Informatics Used In Healthcare for Patient Safety Implementation and Models

The Informatics Used In Healthcare for Patient Safety Implementation and Models. EHRs centralize patient information and make it easily accessible to authorized healthcare professionals, improving care coordination and reducing reliance on error-prone paper records.

The Informatics Used In Healthcare for Patient Safety Implementation and Models

Informatics plays a critical role in patient safety in healthcare. It leverages technology and data analytics to improve care, reduce errors, and optimize overall outcomes. Key informatics applications include electronic health records (EHRs), clinical decision support systems (CDS), telemedicine, and remote patient monitoring. These technologies enable better information management, optimized communication, and proactive interventions, ultimately contributing to a safer healthcare environment.

How the Informatics Used In Healthcare

Patient safety is a priority in health care. The IOM published multiple reports on quality and patient safety that affect patients in this country, including the following: To Err Is Human: Building a Safer Health System (Kohn, Corrigan, & Donaldson, 2000); Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001); Health Professions Education: A Bridge to Quality (Greiner & Knebel, 2003). The Future of Nursing: Leading Change, Advancing Health (IOM, 2011); and Health IT and Patient Safety: Building Safer Systems for Better Care (IOM, 2012).

These reports reflect the important safety and quality issues in our health-care system. The use of evidence-based practice cues within the information system, decision support (rules and alerts), and reminders or tasks that decrease memory-based care all contribute to improved patient outcomes. All nurses are called to assume more of a leadership role in the integration of informatics in health care (IOM, 2011, 2012). All nurses must be able to locate pertinent information and best practices to be able to provide safe and effective nursing care (Wahoush & Banfield, 2014).

Further, nurses must have specific informatics competencies to be able to assist in designing user-friendly technologies that ensure patient safety and improve care delivery and patient outcomes (Sewell, 2016). Nurse leaders and managers must be active in the assimilation of information systems and evaluate and revise patient care processes and systems to facilitate safe and effective patient care (AONE, 2011).

Exploring the Evidence

Wahoush, O., & Banfield, L. (2014). Information literacy during entry to practice: Information-seeking behaviors in student nurses and recent nurse graduates. Nurse Education Today, 34 (2014), 208–213.

Aim

The aim of this study was to describe information-seeking behaviors of student nurses and registered nurses (RNs) within their clinical settings.

Methods

This pilot study used a two-phase descriptive cross-sectional design. Participants included senior nursing students, new graduate RNs, and nurse leaders and library staff. Senior nursing students and new graduate RNs were surveyed to identify the information sources and resources they used in clinical practice. Qualitative interviews were conducted with nurse leaders and library staff to understand the extent of resources available for nurses and how new RNs learned about available resources.

In phase I, 62 undergraduate senior nursing students completed the Nurses Informative Sources Survey. In phase II, 18 new graduate RNs completed the Nurses Informative Sources Survey, and six nurse leaders and library staff members were interviewed. Senior nursing students and new graduate RNs responses were grouped into three categories of information sources: electronic, print, and interpersonal.

Key Findings

Senior nursing students and new graduate RNs reported accessing at least one ex ample from each category for information to inform their practice. Both groups re ported that electronic sources of information were mostly used. Nursing students reported using print resources more than interpersonal resources, whereas new graduate RNs reported using interpersonal resources more than print resources. In all, 11% of new graduate RNs reported using personal handheld devices for clinical information, whereas no nursing students used such devices.

Both groups indicated they had limited access to hospital library resources. All nurse leaders and library staff indicated that their organization provided orientation and mentoring for new staff. Library staff reported that they welcome opportunities to assist new RN staff better access information. However, they also reported that when hospitals encountered financial challenges, services not directly linked to patient care may be reduced. In one example, the library was moved outside of the hospital, thus making it difficult for staff to use the resources.

Implications for Nurse Leaders and Managers

The findings of this pilot study support that senior nursing students and new graduate RNs use various information sources to inform their practice, including personal information devices. Nurse leaders and managers must be aware of current practices and consider needed policies and practice guidelines to ensure information security. In addition, nurse leaders and managers should be advocates for information access by nurses through new library services that provide on-demand information in the clinical setting.

Legislative and Regulatory Impacts on Informatics

Federal and state governments as well as independent institutions are establishing standards and accreditation guidelines to encourage further implementation of information systems within the health-care setting.

Health Insurance Portability and Accountability Act

The Health Insurance Portability and Accountability Act of 1996 (HIPAA), dis cussed in depth in last posts , introduced three rules to protect health information: privacy, security, and breach notification. The HIPAA Privacy Rule was designed to safeguard an individual’s health information. The HIPAA Security Rule established a set of national standards to protect electronic health information. Finally, the Breach Notification Rule requires all health-care organizations to report any data breaches (U.S.

Department of Health and Human Services, n.d.). The electronic age introduced a means to minimize patient data loss, but it also introduced a plat form for making patient information easier to copy and transfer. Health-care organizations need to be vigilant with enforcing data protection policies and/or use software such as data encryption to minimize data breaches.

American Recovery and Reinvestment Act of 2009

The American Recovery and Reinvestment Act of 2009 (ARRA) helped to advance the field of informatics. The health-care component of this bill is known as the Health Information Technology for Economic and Clinical Health Act, or HITECH Act. The requirements include metrics to improve patient care, quality, and public health. The ARRA initially provides incentives when metrics are met by both physician practices and hospitals to move toward electronic documentation and processes to improve patient care. In time, penalties will be assessed if these standards are not achieved. The standards for eligible hospitals and eligible providers are similar.

Regulatory Requirements

The Joint Commission, the Centers for Medicare and Medicaid Services (CMS), and the U.S. Department of Health and Human Services are all regulatory bodies that have standards that must be met. The EHR assists in meeting these requirements. Data are collected from the EHR to improve health-care and patient outcomes. The number and topics of required data vary from year to year as regulatory requirements are updated.

There are also many national quality organizations that provide recommendations for organizations, including Leap Frog, IOM, Agency for Healthcare Research and Quality, National Quality Forum, and Quality and Safety Education for Nurses (Newbold, 2013) Many regulatory requirements also have financial implications. One of these is the Meaningful Use program, part of CMS Quality Incentive Programs. Meaningful Use is a CMS program that requires use of the electronic record to improve patient care. The purpose of this program was to move health care to electronic records.

This program ensures that certain required components will be available, thus providing “meaningful use of the EHR.” Meaningful Use consists of three stages (CMS, 2016):

Stage 1: Data capture and sharing

Stage 2: Advanced clinical processes

Stage 3: Improved outcomes

Reporting must be done directly from a certified EHR and must be from discrete data elements.

Informatics Departments

Nurse leaders and managers will work with many types of IT professionals.

Use of Data In Informatics

Maintaining a high level of data quality is essential in informatics. Data quality must be reliable and effective. Standardizing data can help to provide a higher level of data quality. Data quality should be kept in mind during design of electronic records so that discrete data elements are available. Discrete data elements are much easier to pull from the system’s data repository than are narrative entry (free text) data entry elements. These discrete data elements may be used for research or for meeting regulatory requirements.

Data Set

A data set is simply a standardized group of data. There are multiple types of data sets, which may be used for billing, research, or other data uses. Data sets are used to provide a standard set of data on a patient, as well as standard definitions of data elements. Examples of data sets include the UB-04, which is standard data set required for institutional billing by federal and state governments, and the CMS-1500, which is a similar data set required for non institutional health-care settings. The data from both of these data sets is used by the CMS for health-care reimbursement, clinical, and population trends (Wager, Lee, & Glaser, 2013). There are several other standard data set types for specific settings or data use.

Coding

Coding is the process of taking the data in a patient’s file and applying an industry standard medical code to the data. Two basic types of coding systems are used in health care: the International Classification of Diseases (ICD; 10th revision) and Current Procedural Terminology (CPT). The ICD-10-Clinical Modification (CM) is the system currently used for coding diagnoses in the United States. CPT is the coding system for procedures. CPT coding manuals are published by the American Medical Association every year. They are used widely in both inpatient and outpatient settings. Both of these coding systems are used to provide information for billing, research, and other data purposes.

Data Security

Data security is a critical aspect in a health-care environment. Patient data can be lost, changed, or held hostage by viruses or malware attacks. There are several tools and methods used by health-care organizations to maintain data security. The most basic level of security includes the use of unique usernames and passwords, biometric identification, and security token identification. Unique usernames and passwords allow the system to collect an audit trail of who has accessed the system, when they did, and often which areas of the information system they accessed.

Some systems are also starting to use biometric identification, such as fingerprint or retina verification, or devices that provide a randomly generated code for signature (security token identification). Data that are transmitted can be encrypted, and firewalls can be in place to pre vent unauthorized access. Data encryption is a tool used to protect information that is transferred electronically (e-mail) or physically (laptop computer). This process transforms the data into an unreadable form by using mathematical formulas (Hebda & Czar, 2009).

A firewall is a mix of hardware and software that aims to prevent unauthorized access to a health-care organization’s system (Hebda & Czar, 2009). This added security can also create difficulties for internal systems. A firewall must be taken into account when setting up an interface connection. Nurse leaders and managers are critical to maintaining successful data security. They must take an active role in protecting a health-care organization’s information assets and patient information.

Nurse leaders and managers must enforce a culture that promotes and respects patient information security. They should be involved in the development and enforcement of organizational security policies that reflect rules and regulations and are designed to reduce or alleviate security risks. In addition, nurse leaders must ensure ongoing education for all staff related to information security and HIPAA.

Information System Used in Healthcare System

All nurses must have an understanding of some basics of information systems. Information systems are usually composed of several different applications that work together to provide a comprehensive record. An application is a computer program that performs a certain function or activity. Switching between applications can be either seamless or very apparent (e.g., selecting another application may require another login or another window to open). The following subsections describe some of the main information systems and applications used in a health-care information system.

Electronic Medication Administration Record

A common mantra in nursing school is “if it was not documented, it was not done.” Documentation is the record of all assessments, treatments, and evaluations. Applications supporting documentation need to be dependable and support the clinician’s workflow. The application that supports documentation of medications is the electronic medication administration record (eMAR). The eMAR has multiple features that enhance patient care. It provides a list of medication orders and when they are due to be administered. Once the medication is administered, it also provides a place to document medication administration. After medication administration is documented, the eMAR also provides historical information regarding medications that have been administered.

Computerized Provider Order Entry

An important application within an electronic record is the computerized provider order entry (CPOE). This application allows providers within a health-care organization to enter orders directly into a patient’s record, thus omitting any transcription errors. It also allows integration of decision support systems (e.g., allergy alerting) and helps standardize patient care by encouraging groups of evidence-based orders (order sets). CPOE also has the potential to improve workflow among ancillary services by allowing them to receive notice of an order (e.g., from radiology) immediately, rather than depending on someone to monitor paper orders and relay the order either by fax or pneumatic tube system.

Barcode Medication Administration

Barcode medication administration is the process in which clinicians use a barcode reader to verify a patient’s identity and drug information immediately before giving medication to a patient. This system requires both the patient identifier (wrist band) and drug packaging to have a barcode. Barcode medication administration is one of the best patient safety tools at the point of care (patient bedside).

Patient Portals

Many vendors of EMR systems have developed Web-based platforms for patients to access their health information online called patient portals. Patient portals may allow the patient to e-mail their provider, request refills, and view information such as immunizations, medications, and laboratory results (HealthIT.gov, 2015).

Telehealth

Telehealth is a specialty in health care in which electronic devices (e.g., computers) and telecommunication technology are used to serve education and health care to clinicians and patients (Hebda & Czar, 2009). An example of Telehealth is wound assessment with care done remotely by supplying a health-care provider with images or video of the wound.

Online Health Information

The number of consumers accessing health information online is growing. It is not unusual for patients to arrive for an appointment with their health-care provider equipped with information and questions based on suspect online information. This creates a need to ensure that health-care websites provide credible information. The ability to publish anything on the Internet results in information that may or may not be reliable and credible. Nurses are in the ideal position to assist patients and families in evaluating health information available online and guiding them to trusted websites (Sewell, 2016).

Implementation of an Informatics Project

Identifying potential issues in advance of implementation of the project is important. Superusers can help in this process. Superusers are generally representatives from the local nursing locations who receive enhanced training to help with implementation success and stability over the life of the system. They understand the new application and can help the staff members in the area integrate the new system or application into the future state workflow. Once implementation begins, it is important to remember the following:

Productivity will decrease initially while staff members are learning and becoming comfortable with the change.
People learn at different rates and in different ways.
Motivation to change comes from a positive assessment of the upcoming change.
Communication is the key to successful change management.
The environment should be one that does not expect perfection. This approach allows staff to learn and become use to the new system.

Addressing change management is essential for any informatics projects, such as the successful transition to a new EHR.

Conversion Strategy and Conversion Planning

Conversion is that point in time when you switch from one system to another or turn on a new application. Conversion planning needs to take place to ensure a smooth transition. The following questions should be asked:

Who is involved?
Where will the system be implemented?
When (time and date) will the conversion take place?
Is it better to do the conversion at shift change or mid-shift?
How will chart continuity be maintained?
Will any information be back loaded into the new system?
What activities need to be included, and who will do them?

All of these items must be taken into account during the conversion. There should always be a contingency plan in case the change needs to be backed out (reversed).

Implementation Support Model

Implementation support for conversion to a new electronic system or application requires technical, vendor, education, and support resources. Most sites set up a command center that has these resources available onsite 24 hours day, 7 days a week for a designated period of time. In addition to the command center, support resources are available in the unit. Analysts and educators are placed in the units to assist with support as well as superusers.

Organizations also often have vendor or consultant assistance with support, especially for “big bang” (simultaneous con version from old to new system) implementations. Superusers play an essential role in implementation support. Different models are used at different organizations. One common model is to have three levels of superuser: expert, shift, and unit. The expert user is the representative who assisted with design. Shift experts on each shift help with the actual implementation. The shift expert has both clinical knowledge and supplemental computer training that is helpful as staff members transition to the new system. The role of the unit leader is to solve management issues that arise during the implementation.

Maintenance

The system maintenance phase begins after the implementation and close of the project. Many of the project team members move on to other activities, but some team members continue to support the application and make enhancements to the system throughout the rest of the system life cycle. Each organization has a philos ophy regarding the degree of software and coding enhancements that will be made during the maintenance phase. Some sites make changes only for additional regu latory requirements, whereas other sites may do a high level of customization during the maintenance phase. All sites must perform upgrades to keep the code for the application up to date so that the vendor will continue to support the application.

System Downtime

Downtime procedures need to be developed and communicated before implementation. Staff members must know how they will obtain information when the system is down. There may be different levels of downtime that will determine what can be accessed in the system. There may be an entire network downtime, which may mean that no information is accessible. There may also be partial downtimes which may affect certain parts of the system that will determine what information is accessible. Downtimes may also be planned or unplanned.

Planned downtimes occur when the system is taken down to make some specific changes such as an upgrade or other enhancements to the system. Planning and communication are done in advance to lessen the effects of the downtime. Backup systems are put into place to provide access to important patient data. The backup systems may be electronic or paper. Unplanned downtimes present additional challenges. These situations do not allow the same preparation as planned downtimes.

There needs to be a plan for these situations. Again, the backup plan may be another electronic system or paper. Another challenge during unplanned downtimes is communication to end users as the downtime is taking place. These communication avenues must be established before the downtime. The IT department has formal processes for determining when a downtime has occurred, when downtime processes should start, and what those processes are.

Conclusion

Nursing informatics is crucial to improving patient safety and patient outcomes. Its importance can be seen in administrative and clinical arenas. Information systems comprise a complex arrangement of hardware and software that, once successfully put in place, provide the foundation for an enhanced way of providing patient care. Electronic records provide data necessary to make clinical decisions, do research, and support regulatory requirements.

The field of informatics has expanded the potential roles for nurses. Roles for nurses in informatics span from an entry-level position (analyst or educator) to upper-level management. Nursing leaders and managers may be called on to work with a variety of these technical specialists. Nursing participation is required in all of the phases of an informatics project.

All nurses at all levels must have basic informatics skills to manage the large amount of data involved in safe and quality patient care. Nurses must be “computer fluent, information literate, and informatics knowledgeable” (Sewell, 2016, p. 17). Nurse leaders and managers have a responsibility to ensure that adequate techno logical resources are available to staff to provide safe and quality nursing care.

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