APPLICATION OF NURSING INFORMATICS IN CLINICAL PRACTICE (copy)

1. ASSESSMENT

digitalization helps gathering and storing data about each patient

• assessment data can be physiological measures automatically documented through patient monitoring system. other assessment data can be added to the EHR by departments in the healthcare facility, such as laboratory and radiology. the largeest source of assessment is the ongoing nursing assessment

SOURCES OF DATA

1. patient monitoring

2. nursing-generated assessment

3. goals of “point of care” system

4. points to evaluate in the use of “point of care'“ system

patient monitoring

measures, record, distribute, and display combinations of VS such as HR, SPO2, BP, T

nursing generated assessment data

source data capture

electronic source data capture (eSource)

source data verification

point of care information system

source data capture

gathering data from patients where it originates, this is, with the patient. by entering data where the patient is, the reliability of data is increased

electronic source data capture (eSource)

accessing research data directly from EHRs and can create efficiencies in the clinical research process while:

• improving data quality

• reducing cost

• maintaining integrity

• preserving audit trails

source data verification

data from clinical trial collection systems are compared to source information. this process has been eliminated by the use of electronic source data capture from EHRs

point of care information system

computer data entry must occur whereever patients are found

goals of point of care system

• minimize time spent documenting patient info

• eliminate redundant and inaccurate info

• improve time of data communication

• optimize access to info

• provide info required by the clinician to make the best possible pt care decision

points to evaluate in the use of point of care system

• point of care systems must allow the nurse to interct with the main info system. systems that do not allow information to be extracted, as well as entered are not useful for nurses

• must interface with existing hospital information system. nurse at bedside must be able to access data that has been generated by lab, radiology, or pharma

• open systems concept must be valuably considered. this allows machines from all vendors to communicate. open systems allow the most appropriate type of machine to be selected for each nursing environment

• must have a small footprint (take up small amt of space)

• must be easy to use and must adapt to variety of nrusing environments. patient contact occurs 24 hrs a day

• easily disinfected and cleaned between patients

• nurses require variety of ways to enter data. keyboard require typing skills

• the nurse must go whereevere the patient is

• information to be retrieved using point of care system must be represented in ways that can be quickly used and easily understood

documentation

automated methods for recording nursing observations are some of the most readily available nursing informatics applications

two approaches of documentation

• digital library

• branching questionnaire

digital library

contain frequently used phrases arranged in subject categories. nurses chooses a phrase or combination of phrases that best describe patient’s condition

branching questionnaire

contain a terminal which displays a list of choices. the nurse selects her choice and indicates it by pressing the corresponding number on the keyboard or light pen. the terminal then displays further list of choices appropriate to the original selection. thus, nurse is led through a series of questions that can be customized for each patient

advantages of automated documentation

• content standardization

• improved standards compliance

• increase efficiency

• enhanced timeliness

• augmented data

content standardization

increased chart completeness including increased numbers of observations because of prompting or forced recall and increased standardization, accuracy, and reliability of observations

augmented data archive

ready statistical analysis and easier nursing audit because of use of standardized terminology

Electronic health record

digital patient records

• longitudinal timeline record for all health care encounters for a patient

• integrates all paitnet info into one record, regardless of the number of times a patient enters a health care system

• provides access to patient health record information at the time and place that clinicians need it

EHR GOALS

1. interprofessional collaboration with improved data availability and information synthesis

2. improved patient safety through use of clinical decision support

EHR system types

cloud based

client server

hybrid

stand alone

open source

mobile

Electronic medical record

legal record that describes a single encounter created in healthcare settings, that is the source of data for the EHR

privacy, confid, and security mechanism

• protection of info and computer system is a top priority

• appropriate access to and confidentiality of PHI (personal health information) is the responsibility of all people working in health care

• most security mechanisms for computerized information system use a combination of Logical and physical restrictions to protect informatioN. for example, a automatic sign-off is a safety mechanism that logs a user off a computer system after specified period of time

• other security measures include firewall and the installation of antivirus and spyware-detection software

• physical security measures include placing computers and file servers in restricted areas or using privacy filters for computer screens visible to visitors without access. this form of security has limited benefit, especially if an organization uses mobile wireless devices such as notebooks, tablets, PCs, and personal digital assistants (PDAs). these devices are easily misplaced or lost, falling into wrong hands. some organizations use motion detectors or alarm with these devices to help prevent theft,

• access or log-in codes along with passwords are frequently used for authenticating authorized access to electronic records. a password is a collection of alphanumerica characters that a user types into a computer before accessing a program after the entry and acceptance of an access code or user name

• when using health care agency computer system, it is essential that nurses do not share computer passwords with anyone under any circumstances

• to protect patient privacy, health care agencies track who accesses patient records and when they access them. disciplinary action, including loss of employment, occurs when nurses or other health care personnel inappropriately access patient information

electronic documentation has legal risks. it is possible for anyone who has access a computer station within a health care agency and gain information about any patient. therefore, ________________

• protection of info and computer system is a top priority

• appropriate access to and confidentiality of PHI (personal health information) is the _______ working in health care

• responsibility of all people

• most security mechanisms for computerized information system use a combination of Logical and physical restrictions to protect informatioN. for example, a ___________ is a safety mechanism that logs a user off a computer system after specified period of time

• automatic sign-off

• other security measures include ____ and the installation of ____ and ____

• firewall

• antivirus

• spyware-detection software

• physical security measures include placing computers and file servers in ____ or using ____ for computer screens visible to visitors without access. this form of security has limited benefit, especially if an organization uses mobile wireless devices such as notebooks, tablets, PCs, and personal digital assistants (PDAs). these devices are easily misplaced or lost, falling into wrong hands. some organizations use ____ or ___with these devices to help prevent theft,

• restricted areas

• privacy filters

• motion detectors

• alarm

• ______ along with passwords are frequently used for authenticating authorized access to electronic records. a ____ is a collection of alphanumerica characters that a user types into a computer before accessing a program after the entry and acceptance of an access code or user name

• access or log-in codes

• password

• when using health care agency computer system, it is essential that nurses __________with anyone under any circumstances

• do not share computer passwords

• to protect patient privacy, health care agencies track who accesses patient records and when they access them. ____, including loss of employment, occurs when nurses or other health care personnel inappropriately access patient information

• disciplinary action

HANDLIGN AND DISPOSING OF INFORMATION

destroy anything that is printed when the information is no longer needed. nursing students must write patient data needed for clinical paperwork directly from a patient’s medical record on the computer screen or physical chart

de-identify all PHI, keep the documents secure, and destroy documents by shredding or disposing of them in a locked receptacle

destroy all papers containing PHI immediately after used

______ anything that is printed when the information is no longer needed. nursing students must write patient data needed for clinical paperwork directly from a patient’s medical record on the computer screen or physical chart

destroy

_____ all PHI, keep the documents secure, and destroy documents by shredding or disposing of them in a locked receptacle

de-identify

____all papers containing PHI immediately after used

destroy

PLANNING

automated care planning

• the use of information systems to support and enhance the - development and implemnetation of patient care plans

• use technology to create, implement and manage patient care plans, integrating standardized guidelines with real-time data, decision support, and personalized feedback, to enhance patient outcomes and streamline the work of clinicians

• reduce errors, provide efficient workflows, and enable better management of patient care, especially for chronic conditions

KARDEX

traditional, paperbased system for organizing and summarizing patient infromation, and guiding patient care, it is usually outdated, illegible, irrelevant, inconsistet and incomplete

examples of automated care planning

1. clinical decision support systems

2. automated dispensing cabinets

3. bar code medication administration

4. smart pump technology

5. case management information systems

6. telehelath and remote monitoring systems

1. clinical decision support systems

often embedded with EHRs

1. clinical decision support systems EXAMPLE

1. medicaton management

2. dosing parameters

3. alerts and reminders

4. cost effectiveness

5. data access

6. interoperability

1. automated dispensing cabinets

manage drug storage, dispensing, control and tracking

1. automated dispensing cabinets EXAMPLES

access security

error prevention

1. bar code medication administration

ensures adherence to the rights of medication administration

1. bar code medication administration EXAMPLES

electronic checks

integration with CDS

1. smart pump technology EXAMPLES

drug libraries

1. case management information systems EXAMPLES

trend analysis

care plans

personalized healthcare

1. telehelath and remote monitoring systems EXAMPLE

biometric data

early warning systems

personalized parameters

IMPLEMENTATION

digital devices rarely help the nurse in giving of nursing care. generally, computers are used more in other phases of nursing care

EVALUATION

digital devices can be used to evaulate nursing care through realtime auditing and quality improveent and management activities

WAYS NURSING INFORMATICS IMRPVOES PATIENTS CARE

1. aligning nursing best practice with clinical workflows and care

2. improving clinical policies, protocols, processes, and procedures

3. providing training and learning based on objective data

4. selecting and testing new medical devices

5. reducing medical errors and cost

6. enhancing end-to-end treatment and continuity of care

a system that uses technology to create and manage patient care plans, incorporating realtime data and decision support

automated care planning

a system that ensures adherence to rights of medication administration through elecronic checks

bar code medication administration

use of informaton technology in nursing practice to improve patient care

nursing informatics

system that manages drug storage, dispensing, control and tracking

automatic dispensing cabinets

gathering patient data where it originates , often diretly from the patient

source datA capture

digital version of patient health data that integrates info from all health care encoutners

electronic health record

collection of frequently used phrases arranged by subject, used for documentation

digital library

system that provides clinicians with specific patient data to aid in making decisions

clinical decision support system

patient data that is protected by privacy laws

persona health information (PHI)

system where computer data entry occurs whereever patients are found

point of care system