of 2) explain the impact of diagnostic accuracy in an EHR;diagnostic accuracy in an EHR;3) Propose strategies to improve 3) Propose strategies to improve diagnostic accuracy.diagnostic accuracy.

Assumption: Nursing Assumption: Nursing interventions to help people are interventions to help people are based on data interpretations. based on data interpretations.

Data interpretations may not be Data interpretations may not be accurate enough to guide the accurate enough to guide the

selection of interventions.selection of interventions.

Nursing diagnoses are data Nursing diagnoses are data interpretations of human interpretations of human responses, e.g., Carlson-responses, e.g., Carlson-

Catalano, 1997Catalano, 1997 Disturbed Thought Disturbed Thought

ProcessesProcesses Stress OverloadStress Overload Social IsolationSocial Isolation Sleep Deprivation Sleep Deprivation Chronic Low Self Chronic Low Self

EsteemEsteem Ineffective CopingIneffective Coping

FatigueFatigue Ineffective DenialIneffective Denial HopelessnessHopelessness Ineffective Role Ineffective Role

PerformancePerformance PowerlessnessPowerlessness Ineffective Ineffective

ParentingParenting Decisional ConflictDecisional Conflict

Accuracy is a rater’s judgment of Accuracy is a rater’s judgment of the degree to which a diagnostic the degree to which a diagnostic statement matches the cues in a statement matches the cues in a

patient situationpatient situation (Lunney, 1990).(Lunney, 1990).

+ 5 Highly accurate, a priority & precise match+ 5 Highly accurate, a priority & precise match

+ 4 Close to accurate + 4 Close to accurate

+ 3 Represent the general idea + 3 Represent the general idea

+ 2 Reflects some cues but not highly relevant cues+ 2 Reflects some cues but not highly relevant cues

+1 Reflects only one or a few cues+1 Reflects only one or a few cues

0 Not supported by the evidence0 Not supported by the evidence

-1 Evidence says it is not accurate-1 Evidence says it is not accurate

Example: Case study by Example: Case study by CavendishCavendish

Using the 7-point scale to rate Using the 7-point scale to rate the accuracy of nurses’ the accuracy of nurses’

diagnoses of the Craig C case diagnoses of the Craig C case study.study.

+5+5 Ineffective breathing patternIneffective breathing pattern

+5+5 Ineffective Airway ClearanceIneffective Airway Clearance

+4+4 Respiratory DistressRespiratory Distress

+3+3 Altered Respiration Altered Respiration

+2 +2 Anxiety (before treatment)Anxiety (before treatment)

+1 +1 Situational Low Self EsteemSituational Low Self Esteem

+1 +1 Activity IntoleranceActivity Intolerance

0 0 Asthma, couldn’t breathe rightAsthma, couldn’t breathe right

Theory: Factors in 3 categories Theory: Factors in 3 categories affect the accuracy of nurses’ affect the accuracy of nurses’

diagnoses. diagnoses.

ACCURACYNature of Diagnostic Task

Situational Context

Diagnostician

ACCURACY of Data Interpretation

Interactions of 3 Factors

Research Findings:Research Findings:Nature of Diagnostic TaskNature of Diagnostic Task

Relevance of dataRelevance of data– High, moderate, low relevanceHigh, moderate, low relevance– Amounts of low relevance dataAmounts of low relevance data

↓↓ accuracyaccuracy Amounts of dataAmounts of data

– # of cues that apply to a diagnosis# of cues that apply to a diagnosis– Restricted information accuracyRestricted information accuracy

Complexity of diagnostic taskComplexity of diagnostic task complexity accuracycomplexity accuracy

Research Findings:Research Findings:Situational ContextSituational Context

Time constraintsTime constraints– Time constraints- Time constraints- accuracyaccuracy

Role in healthcare systemRole in healthcare system– Similar roles = Similar inferencesSimilar roles = Similar inferences

Use of SNLsUse of SNLs– Accuracy low without use of SNLsAccuracy low without use of SNLs– Indications in pilot study (Indications in pilot study (Lunney et al., 2004Lunney et al., 2004))

Research Findings:Research Findings:DiagnosticianDiagnostician

Nursing education:Nursing education:– Mixed results Mixed results – Level of education may not be as Level of education may not be as

important as education related to NDximportant as education related to NDx– Positive association with Positive association with

Teaching aidsTeaching aids Continuing education on NDxContinuing education on NDx

Nursing experience:Nursing experience:– Mixed resultsMixed results– Experience related to types of casesExperience related to types of cases

Clinical study showing that Clinical study showing that accuracy of data interpretations accuracy of data interpretations

varies widely varies widely (Lunney et al., 1997)(Lunney et al., 1997) SCORESCORE FREQUENCFREQUENC

YY%% Cumulative %Cumulative %

+5+5 88 12.912.9 12.912.9

+4 & +4 & 4.54.5

2020 32.332.3 45.245.2

+3 & +3 & 3.53.5

1313 21.021.0 66.266.2

+2 & +2 & 2.52.5

1313 21.021.0 87.287.2

+1 & +1 & 1.51.5

33 4.4. 92.092.0

0 & 0 & 0.50.5

44 6.56.5 96.596.5

-1-1 11 1.61.6 100.0100.0

TotalTotal 6262 100.0100.0

The difficulty is that (1)human The difficulty is that (1)human experiences are complex; (2) experiences are complex; (2) we do not know other people.we do not know other people.

This is an example of the This is an example of the complexity of selecting the best complexity of selecting the best nursing diagnosis to guide care.nursing diagnosis to guide care.

S & of DYSREFLEXIA S & S of DECREASED CARDIAC OUTPUT

Paroxysmal hypertension Variation in blood pressure

Severe headache Fatigue

Possible decreased urine output

Oliguria

Profuse Diaphoresis above injury; Chilling

Cold, clammy skin

Pallor below injuryFacial erythema

Skin color changes

Chest pain Chest pain (if angina or MI)

Bradycardia Decreased pulses

Anxiety Anxiety

Summary of Evidence: Research Summary of Evidence: Research findings over 4 decades show findings over 4 decades show

that there is wide variation in the that there is wide variation in the accuracy of nurses’ data accuracy of nurses’ data

interpretations.interpretations.

Thus, the accuracy of nurses’ Thus, the accuracy of nurses’ data interpretations should be a data interpretations should be a

serious concern.serious concern.

With formal use of With formal use of nursing diagnosisnursing diagnosis

OROR

Without formal use Without formal use of nursing of nursing diagnosisdiagnosis

-Does not communicate interpretations-Communicates “problems”

Nurses Nurses who do not usewho do not use standardized nursing standardized nursing

languages are probably less languages are probably less accurate.accurate.

Extensional Extensional meaningmeaning

IsIs

better to use thanbetter to use than

Intensional Intensional meaningmeaning

This picture shows how use of a This picture shows how use of a nursing diagnosis classification nursing diagnosis classification helps nurses to achieve more helps nurses to achieve more accurate data interpretations accurate data interpretations

(Lunney, 2008b).(Lunney, 2008b).

The degree of accuracy is The degree of accuracy is probably not acceptable for probably not acceptable for

quality care; needs to be studied.quality care; needs to be studied.

Lack of attention to accuracy Lack of attention to accuracy compounds the problem.compounds the problem.

Low accuracy contributes toLow accuracy contributes to- Harm to patients & families- Harm to patients & families- Wasted time and energy- Wasted time and energy- Absence of positive outcomes- Absence of positive outcomes- Patient dissatisfaction- Patient dissatisfaction- Higher costs- Higher costs

The status of this prediction The status of this prediction from 1963 is that from 1963 is that we are not we are not

there yetthere yet..

““I envision the day when I envision the day when nurses will spend time nurses will spend time discussing ‘what is the discussing ‘what is the

diagnosis?’diagnosis?’

Komorita, N.I. (1963). Nursing diagnosis. Komorita, N.I. (1963). Nursing diagnosis.

American Journal of Nursing, 63 American Journal of Nursing, 63 (12), 83-86 83-86..

The EHR is being implemented The EHR is being implemented worldwide.worldwide.

With the EHR, nurses’ data With the EHR, nurses’ data interpretations will be visible interpretations will be visible

and used by others.and used by others.

Data, diagnoses, interventions & Data, diagnoses, interventions & outcomes will be transported outcomes will be transported

locally, regionally, nationally and locally, regionally, nationally and internationally.internationally.

The impact of diagnostic The impact of diagnostic accuracy will be exquisitely clear accuracy will be exquisitely clear

to everyone.to everyone.

It is It is time nowtime now to attend to to attend to diagnostic accuracy.diagnostic accuracy.

Strategies can be developed at Strategies can be developed at the system-wide level.the system-wide level.

ProfessionalismProfessionalism AutonomyAutonomy Complex decision-makingComplex decision-making Collaborative practiceCollaborative practice Patient-nurse partnershipsPatient-nurse partnerships Time to think & reflectTime to think & reflect Evidence-based practiceEvidence-based practice

Promote nurses’ image as Promote nurses’ image as diagnosticians.diagnosticians.

Develop and test decision Develop and test decision support tools, e.g., standards support tools, e.g., standards

of care for specific populations. of care for specific populations.

problemproblem

Action

Research Plan

Action

Research Plan

DataData

ResultsResults

Action Research

problemproblem

Action

Research Plan

Action

Research Plan

DataData

ResultsResults

Action Research

Provide resources that containProvide resources that containEBN knowledge.EBN knowledge.http://www.nanda.orghttp://www.nursing.uiowa.edu/excellence/http://www.nursing.uiowa.edu/excellence/nursing_knowledge/clinical_effectiveness/nursing_knowledge/clinical_effectiveness/index.htmindex.htm

Study the effects of high and low Study the effects of high and low accuracy on health outcomes.accuracy on health outcomes.

Develop rewards for accuracy, Develop rewards for accuracy, e.g., acknowledgement, e.g., acknowledgement,

feedback.feedback.

Encourage nurses to collaborate Encourage nurses to collaborate toward the achievement of toward the achievement of

diagnostic accuracy.diagnostic accuracy.

Work together toward the Work together toward the professional goal of diagnostic professional goal of diagnostic

accuracy and treatment of accuracy and treatment of human responses.human responses.

Excellence in nursing is achieved Excellence in nursing is achieved when we provide the best when we provide the best

possible care for patients and possible care for patients and families. The quality of care families. The quality of care

depends on diagnostic accuracy.depends on diagnostic accuracy.

Comments or QuestionsComments or Questions