Using Health Care Technology Systems

Churton Budd, RN, EMTPSystems Analyst, IIIMedical University of Ohio at ToledoInformation Systems division of Clinical Informatics

Objectives

How information technology has changed nursing and health care practice

How technology can reduce errors and improve efficiency and effectiveness

What technology applications are used in patient care

Why technology benefits nurses

Objectives (cont.)

What obstacles to using technology exist

What concerns with privacy have emerged with information technology

What is predicted for the future of technology in health care

Information Systems Integrated and

complex automated systems consisting of networked computers to process data, answer questions, solve problems or make decisions

Seamless integration of information minimizing the need for multiple record keeping

Hospital Information Systems An integrated information

system used in healthcare to manage patient information

Collaborative framework Electronic Medical Record (EMR) Shared and integrated

repository for patient demographics and billing information, orders, results, clinical documentation and images

State of the art HIS include CPOE – Computerized physician

(provider) order entry Point of care devices Expert and decision support

systems Integration with clinical equipment

Patient monitoring equipment (vents, pumps, monitors)

Point of care testing devices (glucose monitors)

Benefits of an HIS Reduce errors Streamline and

improve efficient care Lower costs Improved revenue capture Coordinate services Improve quality of service Improve patient satisfaction Automate repetitive manual tasks Make more efficient use of

resources

Obstacles to adopting HIS User resistance

Of the 2,694,540 licensed registered nurses in the United States. Only 9.1% of all RNs are under the age of 30. The average age of the RN population in the United States is 45.2 years. (www.minoritynurse.com)

Average age of a physician is about 48 “depersonalization of care” Resistance to change False starts on IT adoption with immature systems

Systems becoming more user friendly Widespread consumer use of computers

AC Nielson – 6/2004: over four out of five households (81%) now own at least one PC – up from 78% in 2003

Household use of computers by age group

Source - ACNielson

Management Information System – Executive Dashboard Capture, integrate

and report various financial and operational measures

Real time review of financial and operational health of an institution

Support management decisions

Improve patient care from the top level down

Clinical Information Systems Collect, integrate and deliver

information to the appropriate areas of responsibility Results to the physician Orders to the nurse Inventory and par levels to

central supply and pharmacy Just in time stock

Match research candidates to clinical trials

Patient load and acuity to staff scheduling

Allows providers to have access to aggregate patient information that is otherwise difficult to acquire and manipulate in a timely manner

Clinical Information Systems – For the Nurse Assess patient acuity and

condition Prepare a plan of care or

maintain a critical path Specify and track interventions Document care Observe and

document outcomes

Improve quality control

Typical clinical system example Patient with suspected pneumonia

admitted Sputum specimen sent to lab

(+) culture – physician alerted via automated alert to text pager or personal digital assistant (PDA)

Medication ordered by physician in provider order entry system – physician chooses the medication based on current clinical research results and statistical use by peers for same organism infecting same specimen source (evidence based medicine)

System does conflict checking with other meds the patient is on, does allergy check – reports to physician if any warnings allowing the physician to change med or override and document justification for doing so (patient safety)

clinical system example (cont.)

Pharmacy notified of medication orderPharmacist gets

notified of new order, checks availability of stock, ordered concentration and route, verifies order (patient safety)

Medication placed on electronic MAR

Medication delivered to floor stock to automated medication management system

clinical system example (cont.)

Nurse removes medication from floor stock (unit dose with barcode)

Nurse checks bar-coded ID band of patient and asks name (two method identification), verifies medication with barcode

5 R’s Right Dose, the Right Patient, the Right Time, the Right Medication, the Right Route

Delivers medication to patient Completion of order in HIS

triggers documentation in Nursing Information System

clinical system example (cont.) Antibiotic peak and trough blood

levels automatically ordered in laboratory system with draw times based on time of delivery of medication

Charge for medication sent to billing system

When blood drawn, lab system sends charge to billing system

Results reported to the physician on his text pager or PDA

Nursing Information System Standardized nursing record Reduces reporting workloads Improves the quality of patient care

Standardized nomenclaturenomenclature Standardized data collectiondata collection Standardized care planningcare planning Standardized implementation of careimplementation of care Standardized evaluation of careevaluation of care Standardized documentation of caredocumentation of care

Although a Nursing Information System would be part of a Hospital Information Systems, many HIS fall short of a Nursing Information Systems

Caring – can’t bill for it Nursing is all about caring for a

patient Can’t describe what we do to care

for a patient because of a lack of a standardized nomenclature

If we can’t describe what we do using standard nomenclature, how can we document what we do consistently

If we can’t document what we do consistently how can we bill for what we do

If we can’t bill for what we do, nobody can put a value on it

Nursing Nomenclature Nursing Minimum Data Set (NMDS):

establish comparability of nursing data across clinical populations, settings, geographic areas, and time

describe the nursing care of individuals, families and communities in a variety of settings

demonstrate or project trends regarding nursing care provided and allocation of nursing resources to patients or clients according to their health problems or nursing diagnoses

Stimulate nursing research through links to the data existing in health-care information systems

provide data and information about nursing care to influence practice, administrative, and health policy decision making.

http://www.nursing.uiowa.edu/ni/

Nursing Nomenclature (cont.) North American Nursing Diagnosis Association (NANDA) –

Nursing Interventions Classification (NIC) / Nursing Outcomes Classification (NOC) NANDANANDA Taxonomy II provides nursing diagnostic concepts

that identify and code a patient's responses to health problems or life processes that explain variance in patient outcomes that is different than the variance explained by disease diagnoses.

NICNIC encompasses nursing interventions used in all clinical settings and is used at the point of care to document care planning and nursing practice.

NOCNOC includes a comprehensive list of nursing outcomes, which provides a measurable way to evaluate the effect of nursing interventions on patient progress.

http://www.cap.org

Nursing Information System Provide the legal record of

care Support clinical decision

making Capture costs for billing,

costing and/or accounting purposes

Accumulate a structured, retrievable data base for:

administrative queries quality assurance research

Support data exchange with internal and external systems

Monitoring / Data Acquisition Systems Because so much data is collected in

the critical care environment, documentation can be complex and time-consuming for the nursing staff

Data Acquisition Systems automatically integrate information directly from medical equipment such as cardiac monitors, invasive lines, ventilators, IV pumps This greatly reduces documentation time and the

potential for errors in transcribing vital signs and other readings

Using a data acquisition system nurses can confirm and automatically record key information from medical devices at specified intervals or on demand and insert those readings directly into the medical record

CPOE – Computerized Physician (provider) Order Entry Match the physician's workflow with point-of-care

clinical decision support powered by an interactive expert knowledge engine that displays clinically relevant information about a patient's condition along with treatment protocols to assist them in making the best possible decisions for patients

Provide adaptive order sets and treatment guidelines based on the role of the clinician, the patient's condition, and evidence-based clinical knowledge

The system revolutionizes the order entry process and produces real-time alerts when inconsistencies are detected, helping to improve quality of care.

Point of Care (POC) Devices Allow clinicians to access

information, enter orders, monitor patients and complete record keeping at the bedside or while mobile

There is growing evidence that access to medical information at the point of care can reduce costs, improve accuracy in diagnosis and treatment, reduce errors, and optimize workflow

Personal Digital Assistants in Medicine: Critical Data in the Palm of your Hand. Zafar A. Chaudry, UK Health Informatics Today, No. 45, Winter 2004, pp4-6.

POC devices

Personal Digital Assistant (PDA) In a recent survey of health care

PDA users at MCO - top three ranked PDA applications used by survey respondents are:

Drug information applications (e.g. ePocrates)

Medical textbooks (e.g. 5 Minute Clinical Consult)

Personal calendar/address book/to do list/memos.

POC Devices – Tablet PC Using the Tablet PC, healthcare professionals

can be more productive with real-time access to patient information and other data, whether you are with a patient, a colleague, at your desk, or on the go.

Features: Full Capabilities of Windows XP Natural more intuitive computing – Pen and voice

input Minimal requirements on Memory and hard drive

space Grab-and-Go docking and “Instant On” – 30 seconds Instant screen rotation Active Pen vs passive pen Wireless network connectivity Extended Battery life and hot-swappable batteries

POC Devices (COW)

Computer on Wheels (COW) Enable nurses, doctors and

other clinicians to wirelessly access real-time patient data in a convenient, secure, and cost-effective mobile computer cart

Healthcare professionals are empowered to access electronic medical records (EMR) from any wireless-enabled location within the healthcare facility.

Wireless Networks Local Area Networks: WiFi - 802.11 –

802.11a, 802.11b, 802.11g, 802.11n 150 ft from access point 11-200 Mbps

Personal Area Networks: Bluetooth 30 ft from device / access point 700kps – 3mbs

Wide Area Networks: WiMax,EV-DO, UMTS 1 – 5 miles from antenna 2 – 75 Mbps

Radio frequency identification technology (RFID) Wireless, automated, and secure Ensures positive patient identification Ensures the integrity of information between

patient, host device, and/or Hospital Information System (HIS).

RFID wristband acts as a portable, dynamic database that carries patient information to be used and updated during the patient's stay

RFID helps to ensure that the "Five Rights of Medications Safety" are achieved, facilitating real-time confirmation of the Right Patient, Right Drug, Right Dose, Right Route, and Right Time

Unlike bar code, RFID's non-line-of-site data transmission can be read through and around the human body, clothing, bed coverings, and non-metallic materials.

RFID tags can be placed on medical devices such as pumps, monitors, carts, wheelchairs and other durable medical equipment to help locate and track these resources

RFID can help warn of wandering patients

RFID and medications Some drug manufacturers have announced

plans to use RFID technology to track the distribution of drugs particularly susceptible to counterfeit or diversion

FDA Guidelines on RFID RFID will not be used in lieu of current

labeling control systems and the tag will not obscure or alter any existing labeling information

The RFID tag will not substitute or interfere with a linear bar code

The tag will not contain or transmit information for health care practitioners or consumers

Tag readers will work at specific radio frequencies

Pfizer will place RFID tags on all bottles of Viagra;

Purdue Pharma will do the same with OxyContin and its new Palladone pain medication.

GlaxoSmithKline intends to use the technology in the next 12 to 18 months to protect at least one product from counterfeiting.

Biomedical Sensors Camera Pill: Tiny ingestible video camera is

not only less invasive than conventional tools for diagnosing bowel diseases but has now proven to be vastly more sensitive

WrisTASTM: device for continuous, passive monitoring of blood alcohol in human subjects transdermally (through the skin).  The sensor and instrumentation are contained in a wrist-mount configuration suitable for long-term wear.   It has applications in abstinence monitoring, treatment compliance, re-licensing, validation, alcohol abuse assessment, and alcohol treatment research

Targeted Medications

Telemedicine Provides access to shared

and remote medical expertise by means of telecommunications and information technologies, no matter where the patient or relevant information is located

Has the potential to improve the delivery of health care by bringing a wider range of services such as radiology, mental health services and dermatology to underserved communities and individuals in both urban and rural areas.

Help attract and retain health professionals in rural areas by providing ongoing training and collaboration with other health professional

Telehealth Remote monitoring of patients Using wireless and internet

technologies that are seamlessly integrated into everyday health monitoring devices such as a blood-pressure monitor, weight scale, and glucose monitors

The caregiver can track the patient's data, graph the results, monitor trends, annotate variances, set alert criteria, and send reminders and receive alerts via e-mail or pager

Patient Simulation / Virtual Patient specially instrumented patient

mannequin stands in for the patient, and real clinical equipment is used to make up the work environment

simulate accurately the patients responses in many situations such as anaphylaxis, septic shock and heart failure, producing 'patterns' of physical signs and corresponding monitor data. These include heart sounds, central and peripheral pulses, muscle twitches, breathing sounds and urine output.

Consumer Health Information Consumers are better educated

on issues of their own healthcare•Accuracy of online information often unknown

•Consumer may be unable to interpret the information

•However, consumers are more likely to be aware of research results and available therapies

Privacy / Security concerns HIPAA 1996 – Security rule goes

into affect April 2005 Threats: virus, hardware failure,

data integrity, hacking / eavesdropping

Secure system should: Allow only authorized users Limit access to need to know Ensure security, integrity,

accountability, reliability

Nursing Informatics Graves and Corcoran state that

nursing informatics is: "a combination of computer science,

information science and nursing science designed to assist in the management and processing of nursing data, information and knowledge to support the practice of nursing and the delivery of nursing care".

Graves, J.R. and Corcoran, S. The study of nursing informatics. Image: Journal of Nursing Scholarship, Vol 21(4), 1989, pp.227-231.

Nursing Informatics "Today's nurses are identifying and

developing new ways of using computers and information science as a tool to support the practice of nurses in the performance of their duties.

At the same time, computers and information science are facilitating a more sophisticated and expanded level of nursing practice.

There is an interactive and synergistic effect between nursing informatics and nursing practice

The boundaries of nursing informatics are contiguous with those of nursing and like them dynamic and constantly changing.“

Ball, M. and Hannah, K. What is informatics and what does it mean for nursing? In: Ball, M. Hannah, K. Gerdin Jelger, U. Peterson, H. (Eds.), Nursing Informatics: Where Caring and Technology Meet. New York: Springer Verlag, 1988, pp.81-87.

Nursing Informatics The work of an informatics nurse can

involve any and all aspects of information systems including theory formulation, design, development, marketing, selection, testing, implementation, training, maintenance, evaluation, and enhancement. Informatics nurses are engaged in clinical practice, education, consultation, research, administration, and pure informatics

From the ANCC description of practice for Nursing Informatics

Informatics Nurse certification

baccalaureate or higher degree in nursing or a baccalaureate degree in a relevant field OR completed at least 12 semester hours in nursing informatics courses AND had 30 continuing education contact hours applicable to the specialty area within the last three years

Examination topics System Life Cycle

System planning System analysis System design System implementation and testing System evaluation, maintenance, and support

Human Factors Ergonomics Software and user interface

Information Technology Hardware Software Communications Data representation Security

Information Management and Knowledge Generation Data Information Knowledge

Professional Practice, Trends, and Issues Roles Trends and issues Ethics

Models and Theories Foundations of nursing informatics Nursing and health care data sets, classification systems, and

nomenclatures Related theories and sciences

Future trends in Healthcare Technology New technology will allow

Healthcare Information Technology to go places it has not gone before Exam rooms Patients homes

More information means we have a “movie” rather than a “photograph” on how patients are doing, thereby improving the quality of patient care by detecting changes in health status early

Leapfrog Group Healthcare purchasing association The Founding “Frogs” : General

Electric, General Motors, GTE, etc. IOM 1999

44,000-98,000 deaths per year from medical errors

The Leapfrog Group’s Mission Trigger a giant leap forward in

quality, customer service and affordability of healthcare of all types by:

Making the American public aware of a small number of compelling and easily understood advances in patient safety

Specifying a simple set of purchasing principles designed to promote these safety advances, as well as overall customer value.

Healthcare IT in the future? Genomics, nanotechnology, robotics Community or Regional Electronic

Medical Record Disposable and

unobtrusive health sensors

Expert based and evidence based decision support systems

Ubiquitous wireless access