Informatics: The Big Picture

Are you asking yourself what could Florence Nightingale possibly have to do with informatics?

 

Here we will connect how the past, present, and future of informatics impacts nursing care and nursing leadership. This post is full of media aids as well as links for you to explore where your interest lies. The first section is a discussion on the history of informatics. If you are someones less historically inclined you can scroll past to the infographic I created as an overview. 

The History and Development of Nursing Informatics

Florence Nightingale was highly educated and passionate about collecting and interpreting data from a young age. When she volunteered in 1853 for the Crimean war as the "Superindenent of the female nursing establishment," she was appalled at the condition of the hospitals and the records. Nightingale understood that standardized data would allow for accurate compilation and interpretation of vital healthcare statistics that can be used to drive evidence based practice and result in better outcomes for the patient. In 1958 she published Notes on Matters Affecting Health, Efficiency, and Hospital Administration of the British Army after working tirelessly to compile comprehensive notes and analyze her statistics to demonstrate poor outcomes for the soldiers due to the condition of the hospitals. She devoted her life to improving the nursing profession but also improving public health through the use of knowledge derived from statistical data. Florence Nightingale called for standardization of documentation over 150 years ago, laying the groundwork for the nursing informatics revolution that began to emerge 100 years after her sojourn into the Crimean war.

In the 1950s Harriet Werley, employed as the first dedicated nursing researcher at Walter Reed Amy research Institute, was approached by IBM to consult on the possible use of computer in the healthcare field. She, like Nightingale, immediately recognized the need for the collection of standardized information. In the 1960s computers began to make data aggregation more accessible and Werley convinced the ANA to focus on Nurses' use of information and communication in decision making. There remained no data or language standardization limiting the use of computer functionality for the healthcare data. 

The 1970s showed the first emergence of discussion of computer applications in nursing noting the potential for more efficient, complete, and quality documentation. This decade also produced the first comprehensive hospital information system which allowed planning, documentation, and feedback to be adjusted to each patient's specific needs. Home Healthcare created standardized data and forms which helped with newly increased reporting requirements demonstrating the value of standardized collection. 

The 1980s was the dawn of personal computers made information systems more accessible to the general population. Informatics was introduced into the nursing educational system and 16 standardized data elements were agreed upon including; nursing diagnosis, nursing intervention, nursing outcome, and intensity of care.

The 1990s produced mobile devices permitting access to knowledge databases from outside the hospital in settings such as home care. Although there remained no official standardized language some systems were emerging; Clinical Care Classification System, Omaha System, and nursing concepts were integrated into SNOMED. Even with the recommendation to utilize standardized language there was minimal adoption and many organizations utilized personalized language to document.

In the early 2000s SNOMED was established as the international reference term standard, electronic health records were mandated by 2014, and healthcare reform was initialized. Read more about SNOMED here in a previous post about Standardized Language.

For more resources:

Florence Nightingale: The Compassionate Statistician

Nursing Informatics History Project

 

Informatics Today

Technology understood and used in purposeful, informed, and constructive approach can elevate a manager to a true transformational leader by addressing patient safety, quality of care, nursing workflow, staff satisfaction, and a healthy work environment. We discussed in a previous post how a nurse leader can utilize informatics to address staffing challenges.

 Understanding Data

The first step to understanding how to use data and turn it into knowledge is to understand where and how the data is collected. Nurse Leaders and administrators who have this basic understanding will understand how to leverage informatics to collect the data they need, and utilize the information for improving patient care and nursing work flow.

Data sets are related information complied and able to be analyzed by a computer. Data is collected, stored, sorted, and then interpreted. With the high volumes of data collected in EHRs it is important that the data is entered in an efficient, accurate, and standardized manner to analyze and apply in meaningful ways.

Missing Data

Nursing Data is traditionally notes and other similar documentation which remains largely unregulated and non-standardized making data collection difficult. Therefore traditional means of data collection may be inadequate to capture the nursing knowledge from within the EHR.
Text data mining helps address that problem by extracting key words or phrases and connecting concepts. This allows the extraction of nursing knowledge overlooked in the typical data mining process.

 Application of Data

Once the data is collected nurse leaders, administrators, researchers, and government entities can use analysis of the data to find benchmarks, note trends, or measure the efficacy of an intervention.
Here is an example of a Nurse Leader applying statistical results to the clinical setting in order to communicate with bedside staff about the progress toward desired goals.

 

 

 

Other Applications

As we have discussed in other posts, Nursing Informatics is not just about data or the EHR. Technological applications can also contribute to the nursing work flow, patient safety, and quality of care. Sometimes this technology interacts with the EHR through interoperability, and sometimes they function independently. 
Some telemetry monitors are compatible with EHR and permit the automatic exchange of vital sign and cardiac waveform data, the same can be applied to fetal monitoring. This application potentially improves documentation, nursing workflow, and increases quality of care by allowing the trending of more real-time data on the patient. Blood Glucose machines and lab analyzers can also populate the data directly into the record again allowing for real-time information on the patient and a reduction in the risk for transcription error. 
Medication dispensing from a pharmacy robot or automated medication cabinet also reduces the risk for error. Below is an infographic on BCMA, another common application associated with medication administration.

The Future of Informatics

Informatics will continue to identify ways to improve patient care and nursing workflow through the use of technology. Currently much of the focus is on the EHR and achieving interoperability. To achieve true interoperability standardized documentation and terms will need to be addressed, as well as continued concerns about patient privacy and possibly a personalized national health identification number.
The TIGER project was initially started as a committee to advocate for the ideal EHR, in 2008 the group identified the following 9 areas of focus to improve healthcare delivery and patient outcomes:

1. Standards and Interoperability
2. Healthcare Information Technology National Agenda/Policy
3. Informatics Competencies
4. Education and Faculty Development
5. Staff Development/Continuing Education
6. Usability/Clinical Application Design
7. Virtual Demonstration Center
8. Leadership Development
9. Consumer Empowerment/Personal Health Record 

                                                                                                                       (Dulong, 2008) 
Now an interdisciplinary council, the TIGER project remains focused on education, innovation, and improved care through the use of technology. 
The Human-Technology Interface will continue to expand and possibilities we could never imagine will begin to emerge. Nursing Informatics is growing in demand as organization see the value in dedicated informatics qualified staff that can not only help achieve meaningful use of the EHR but also value into other applications. 

For more reading:
Informatics and the Future of Nursing Practice
Nursing Informatics; Designing the Healthcare of the Future




What other informatics applications can you name? 

Were you suprised that computers were used in nursing as early as the 1970s?

What can be done to create more standardization in nursing documentation without loosing the human essence?

Where do you think the future of Nursing Informatics will lead us?

Let us know your thoughts below.



References

Biddle, S., & Milstead, J. A. (2016). The intersection of policy and informatics. Nursing management, 47(2), 12-13.

 

Collen, M. F., & Walker, P. H. (2015). Nursing Informatics: Past, Present, and Future. In The History of Medical Informatics in the United States (pp. 385-406). Springer London.

 

DuLong, D. (2008). Informatics: the TIGER project. Online Journal of Issues in Nursing, 13(2).

 

Ozbolt, J. G., & Saba, V. K. (2008). A brief history of nursing informatics in the United States of America. Nursing outlook, 56(5), 199-205.

 

 

 

 

 

Changing the Rhythm: Considering Information and Workflow Management

 Clinical leaders are often faced with the dilemma of how to improve work efficiency, therefore many institutions have looked to the principles of lean.  The idea of lean was first identified in Toyota manufacturing plants; as the factories focused on optimizing production and minimizing waste focusing on a "value stream" or flow process. Lean has exploded in healthcare as organizations look for ways to improve their efficiency and patient outcomes while decreasing cost and do this by cutting out steps that add no value.

Lean focuses on the individuals who are actually doing the work as resources for improving a value stream and eliminating waste (Toussaint & Berry, 2013). The role of the leader is to facilitate the process of change while the actual individuals performing daily tasks help identify points of waste and alternative methods. In turn, these individuals feel valued and know each step in their workflow is valuable.



The same principles can be applied to information management; how the information is acquired, processes, and utilized. Here we will discuss the widespread problem regarding information of cardiac monitoring rhythm strips with the proliferation of the EHR.

Stuck in Time

As many institutions move to EHR and strive to prove meaningful use some bits of data are left in the pre-EHR era. One such pool of data is cardiac rhythm strips. Nurses, depending on the policy of the institution, are required to document the cardiac rhythm of patients of telemetry. With paper charting it was just one more piece of information that was added to the chart, now with the EHR it is one of the few pieced of data that are documented outside the chart. Here is a thread on allnurses discussing the successes and challenges of this transition.
In my institution we are required to document a minimum of one telemetry strip per 8 hours, in addition to documentation of any cardiac events. This entails printing the strip, walking to another part of the department to get the paper form for documentation, tracking down a glue stick, cutting and gluing the strip to the form, returning the chart, and then the strip is eventually scanned in the system by health records probably only to be viewed again if there is a complaint or adverse event requiring legal action.
This is of course the current best case scenario with room for error, increased inefficiency, and non-compliance. The printer may be out of the monitor paper which is in a far-off closet, the nurse may be unable to find a glue stick or the documentation sheets are out of copies, the nurse is unable to find the patient's chart which is now hold minimal information, he chart may be lost before it even gets to health information management, and once there the sheet could be lost or scanned wrong. Each of these steps increased the chance of non-compliance or error in addition to wasting nursing time and increasing frustration. In fact cumbersome documentation workflow is a major frustration and dissatisfied among nurses in institutions that transitioned to an EHR (Laramee, Bosek, Shaner-McRae, & Powers-Phaneuf, 2012). When we upgraded to an EHR our tele strip documentation plummeted because it was no longer part of the main documentation workflow and became a cumbersome task.

Integration into the Workflow

Currently we have some device integration with our EHR, if a patient is on a wall monitor their vital signs automatically pull into the EHR and then are documented by nurse verification. The cardiac strips and the vital signs come from the same device but we are still unable to verify a rhythm strip with the EHR. When automatic vital sign documentation was integrated into the EHR error rates were shown to decrease from 10% on paper and 4.4% for manual entry into the EHR to less than 1% (Smith et al, 2009). It would be reasonable to anticipate a lower error rate and higher rate of compliance with a similar move toward automatic telemetry documentation. Nursing started to ask "if we can pull vital signs why can't we pull a rhythm strip."
Well, with the spring upgrade there is a feature that will be added or turned on to allow the documentation of the rhythm strip directly in the EHR. This adds a number of advantages:

• eliminates wasteful steps
• increase ease of compliance
• allow availability for clinicians to view the strip in real time, in the chart
• allows for further integration of best practice alerts and medication warnings

 Below is simplified depiction of the change in workflow.

 As you can see the principles of lean can really be applied in this situation. Wasteful steps are eliminated allowing for increased efficiency. To document a rhythm strip will require less nursing time and improve the accuracy and availability of the documentation. Considering new ways to manage healthcare data can provide improved care quality, staff satisfaction, and workplace efficiency.

Questions

Are you experiencing a similar challenge with rhythm strip documentation? If yes, what are some solutions being utilized at your institution?

Can you think of any other areas where a change in information management would result in improved workflow?

Let us know in the comments below.

References

Smith, L. B., Banner, L., Lozano, D., Olney, C. M., & Friedman, B. (2009). Connected care: reducing errors through automated vital signs data upload. Computers Informatics Nursing, 27(5), 318-323.

Toussaint, J. S., & Berry, L. L. (2013, January). The promise of Lean in health care. In Mayo Clinic Proceedings (Vol. 88, No. 1, pp. 74-82). Elsevier.

Laramee, A. S., Bosek, M., Shaner-McRae, H., & Powers-Phaneuf, T. (2012). A comparison of nurse attitudes before implementation and 6 and 18 months after implementation of an electronic health record. Computers Informatics Nursing, 30(10), 521-530.

Can Technology Help You Be a Better Leader?

Nurse Leaders struggle to create a nearly impossible environment of improved quality of care and patient outcomes while fostering a desirable and healthy work setting that retains and recruits experienced nurses. Incorporating technology to assist with the advancement of these goals is an absolute must for a successful nurse leader. Although there are many such examples that support this claim, in this post we will look at staff scheduling and how technology can impact staff satisfaction, quality of care, and patient outcomes. Scheduling failures lead to decreased nursing and patient satisfaction, compromised quality of care and increased turnover; nurse leaders must find ways to meet these challenges and maintain a budget while increasing staff and patient satisfaction in the setting of quality care (Wright & Mahar, 2013).   

The Challenges of Scheduling

Effective and efficient personnel management is crucial to improving working conditions and quality of care (Maenhout & Vanhoucke, 2013). It is well known there remains a nursing shortage but implications for inadequate staffing on units is discussed much less frequently. With the nursing shortage Nurse Leaders not only have the challenge of scheduling enough nursing bodies on the unit but also struggle with scheduling the right mix of skill sets and competencies. The night shift on a unit will not be a safe place with a 8:1 ratio and all nurses with less than 18 months experience, nor will it foster an environment where nurses feel supported and engaged. Utilizing technology to gain insight into scheduling failures can address the issues of unattractive schedules for nursing staff, a poor practice environment, and increased workload (Maenhout & Vanhoucke, 2013).

Maenhout and Vanhoucke discuss how current scheduling is typically done on a unit by unit basis and in a multi-sequential approach; staffing is established, routine shift scheduling is accomplished, and then nurses are allocated to different roles, areas, or shifts. Each phase restricts the following phase; scheduling is restricted by staffing and allocation is restricted by scheduling. Ideally Nurse Leaders would be able consider cost, schedule, and quality through use of a formula that can be automated and adjusted in real time. Par level unit staffing needs, personal satisfaction and shift preferences, as well as competency and skill sets should be considered in concert.

The Roster

The dynamic nature of healthcare and nursing leads to frequent changes of the roster, the list of staff allocation for a day or a shift. Often times these changes come after the roster is approved by leadership due to acuity, volume, or unexpected shift vacancies such as a call-in. Even worse is when the roster is approved and does not meet minimal staffing needs. Electronic rostering provides an increase in flexibility, tracking, and interpretation (Drake, 2014). An electronic roster will alert the user if minimum staffing needs are not met such as lack of a charge nurse. They can also be utilized to analyze post-shift efficacy of the roster; if it was fair, safe, and if there were changes. This information can be used to help track staff and unit performance, influence future scheduling needs and allocation choices. For instance maybe there is a high call-in rate certain times of the year or on summer weekends. Noting these trends Nurse Leaders can help anticipate previously unrealized needs and possibly create policies that help ensure fair staffing, quality staffing, and safe patient care. 

What to Do...

Drake recommends an electronic roster as a means to streamline scheduling and extract data for future use, while Wright and Mahar agree noting the importance of ability to make real time scheduling decision such as access to a float pool and information on staffing qualifications to reallocate staff each shift as necessary.
There are a plethora of programs, web-based and otherwise, that market to the medical field. Each institution or unit needs to determine what exactly there needs are from a scheduling system and how it coincides with current or intended policy.

Tracksmart is a web-based program that allows for mobile schedule access; time-off requests and management; and the ability to swap, drop, or add shifts. Set schedules, repeating shifts slots, payroll reports, shift cost management, instantaneous views of scheduling gaps, automatic error notification, and staff ability to enter favorite shifts, conflicts, or availability coupled with an option for automatic scheduling would make this program a viable option for many organizations or units. Just watch this program demo video:




Giving staff the ability to express their preferred shifts and take that into account would be a huge satisfier and a potential safety boost. Utilizing a software that considers complimentary preferences will minimize your night owls coming in at 7am after sleeping 3 hours and your early birds to avoid working until the sun is rising after being up for 24.

Software that also allows for swing shifts, 4, 8, 10, and 12 hour shifts,  and on call in valuable in the healthcare setting.

ePro Scheduler and the eCore suite of management software is popular with EMS crews and the hospital setting. Typically this software is used by staff to schedule availability and the assigned scheduler allocates shifts or utilizes the automatic scheduling option.

Snap Schedule looks to have similar functionality to Tracksmart, and has similar features as the previously mentioned programs like automatic scheduling, mobile access, interoperability, and report generators.

All three of these systems also allow for communication with staff to seek shift coverage minimizing the need to contact multiple nurses by phone.


Is you current scheduling process efficient?

Does it meet your unit needs?

What are some current staffing challenges you currently face that could be addressed with technology?

What is your current method and do you have a software you can recommend?


Comment below and let us know!

 

References

 

Drake, R. G. (2014). The ‘Robust’roster: exploring the nurse rostering process. Journal of advanced nursing, 70(9), 2095-2106.

Maenhout, B., & Vanhoucke, M. (2013). An integrated nurse staffing and scheduling analysis for longer-term nursing staff allocation problems. Omega, 41(2), 485-499.

Wright, P. D., & Mahar, S. (2013). Centralized nurse scheduling to simultaneously improve schedule cost and nurse satisfaction. Omega, 41(6), 1042-1052.

The Future is Here: The Human-Technology Interface

The Human/Technology Interface

The human technology interface is how technology enables an individual to interact with world around them. In the video above Paul McAvinney, from my hometown of Rochester, NY, describes his engineering goal of using technology to capture human expression. This philosophy can easily be translated to the medical profession and more specifically the nurse-patient interaction. Imagine an application that could help nurses assess subconscious responses to pain therapy or assist an elderly home care patient maintain their independence.

Applications that follow the basic tenets of good informatics will achieve system integration and allow for a single bit of data entered and used throughout the information systems and peripheral devices. They also take into consideration effective screen design making utilization intuitive for the end-user on all likely hardware.

With the advent of a more prolific system of EHRs nursing practice was introduced to much wider access to information and improved work-flow with optimized technology. Educational institutions and healthcare organizations are taking advantage of simulation technology to prepare healthcare workers for different patient care scenarios and now as focus for care shifts from the inpatient setting to preventative care and the outpatient setting mobile health technology will continue to develop. The use of technology is developing to going beyond delivering care for the ill to enabling health for all.

The Future?

Envision a future with a medical support system that allows individuals with chronic conditions to move from self-management to supported management with the assistance of telehealth. Well, in some regions that future is here and the possibilities are endless! Telehealth can be utilized to go beyond data collection and assist with interpretation and strategies in the home or outpatient setting. Telehealth combined with consumer engagement can provide social support, education, and condition management to decrease the number of hospital visits, length of stay, costs, and emergency department visits.

For instance Kentucky implemented Anywhere Care to allow individuals in the community access to physicians through telehealth 24/7. With this system patients can access a provider from home and determine if they need to seek care in a hospital setting.

 

 How to Get There

Utilizing telehealth to manage acute or chronic conditions can only be achieved with patient participation. Achieving that level of engagement may be difficult with patients who already struggle with compliance, follow-up, or technical challenges. Ideally we will see more programs initially targeted at populations that will readily be able to utilize telehealth; pediatrics, home care, and people with social services.
A teenager with newly diagnosed diabetes can be raised to utilize telehealth to manage their chronic condition by interacting on a regular basis through the available technology with the nurses and providers, learn about adjusting their pump, trending blood sugars, diet concerns, and long-term health management. Parents with a newly arrived infant with a chronic condition can learn about care management, developmental consideration, and access providers one on one in real time when questions arise.
A patient with hypertension can regularly interact with a nurse or provider to assess their state of health, condition management, and strategies. Vital signs can be uploaded to a nurse and trends can be monitored to ensure proper dosing, compliance, non-pharmaceutical interventions and reminders can be pushed to the patient on a routine or as-needed basis. The patient can develop a relationship with a clinician and have consistent follow-up care without needing to worry about transportation or other logistical concerns.
Patients already enrolled in home care can initially be introduced to telehealth with the assistance of the home health nurse and aids. The hardware, software, and training can be introduced when the patient still has a coach to guide them through the process with intuitive interfaces with simple icons, touch screens, and data uploading.  As the need for homecare decreases or as a condition moves from acute to chronic more of the care delivery and interaction can occur with telehealth.
Patients enrolled in social services may already have home visits or regular appointments with a case manager at an office. Telehealth can be utilized in these situations to touch base with the client and ensure they do not have any health care needs to be addressed.
As each of these situations becomes more common telehealth will continue to expand as a mainstream means of care delivery. Nurses will be instrumental and research demonstrates that quality telehealth programs require more home visits with the nurse who develops a relationship with the client, helps facilitate the care, and still manages to decrease cost with proper utilization.
Nursing leadership can help drive these care changes as the potential for the human-technology interface is really only limited by the imagination. Leadership should listen to their staff nurses and help identify needs, gaps in care, or potential areas for non-traditional care that provides the quality and experience of traditional care with added benefits. The leader can then use their position to advocate for implementation or development of the innovation. Paul McAvinney states that scientists tell us where the universe came from and engineers decide where it is going. Nurses and their leadership team need to play an active role as the engineers of healthcare delivery ensuring a quality patient experience that with safe and effective care.


What kind of technology would you like to see developed? 

What technology would make interacting with patients and providing quality of care easier?

Let us know in the comments below.

 References

Kaufman, N., Khurana, I., Holmen, H., Torbjørnsen, A., Wahl, A. K., Jenum, A. K., ... & Stadler, M. (2016). Using Digital Health Technology to Prevent and Treat Diabetes. Diabetes Technology & Therapeutics, 18(S1), S-56.

Paré, G., Poba-Nzaou, P., & Sicotte, C. (2013). Home telemonitoring for chronic disease management: an economic assessment. International journal of technology assessment in health care, 29(02), 155-161.


Thede, L. (2012). Informatics: where is it?. OJIN: The Online Journal of Issues in Nursing, 17(1).

Alphabet Soup: Standardized Language

Dee McGonigle, senior advisor and former editor-in-chief of the Online Journal of Nursing Informatics, asserts "informatics nurses are bilingual—they can talk IT and can talk nursing."

To understand informatics and it's role within nursing one must speak the language. In this post we will review two terminology systems to start your journey into the the language of informatics.

 

ICNP 

The International Council of Nurses (ICN) is an organization dedicated to the advancement of nursing and health worldwide through professional practice, regulation and social economic welfare. The ICN created a database of formal terminology for nursing to utilize to describe their practice through descriptions, diagnoses, and interventions. The database is referred to as the International Classification for Nursing Practice (INCP) and is intended to be used by nursing as the international terminology standard to improve data collection and communication in order to inform nursing practice, influence education, and shape policy.

 

SNOMED CT 

The Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT) is also a resource of standardized and comprehensive clinical terminology. SNOMED CT was created by the College of American Pathologists and therefore is not nursing specific, however it is touted as the most comprehensive clinical vocabulary available. SNOMED is owned and maintained by The International Health Terminology Standards Development Organisation (IHTSDO) and the U.S. Federal Government is one of over 50 countries that recognize SNOMED CT as a standard for the exchange of health information. SNOMED CT is the basis for coding diagnoses and problem lists within the Electronic Health Record (EHR) to support interoperability and meaningful use; the language allows for consistent valuable communication and content that can be retrieved and processed for meaningful data.
In the video below you can see how SNOMED CT is used in the Emergency Department setting to utilize consistent, collectible, meaningful data in an EHR.

 

Why is a Standardized Language Important?

Leaders within the nursing community recognize the importance of a standardized language for nurses to achieve increased communication and professionalism as well as increased identification and collection of data related to interventions, care, and outcomes. The National Association of School Nurses' official position is that standardized language contributes to the advancement of care and research and therefore should be used in practice, EHR, and education. The American Nurses Association supports initiatives that develop a standardized nursing language and made the official recommendation to utilize recognized terminologies within clinical settings and SNOMED to document observations, interventions, and outcomes in the exchange between clinical settings.

Please share with us in the comments: 

What do you think?

Is a standardized language in nursing and/or the medical setting important?

Are you familiar with either of these terminology systems?

Do you know of any other systems?




References

Agrawal, A., He, Z., Perl, Y., Wei, D., Halper, M., Elhanan, G., & Chen, Y. (2013). The readiness of SNOMED problem list concepts for meaningful use of electronic health records. Artificial intelligence in medicine, 58(2), 73-80.

Matney, S. A., Dolin, G., Buhl, L., & Sheide, A. (2016). Communicating Nursing Care Using the Health Level Seven Consolidated Clinical Document Architecture Release 2 Care Plan. Computers, informatics, nursing: CIN.

Warren, J. J., Matney, S. A., Foster, E. D., Auld, V. A., & Roy, S. L. (2015). Toward Interoperability: A New Resource to Support Nursing Terminology Standards. Computers Informatics Nursing, 33(12), 515-519.