Collins-CIC2018 Plenary CDS that works for Nursing


May 10, 2018 - Many required manual data entry. • Only 25% ... Integrating evidence into clinical information systems for nursing decision support. Int J Med ..... Epic 2017 User Group Meeting, Verona, WI, USA, September 25-28, 2017. 11.

Clinical Decision Support that Works for Nursing Plenary Panel: Building CDS that Works, May 10, 2018, AMIA CIC

Sarah Collins, RN, PhD Assistant Professor of Biomedical Informatics and Nursing Department of Biomedical Informatics Columbia University Medical Center

Disclosure I have no relevant relationships with commercial interests to disclose.

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AMIA 2018 Clinical Informatics Conference

Learning Objectives After participating in this session the learner should be better able to: • Articulate how the Data-Information-Knowledge-Wisdom (DIKW) Framework provides value in identifying and prioritizing CDS for nursing • Articulate the importance of tailoring CDS to patient-specific risk profiles

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AMIA 2018 Clinical Informatics Conference

CDS Targeting Nurses CDS is defined as providing clinicians with computer-generated, clinical knowledge and patient-related information that is intelligently filtered and presented at appropriate times to enhance patient care (Teich, Osheroff, Pifer, Sittig, & Jenders, 2005).

• • • •

Diagnostic decision-making (36%) Guideline adherence (32%) Medication management (29%) Situational awareness (25%)

(Dunn Lopez, 2017: Review of 28 studies from 2006-2013)

• Lack of user testing and monitoring • Many required manual data entry • Only 25% using real-time EHR data • No studies using EHR data to generate knowledge for nurse decision-making across conditions

AMIA 2017 | amia.org

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CDS should… •

Enhance nursing decision-making and drive evidence-based practice (Bakken et al., 2008)



Supportive of nurses' holistic view of the patient (Keenan et al. 2017) Concept

Definition (Matney et al., 2011)

Wisdom

Understanding and internalization

Knowledge

Derived by discovering patterns and relationships between types of information

Information

Data plus meaning

Data

Little or no meaning in isolation

DIKW Framework for Nursing CDS (ANA 2008; 1. 2. 3. 4. 5.

Matney, 2011)

Teich JM, Osheroff JA, Pifer EA, Sittig DF, Jenders RA, The CDS Expert Review Panel. Clinical Decision Support in Electronic Prescribing: Recommendations and an Action Plan: Report of the Joint Clinical Decision Support Workgroup. J Am Med Inform Assoc. 2005 Jul-Aug;12(4):365-76. Matney S, Brewster PJ, Sward KA, Cloyes KG, Staggers N. Philosophical approaches to the nursing informatics data-information-knowledg e-w isdom framework. Adv Nurs Sci 2011; 34(1): 6–18. doi:10.1097/ANS.0b013e318 207 181 3 Nursing Informatics. Scope and Standards of Practice. Silver Spring, MD: American Nurses Association (ANA) 2008; 1: 177. Keenan, G. M., Lopez, K. D., Yao, Y., Sousa, V. E. C., Stifter, J., Febretti, A., … Wilkie, D. J. (2017). Toward Meaningful Care Plan Clinical Decision Support: Feasibility and Effects of a Simulated Pilot Study. Nursing Research, 66(5), 388–398. http://doi.org/10.1097/NNR.00000000 000 002 34 AMIA 2017 | amia.org Bakken S, Currie LM, Lee N-J, Roberts WD, Collins S, Cimino JJ. Integrating evidence into clinical information systems for nursing decision support. Int J Med Inf 2008; 77(6): 413–420. doi:10.1016/j.ijmedinf.200 7.08.00 6

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DIKW Strategic Plan Long-term Strategy

Clinical interpretation

Wisdom

• predictive analytics • personalization to nurse • patient preferences • social behavioral determinants of health

Knowledge Guide knowledge-based decision making

Short-term Strategy

Information Meet information Needs

Minimize

Data Facilitate data capture

AMIA 2017 | amia.org

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Types of CDS Available in EHR for Nurses CDS Recommending to….

% (n)

Document a Plan of Care Template

21% (9)

Order a Consult

17% (7)

Perform a Care Activity to Impact Clinical Outcomes

12% (5)

Document a Quality/Compliance Measure

12% (5)

Document Required Item to Documentation Task List

12% (5)

Perform a Care Activity to Impact Clinical Processes

10% (4)

Review an Order

7% (3)

Document Missing Required Documentation

5% (2)

Document Patient Education

5% (2)

Wisdom Knowledge

Information

Data AMIA 2017 | amia.org

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Types of CDS Available in EHR for Nurses CDS Recommending to….

% (n)

Document a Plan of Care Template

21% (9)

Order a Consult

17% (7)

Perform a Care Activity to Impact Clinical Outcomes

12% (5)

Document a Quality/Compliance Measure

12% (5)

Document Required Item to Documentation Task List

12% (5)

Perform a Care Activity to Impact Clinical Processes

10% (4)

Review an Order

7% (3)

Document Missing Required Documentation

5% (2)

Document Patient Education

5% (2)

Wisdom Knowledge

Information

Data AMIA 2017 | amia.org

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Types of CDS Available in EHR for Nurses CDS Recommending to….

% (n)

Document a Plan of Care Template

21% (9)

Order a Consult

17% (7)

Perform a Care Activity to Impact Clinical Outcomes

12% (5)

Document a Quality/Compliance Measure

12% (5)

Document Required Item to Task List

12% (5)

Perform a Care Activity to Impact Clinical Processes

10% (4)

Review an Order

7% (3)

Document Missing Required Documentation

5% (2)

Document Patient Education

5% (2)

Wisdom Knowledge

Information

Data 9 AMIA 2017 | amia.org

CDS Requests by Registered Nurses (n=46)

Wisdom Knowledge

Information

Data AMIA 2017 | amia.org

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CDS Requests by Registered Nurses (n=46)

Whalen, K., Bavuso, K., Bouyer-Ferullo, S., Goldsmith, D., Fairbanks, A., Gesner, E., Lagor, C., Collins, S. (2016). Analysis of Nursing Clinical Decision AMIA 2018 Clinical Informatics Conference 11 Applied Clinical Informatics, 7(2), 227–237. Support Requests and Strategic Plan in a Large Academic Health System.

Risk Assessments/Risk Reduction Examples: • Pressure injuries (ulcers) prevention and management • Falls and injury prevention • Restraint safety • Nurse Driven Protocols • CLABSI (Central line-associated bloodstream infections) • CAUTI (Catheter Associated Urinary Tract Infection)

Evaluation

Assessment

Nursing Process Implementation

Nursing diagnosis

Planning • •

Interprofessional and team-based or Nursing specific

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AMIA 2018 Clinical Informatics Conference

Evaluation of Risk Assessment CDS for Nurses

“Every patient gets it, so I just ignore it” “I wasn’t ready to go to the plan of care”

FROM: Goldsmith, D., Bavuso, K. Lagor C., Collins, S. Adoption of Nurse Facing Clinical Decision Support AMIA 2018 Clinical Informatics Conference 13 following EHR Implementation. AMIA Annual Symposium, Chicago, IL, USA, November 12-16, 2016.

Activities Performed by Nurses During a Shift (Yen, 2017) Type

Definition

Examples

Direct - Assessment

Heart and breath sounds, palpating limbs for edema, etc.

Direct - Medication Indirect - Med Prep

RN performs direct physical assessment RN performs treatment or procedure that cannot be delegated (top of license tasks) Direct patient care that may be delegated to a PCA or other unlicensed persons RN preparing for or administering any patient medication in the patient room Any medication preparation not completed in the patient room

Indirect - Get Med Direct - Feeding

Pulling medication from the pyxis or from the tube system Helping patient eat or administering tube feedings

Direct - ADL Direct - Bed Direct - position Direct - Ambulating Direct - Alarm Direct - Vital Indirect - Food Tray Indirect - Prep Docs EHR-Charting EHR-Review Info Lookup Paper-Charting Paper-Review Email/Text Paging Handoff/Rounding Supply-Get Supply-Fill up Supply-Call Transportation-prep Transportation-travel

Helping patient with ADLs Helping patient in and out of bed. Directly positioning the patient in bed or chair. Helping patient ambulate Reacting to alarm(s) - silencing alarm or resetting alarm RN gets vitals (BP, HR, RR, temp, accucheck) Delivering, removing or setting up food tray Preparing discharge, transfer documents recording, entering or updating data in the EHR reviewing patient information in the EHR looking for information - med info. dx info tx info Updating patient's paper chart or her own patient notes. reviewing or looking up patient information in a paper format Accessing work email or text paging interdisciplinary team Talking to team member about patient assignment Gathering supplies restocking supplies on carts or patient rooms requesting supplies from others Get patient prepared to travel for procedure Traveling with patient to destination Doing a task that is directly helping another person, not for self or for own patient Cleaning/maintenance that is not directly related to nursing care Any tasks associated with emergency procedures

Direct - Procedure Direct - Procedure delegable

Help others Housekeeping Code/ERT

List not exhaustive EKG, peripheral blood draws, bladder scans, etc. - excludes Scanning pt. ID band, scanning medications, preparing medications, and directly administering medications in the patient's room communication Drawing up IVP protonix in the medication room RN pulls all pt. morning medications from pyxis; RN gets IVPB vancomycin bag from pharmacy in the activities tube system IV insertion and regulation, dressing change, oxygen admin., etc.

**tube feedings are not able to be delegated emptying urinal or bedpan; assisting with shower/bath, or oral care; linen change; all able to be delegated to PCA After ambulating with patient from the bathroom assisting pt. to sit on side of the bed Positioning pt. on left side with pillow support Walking with pt. from bedside to bathroom IV pump, tele, call light, bed alarms RN gets automatic BP after pt. states he is dizzy RN brings food tray into pt. room for dietary Charting discharge summary Charting on adult care summary, nursing notes, MAR, etc. Scrolling through or reading the EHR Searching for info. on internet outside of the EHR (information about medication, procedure) Writing down lab values, print tele strips Looking at paper chart, looking at personal notes for patient Looking at work email, writing a text page on the computer or phone Receiving report at shift start, giving report at shift end, giving report to PCA in middle of shift Gathering linens, IV tubing, urinal, blankets, food or drink Food is given to patient, IV tubing is placed on WOW to be used, isolation gowns filled up using call light system to ask for supplies from unit clerk, calling out to nurse for supply placing oxygen tank on cart, putting blankets on cart, prepare ticket to ride Walking to xray, MRI, room change

Decisions are embedded within and between these activities

Help find a medication, help in other patient's room, clarify a procedure for other nurse mopping/sweeping floor, changing lightbulb, changing hand sanitizer AMIA 2018 Clinical Informatics Conference 14 Participating in code, calling a code or ERT

Risk Assessments/Risk Reduction Evaluation



CDS Gap: Static, Generic Plans of Care



Nursing surveillance decisions and evaluation of response to interventions are continuous throughout the nursing process



Plans should be personalized to patient specific risk profiles



Implementation of plan occurs outside of the EHR by nurses



Siloed focus

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Assessment

Nursing Process Implementation

Nursing diagnosis

Planning

AMIA 2018 Clinical Informatics Conference

CDS for Personalized Plans of Care (Keenan et al, 2017) • CDS to support knowledge-driven decisions • NOT templated plans • Results • More tailored to patient • Relevant to continued patient progress • Beneficial ‘side effects’ • Decreased amount of documentation • 30% less time [(p
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