REVIEW MATERIALS FOR NURSING INFORMATICS

Ambulatory Care Systems

April 27, 2004 Pres. George Bush created the position of the Natl health information technology coordinator to develop a nationwide interoperable health information technology infrastructure. The national coordinator must improve the coordination of care & information among hospital, laboratories, physician office & other ambulatory care providers through the effective infrastructure for the secure and authorized exchange of healthcare information.

Tommy G. Thompson announced the decade of health Care Information Technology and the publication of a report. The report identifies the major goals Goal 1 Inform clinical practice Goal 2 Interconnect clinicians Goal 3 Personalize Care Goal 4 Improve population Health

Issues for Ambulatory Care The increase accountability The need for continuous and documented service improvement Pressure to control utilization Protection of confidential information

Financial Benefits Cost effective and timely and accurate bill submission process.

Credit card payment.

Administrative Benefits Reduction in the size of record room

Reduced time spent finding and delivering charts Increase in the privacy of data Formats that are legible and comply w/ the legal regulations

Promotion of quality assurance and improved patient satisfaction Ability for the home access by physicians and nurse practitioners, alerts for incomplete data and integration of clinical data

Credentialing exhaustive verification of medical licenses and qualification Clinical Benefits Automated health care record can provide a: Problem list Medication record Vital signs Progress notes Results from the laboratory Radiology department Flow sheets grow chart Immunization record Medication allergies Profiles Alerts and reminders Follow-up system

A Patient master index is the basis for collection of patient related data. It is a central for repository for patient/member information across the enterprise including sophisticated tools for querying, updating and managing the index.

Implementation Issues and Challenges

In 2004, 84% of 7,808 ambulatory care facilities were not automated, 13% had software installed and 3% of them do not implement the software.

Role of the Nurse in the Ambulatory Arena

Use and put data in meaningful ways

Maybe involved in the selection of automated system based on the needs assessment of the environment Instrument in the implementation of automated customs Maintained confidentiality and security of information

Regulatory Requirements RBRVS (Resource Based Relative Value Scale) is a model designed by Department of Health & Human Services(DNHS) In this system, each physicians current procedural terminology (CPT) code has a relative value where in the payer will pay the physician based on the RVS value. The Health Care Portability & Accountability Act of 1996 requires six code sets CPT (Current Procedural Terminology) describes medical procedure performed by the physicians & other health providers - Codes were developed by (AMA) American Medical Association to assist in assignment of reimbursement amounts to providers by Medicare carriers. - The most recent version is CPT 2004 which contains 7755 codes & descriptors.

ICD-9 (Ninth Revision of the International Classification of Disease) -design for the classification of morbidity and mortality information for statistical purposes, indexing hospital records, and data storage and retrieval. - Diagnoses and procedures determine the (DRG) diagnosis related group that controls reimbursement and most of the other payers.

HCFA HPCS (2004) Health Care Common procedure Coding System) -collection of codes that represent procedures, supplies, products & servi provided by the Medicare beneficiaries & to individuals enrolled in private health insurance program.

4. NDC system (National Drug Code)

- identifies pharmaceuticals in packaging. - At the end of 2001, there were - The current edition is limited OTC by (FDA 2004)

detail including the 1 313 786 NDC codes. to prescription drugs & few

5. APC (ambulatory payment - Prospective payment system - were mandated by the Act of 1997.

classification) for outpatient services. budget which

Congress as a part of Balanced are divided into 451 groups to predid cost.

- All covered outpatient services is called APC. - Software determines patterns Members Associations Involved in

Ambulatory Care

The American Academy of Ambulatory Care Nursing -is a member organization for - offers networking - represents ambulatory organizations. nurses. opportunities by geographic location. practice to other political advocacy

- offers education through publication, electronic media and conferences. The American Medical Informatics Association - has physicians and nurses that are members - the spring 2005 meeting was dedicated to "Best Practices for ACPOE & population Management w/ EHR." The Medical Group Management Association - founded in 1926 - is a major organization representing the physicians in group practice nationwide - supports education, networking, job recruitment, research & political action.

The Society for Ambulatory Care Professionals - associated w/ the American Hospital Association - organization of management professionals across the continuum of healthcare services - offers networking opportunities, education, publication & legislative advocacy Federated Ambulatory Surgery Association - non profit association representing interests of ambulatory surgery centers - represents the medical staff & owner to the media & other regulatory bodies - publishes a bimonthly journal & other publications to inform its members & the public - conducts educational programs on a variety of topics The American Association of Ambulatory Surgery Centers - promotes advocacy at the national level through relationships w/ CMS & congress The Association for Ambulatory Behavioral Healthcare - dedicated to the delivery of high quality psychiatric & chemical dependency treatment AHIM - foster professional development of the members HIMSS - response to trends by launching HIMSS Ambulatory Care Initiative

INTERNET TOOLS FOR ADVANCED NURSING PRACTICE BASIC AND ADVANCED INTERNET SEARCH METHODS Regardless of the search engine used, certain search methodologies if applied correctly, increase the efficiency of retrieval of needed information Clinical ex. Are provided to facilitate learning The strategies are:

-Name precisely the information being sought - Used search strings rather than single words - Enhance search strings by using Boolean or natural languages methods Namely precisely the information being sought Use a search strings rather than a single word to increase the preciseness of a search Enhance search strings by Boolean: Boolean terms are AND, OR or NOT. When using web sites for clinical decision support purposes An organizational web sites likely to present organizational interest and bias

The term metasearch represents a process similar to parallel, federated, broadcast or cross- database searches.

INTERNET- AVAILABLE CLINICAL PRACTICE TOOLS BASIC COMPONENTS OF NURSING PROCESS: - ASSESSMENT - DIAGNOSIS -TREATMENT -OUTCOMES EVALUATION

 These components provide outward structure for the development of clinical information database for advanced practice nursing ASSESSMENT Refers to the systematic collection of data needed to arrive at one or more diagnosis

The tools included in this section include forms, miscellaneous screening tools, risk assessment instrument and information of the manifestation of s/s Nursing assessment is the first step in nursing process Domestic abuse assessment is an integral part of primary care practice Risk assessment is an important part of clinical practice

GOVERMENT DOMAINS Several government web sites were selected: The Food and Drug Administration (www.fda.gov) The NLM PubMed database (www.pubmed. Gov) The national Center for Complementary and Alternative Medicine (NCCAM)

This is to provide quick access and the most concrete information on drug interaction was the FDA web sites The PubMed site provided additional information relevant to clinical decision making

EDUCATIONAL DOMAINS The phrase P450 drug interactions was entered into the Google search box, the first site listed in an edu domain was Indiana Univesity, Purdue University ORGANIZATIONAL DOMAINS The first 10 site listed, only one was organizational site and when activated in linked to a commercial site. COMMERCIAL DOMAINS The credibility of commercial sites was mixed

CONCLUSION Credible information on specific clinical topics is readily available on Internet. The type and depth of information varies by domain of the web sites.

HEALTH PLAN OUTCOMES HEDIS Health Plan Employer Data and Information Set

 Trademark name of the National Committee for Quality Insurance (NCQI) Reports are issued annually and some states issue their reports online.

2003 REPORTS ISSUED BY MINNESOTA AND MISSOURI 1. MINNESOTA DEPARMENT OF HEALTH HEDIS REPORT Features allow for quality and services comparisons among health plans 2. MINNESOURI DEPARTMENT OF HEALTH AND SENOIR SERVICES Features a consumers guide to commercial Managed care Plan OFFICE TOOLS: ONLINE CARE RECORD AUDIT AND PATIENT SATISFACTION FORMS The following links provide resources on auditing the health record and patient satisfaction

MEASURES INCLUDED TOGETHER FOR 2 REASONS: Both the quality of the health care record and patient satisfaction reflect upon the quality of the care provided, a healthcare outcome. Patient satisfaction variables provide clinicians with criteria to evaluate their own performance and that of the office in which they are practicing. Health care record audit criteria, adapted from the Santa Barbara Regional Health Authority Patient satisfaction form (four-point scale) Patient satisfaction form (five-point scale) SHORT FORM (SF) HEALTH SURVEY One of the long lasting outcomes of the medical outcome study Ware and Sherburne, 1992, was the dissemination and use of the 36 item SF health survey (SF-36) and its subsequent versions and redactions Another outcome was the formation of a non-profit trust called MEDICAL OUTCOMES TRUST and SF-36.org SF-8 internet demo is available. This survey tool is especially useful for the population based intervention studies or in cohort studies PHYSICAL HEALTH ITEMS survey overall health physical activity, interference with ability to work secondary to physical health problems and pain MENTAL HEALTH ITEMS survey overall energy, social activity, emotional problems, interference with ability to work secondary to emotional problems

OUTCOMES MEASUREMENTS: INTERNET AVAILABLE BIOSTATICAL AND ANALYTICAL TOOLS Likely to assume an important role when new program or initiatives are began. 1. Qualitative data base software 2. Qualitative data creation, management and analysis software 3. Epidemiology analysis software 4. Chi square calculator 5. Students t-test calculator 6. Extensive listing of free biostatical software and biostatical test online (AOL)

e CLINICALOG (http://www.eclinicalog.org) A WEB-BASED CLINICAL ENCOUNTER DATABASE Part of an educational strategy, initially designed to build data entry, analysis, and synthesis skills in nurse practitioner students Like other logs, e clinicaLog started out as a paper and pencil format. Nurse practitioner students used logs to track the number of the Patients seen in clinical practical and record basic demographic data, medical diagnosis, and medications prescribed. Useful pedagogic tool. It gives through an informatics skills building and refinement process and assists professionally development. Migrated to a web-based format

Informatics Solution for Emergency Preparedness and Response

Role of the HRSA in Promoting Informatics Educational Solutions Two Grant management programs under the HRSA related to bioterrorism:

 National Hospital Bioterrorism Preparedness Program Purpose: To aid state, territory, and selected entities in improving the capacity of the health care system, including hospitals, emergency departments, outpatient facilities, emergency medical services systems, and poison control centers. Bioterrorism Training and Curriculum Development Program (BTCD) Provides continuing education and curricular enhancement for practicing healthcare providers and current students. Developed materials are designed: o To equip a healthcare workforce o To recognize indications of a terrorist event o Meet the acute care needs of patients, including pediatrics and others o Rapidly and effectively alert the public health system of such an event at the community state, and national level. o Participate in a coordinated, multidisciplinary response to terrorist events. CHANGES IN THE FEDERAL SYSTEM AFFECTING EMERGENCY PREPAREDNESS AND RESPONSE Community health traditionally been defined in the United States as the provision of healthcare outside the hospital infrastructure. Public Health Department viewed as the major delivery system of healthcare. The public health infrastructure has been deteriorating to the point that many if the rural health department settings did not even have fax machines to receive notices about potential public health threats. Federal Funds were channeled through the centers for Disease Control and Prevention (CDC) to the states in order to strengthen the public health infrastructure.

- At the same time federal funds were directed to hospitals through the Health Resources and Services Administration (HRSA) Both funding agencies encouraged the development of systems that would intersect one another, and for the first time a concerted effort was made to promote a collaborative system that would best meet the needs of the national health. After the attacks of September 11, thousands of family members circulated throughout the hospitals in the area in the futile attempt to locate their family members. They developed a bar code system to log and track their victims (Hamilton,2003) PDAs were used by medics to log patients and belongings as well as notebook computers with wireless technology and networked desktop machines in command centers. A report of 2002 Coastal North Carolina Domestic Preparedness Training Exercise descried the innovative use of telehealth technologies for terrorism response. The inability to access electronic health data creates barriers to continuity of care, quality of care, cost analysis, and vulnerabilities to exposure during bioterrorism events. Informatics and Volunteerism

*Healthcare Volunteers- are a necessary component of mass casualty events but also create challenge.

*It is possible for state- wide data bases to be built, but these are only shared within the state system.

DMATs (Disaster Medical Assistance teams) -members of the teams are federalized or made temporary workers of the federal government, which then assumes the liability for their services.

Medical Reserve Corps Initiative -was designed to assemble healthcare volunteers who are willing to respond at their local levels.

NNRT (National Nurses Response Team)

-initiative sponsored by ANA. -will comprise to regionally- based teams of 200 registered nurses who could be called on to assist in chemoprophylaxis or vaccination. -the members will be enrolled in the National Disaster Medical System.

*American Red Cross- has a long history of volunteerism during disasters, and has education requirements for nurses depending on what roles they will play in disaster relief.

CHARACTERISTICS OF NATIONAL VOLUNTEER *Verification of licensure (can be multiple states) *Records of continuing education *Records of certifications *Organization volunteering for (will need to decide how to only count individual once during an event) *Activation Instructions *Prior emergency response experience (including dates of Service) *Security clearance level

NHII (National Health Information Infrastructure) *David J. Brailer MD, PhD

-

1st national coordinate for Health Information Technology

*National Coordinator- charged with directing health IT within DHHS and coordinating them with those of other relevant executive branch agencies

* Public Health monitoring, bioterror surveillance, research, and quality monitoring require data that depend on the widespread adaption of the principles of health IT.

Role of AHRQ in Stimulating New Informatics

AHRQs involvement in bioterrorism comes from the recognition that clinicians, hospitals, and healthcare systems have essential roles in public health infrastructure.

Decision Support Systems

Decision support systems and their role in disease management of significant interest and importance. AHRQs integrated delivery system research network ( IDSRN) based at the Weill Medical College at Cornell University has collaborated with the New York City Department of Health And Mental Hygiene and Mayors Office of Emergency Management to develop a computer simulation model for citywide response planning for mass prophylaxis and vaccination during bioterrrorist attacks and other public Health emergencies.

Researchers at the Childrens Hospital of Boston are building decision support models for information systems of linked healthcare data, which rapid dissemination of relevant information. The University of California at San Francisco has reviewed and synthesized available evidence on the Information Technology (IT)) needs of first responder physicians in the event of bioterrorism or other public health emergencies.

It has also examined the role of information technologies and decision support systems to assist in rapid diagnosis and management of disease resulting from an increased caseload. Another project involving decision support systems is being undertaken at Boston Childrens Hospital and Harvard University, in a joint study funded by AHRQ, this project seeks to develop a prototype database and Web site to facilitate clinicians reporting of trends that will be used to diagnose possible bioterrorist attacks.

Four prototypes of decision support systems are being developed, so that clinicians can give just-in-time information and device an appropriate responses. SYNDROMIC SURVEILLANCE

Detection of a disease outbreak before the actual disease or mechanism of transmission is identified.

Real-time Outbreak and Disease Surveillance (RODS) Developed by the MPC Corporation together with the University of Pittsburgh and Carnegie Mellon University. A system that provides early warning of possible infectious disease outbreaks caused by bioterrorism or other public health emergencies.

An assessment tool has been developed, which will aid public health officials in acquiring tools related to early warning surveillance systems and other IT systems addressing bioterrorism.

HELPING CLINICIANS RESPOND Researchers at the University of Alabama at Birmingham have developed continuing medical education training modules to teach healthcare professionals to identify various biologic agents anthrax, smallpox, botulinum toxin, tularaemia, viral hemorrhagic fever, and the plague classified at the Biosafety Level 4 (BSL-4) and are considered to be the most deadly agents.

Research Triangle Institute (RTI) Developed two prototype simulations to aid medical providers in responding to bioterrorist attacks and other public health emergencies.

 Practice-Based Research Network (PBRN) Developed a system to allow for electronic solicitation of data using handheld devices and wireless communications. Has a primarily pediatric focus and allows real-time transmission of clinical impressions and symptoms, which will aid in bioterrorism surveillance.

Researchers at Vanderbilt University Medical Center have undertaken a study to determine the effectiveness and efficiency of learning programs to educate nurses volunteering in their local community Medical Reserve Corps.

In 2004, AHRQ also hosted a series of web conferences for state and local health system preparedness, further demonstrating how informatics can help providers learn about ways to improve response and preparedness in their respective healthcare systems.

Other changes affecting emergency preparedness and response COMPETENCY BASED LEARNING Since the emerging department would most likely to received first the first victims of bioterrorism chemical or nuclear attack it is no surprise that the first efforts to conduct a needs of assessment and curricular review centered on activities ACEP - AMERICAN COLLEGE OF EMERGENCY PHYSICIAN ; identify barriers to this training and efforts recommendation for effective education -the task force focus on a thorough explanation of the problem that would result to specific recommendations specific were used including -group interaction -interview -review material -agreement by the task force -a subject matter analysis -the content was organised into three proficiency categories -awareness

-performance -planning -the focus of ACEP was on assuring that the nation public health work force was ready to response to emergencies INFORMATICS AND THE EMERGENCY OPERATIONS CENTER IMS -incident management system -first use by firefighters to control disaster scenes and multijurisdictional and interdepartmental manner HEICS -HOSPITAL INCIDENT COMMAND SYSTEM -new name of IMS after being adopted for hospital use Organization structure of an incident commander with 8 direct reports 1 planning officer 2 operations officer 3 logistics officer 4 security officer 5 public information officer 6 liaison officer 7 safety officer 8 finace officer

VENDOR APPLICATION Current Trends Toward Prime Vendors, EHRs, and systems Integration Niche Applications focus on a discrete set of nursing functions. Departmental systems address more comprehensive set of functions for a single point of service. Are more targeted and rebust than comparable modules of EHr solutions since departmental system focus on one or few specialties and points ofservice. Continue to be saught by manu organizations particularly in academic medical centers and for high acuity, specialized care department. The current trend is to limit niche and departmental system to create an EHR via well integrated applications with a common data base tools and technologies.

HCIT environment is by nature heterogeneous health care organization or HCOs , increasingly seek a primary clinical vendor who to the degree possible, delivers a single system or suite of tightly coupled solutions. New Technologies New and emerging hardware and software technologies are increasingly being incorporated in nursing applications. Key goals are to improved quality of care, mobility of care givers and collaboration among the care team. Strong emphasis is being placed on delivering technology at the point of care via bedside terminals and wireless devices. Bedside terminal access can facilitate real time changing increase nursing time at bedside and eliminate batch end of shift charting. Vendors are introducing a variety of enabling technologies that minimizes nonproductive entry time. HISTORICAL PERSPECTIVES

Historically, nurse executives have not widely embraced IT as strategic business tool. Savvy nursing leaders increasing view IT as viable means to address resource shortages, care delivery challenges and fiscal pressures. (RNs) is entering the field with greater appreciation for the value of technology as a means to improve patient care and job satisfaction. Nurses are by far the single largest user of clinical system and key potential beneficiaries of information technology.

Contributing Factors are: Cultural Gender related Power based and economic in nature

Nurse largest and most well respected health care professional group based on numerous national consumer surveys. Nursing is the only profession that does not charge for services rendered.

Current Situation Healthcare without Bounds: Mobile Computing in Nursing, June 2004 Gregg Malkary, managing director of Spyglass consulting, reports that an alarming percentage of nurse respondents perceived that nursing applications are not a high priority for their organization and, by and large, many current solutions are poorly designed,disjointed and user-unfriendly for nurses. Commonly reported perceptions were: Nursing is an untapped and underserved resource in provider organizations. Workflow inefficiencies are not well addressed by existing solutions. Automation is not a high priority for nursing in their organizations. Vendors are out of sync with nursing needs.

Some new tools and technologies have complicated rather than simplified nursing practice, at times decreasing productivity and introducinmg an element of increased risk to patients.

Root causes of poorly designed nursing applications include: Vendor product design processes driven by engineers, financial system analyst or MDs (non-nurses) Insufficient nursing representatives on vendor executive and development teams The HCIT industrys overall woeful lack of adequate requirements definition, functional specifications and process analysis. Early on automation of the paper chart without a full understanding of underlying nursing process, workflows and egonomic challenges.

Two primary HCIT initiatives: Computerized physician order entry (CPOE) Bar-code-enabled medication administration (BCMA)

Haelthcare information and management systems society (HIMSS) survey data, the two initiatives dominate clinical system selection processes and are top IT priorities for HCOs study. Vendor response HCIT vendors are delivery more reburst and tightly integrated clinical solutions that better address the needs of all care providers for more coordinated, streamlined patient care delivery

Vendors are now expected to deliver next generation clinical applications: Support multi and interdisciplinary care Promote data integrity via data validity checks and embedded tools Provide ready access to internal standards Enabled evidence- based care via automation of integrated multidisciplinary clinical pathways and corporation of decision support mechanism

 Collect work load and management data as a by product of clinical documentation Support productivity management, staffing and budgeting activities Support process and outcomes monitoring, management and continual improvement via standard reports and database mining Support change capture, supply management and inventory reconciliation Support for medical Care Flow Diagram It is a conceptual model that represents a patient- centric, interdisciplinary inpatient oriented view of a clinical information system that supports a fully integrated EHR e.g., care planning and documentation that are automated in EHR systems as well as, in whole or part, in niche and departmental applications

KEY CLINICAL SYSTEM NURSING AND MULTIDISCIPINARY CARE COMPONENTS Patient access The patient record is initiated in the admission, discharge and transfer (ADT) system or administrative portion of the EHR. The collection of initial registration and admission data establishes a patient record and begins the clinical and financial encounter with the provider organization

DIAGNOSIS/PROBLEM

The concept of nursing diagnosis has been somewhat controversial since its inception. A problem list is a common set of patient specific problems that are maintained by the MD and care team

NURSING MULTIDISCIPLINARY ORDERS @ PLANS OF CARE Physicians can enter medical orders directly online (CPOE) or via authorized designees

In manual system, physicians order are separate from orders of other care providers. Nursing orders and care plans are typically entered into the system after an initial nursing assessment. In some systems, charting of specific data in the initial assessment prompt the nurse for associated plans of care. Nursing care plans are based on diagnosis, organizations, and department standards of care and patient specific nursing orders The scope of nursing orders depends on national @ state legal @ regulatory requirements, professional practice standards @ individual organizations policies. Ex. Of nursing orders include: o Activities of daily living o Treatments o Interventions

Clinical pathways---known as care maps, based on patient diagnosis. They provide a standard, evidenced based, time driven plan of care, w/ predefined interventions to be performed @ outcomes to be achieved in targeted time frames. Clinical systems automatically generates @ where appropriate schedules all orders for all services to be provided to the patient

INTEGRATED PLANS OF CARE ---includes all orders for all services to be provided for a patient ---provides a single, patient centric, rather than fragmented department oriented, plan of care that can be accessed @ used by the entire care team KARDEX--- a patient management tool used by nurses to collect, organize and display summary patient information in one place In paper environment, kardex is a flip-file holding paper cards that contain patient data snapshots. Kardex includes:

o Patient name o Medical record number o Admission date o Special needs/request o Diagnosis o Service o Attending physician o Allergies o Primary nurse o Patient age o Date of birth o Medical allerts o All currently medical orders In automated environment, kardex is more than just an online view of summart patient data An electronic kardex automatically gathers appropriate data already in a system via previously entered order, plans of care @ clinical documentation. In advanced nursing systems, direct entry of data into the kardex will update associated parts of the electronic records Kardex is not a legal document @ therefore it is not saved in the permanent patient records

WORK PLANS/TASKLISTS EHR support generation of work plans ---known as tasklist > as an automatic byproduct of orders and plans of care Tasklist help nurses organize, document @ manage patient care activities for individual or groups of assigned patients.

2 types of activities are presented on tasklists: o Treatments/interventions o Medications

Consumer and Patient Use of Computers for Health

Consumerism has seen a dramatic rise in the U.S over the past decade. Consumers of health services are educating themselves on all aspects of health, wellness, and disease.

Health Insurance Portability and Accountability Act( HIPAA) Privacy Rule

Grants specific rights to the patients and family members regarding thier health information.

Application Areas: Consumer Use Of Computers for Health

Information Seeking

Information seeking about health matters is a common use of computers. Approximately 2/3 of the U.S population has access to the computer and 80% of it uce computers recently for health matters. Mayo Clinic (mayoclinic.com) provides a wealth of health information and tools. Diabetes.com sponsored byn GlaxoSmithKline Heathfinder.com a collection of vetted links to health related Web sites that is sponsored by Disease Prevention and Health Promotion of the U.S. Medline.gov developed by the National Library of Medicine and National Institute of Health. A consumer- friendly site.

Medicare.gov devoted to information specific to the Medicare program and to health topics for seniors. - sponsored by the Centers of Medicare and Medicaid Services.

Communication and Support

Electronic mail or e-mail continued to be the killer- appof the Internet.

Benefits of E-mail:

1. May communicate information with friends and family about health. 2. May use e-mail to keep family informed about the health status of the family members. 3. May engage in online support group whose focus is on a particular disease or condition or they may communicate directly with their health care providers.

Reasons for wishing this type of communication: Get health reminders. Get personalized information after the doctors visit. Ask questions when a visit is not necessary. Make appointments. Renew prescriptions. Get lab results. Reasons for reluctance to offer the service: Liability Reimbursement Confidentiality and security. Impact on the office workflow.

1. 2. 3. 4. 5. 6.

1. 2. 3. 4.

Patient Health Records

many keep their own PHR both for themselves and for their family members. it encodes users' entries with ICD9 and CPT codes, or even with the broad range of terms found in the Nat'l Library of Medicine's Unified Medical language System Consumers can buy a PHR application an any software store, loading the program onto their own computer and soring their recoed there. example: RecordSmart supplied by MyHealth123 and Health-Minder, which can be downloaded from www.healthminder.com. many healthcare organizations offer the service and application on their community Web sites like interactive health management tools such as health rirsk assessments, smoking cessation programs, fitness trackers, pregnaancy centers, calorie intake monitors and any numbers of calculator. a number of sites allow the consumer to keep a record of personal disease-specific information (e.g. MyDiabetes.com and MyAsthma.com) and allow the patient to record parameters specific to those diseases, providing graphs, decision aids, and a wealth of related materials geared to supporting the patient who has those conditions. several organizations have developed standards and guidelines relating to the consumer's relationshp with vendors who suupply PHR systems over the internet. (e.g. URAC www.urac.com, Hi-Ethics www.hi-ethics.org, and ASTM International www.astm.org

Columbia University, Cimino and colleagues concluded that "use of the system enhanced the patients' understanding of their conditions and improved their communication with their physicians,'' with no reported side effects

Educational and Cultural Barriers

Factors such as literacy, language preference, and cultural background can be barriers to use of the Internet for health. The 1992 Adult Literacy Survey found that up to 47% of adults were functionally or marginally illiterate, and that up to 66% of adults age 60 or over had inadequate or marginal literacy skills. Some vendors have developed consumer-friendly terminologies that map to medical terminologies to assist consumers with finding, understanding, and recording health-related material like the Consumer Health Thesaurus, a large thesaurus for consumer terms that maps to terms in the Unified Medical Language System.
Physical and Cognitive Disabilities

People with physical and cognitive disabilities are somehow finding it hard to use the internet for health, but the internet has enormous potential to assist the disabled and the homebound patients.

The Nurse Informaticians Role in Consumer and Patient Computing

Areas of Nursing Expertise that can be Applied in Consumer/Patient Computing

Informaticians who are nurses bring unique skills to the arena of consumer informatics by virtue of their professional education in nursing. Some of these skills are: 1. Deep expertise in patient education: A core competency of nursing professionals is patient education. Nurse informaticians can combine their expertise in patient education with their informatics skills to design content and applications that are effective for imparting knowledge and skills needed to maintain health and manage acute and chronic conditions.

2. Cultural diversity in the workforce and a strong ethic of cultural sensitivity: Cultural sensitivity is highly valued in nursing education and practice. The nursing workforce itself is more ethnically and culturally diverse than most professions.

3. Strong background in both patient-and-community-focused researches: Nurses have a long tradition of patient-focused research, a strength that can be applied to the many areas of consumer and patient computing that are begging for research.

4. Strong heritage of patient advocacy and patient empowerment: While nurses are not immune to feeling threatened by the empowered patient, it is also true that nurses have always had as a central goal to assist each patient to achieve as much self-sufficiency as possible.

Special Conditions in Designing Applications for Patients

Lay versus professional nomenclature Professional nomenclature is so ingrained In most clinicians that they often are not even aware that they are using language that is foreign to the patient or consumer that is why lay terms must be substituted whenever possible. General literacy and health literacy All readers, no matter what their educational level, appreciate material that is written clearly and plain language. Computer literacy and the digital divide Nurses who have implemented health-related systems to person s who are not literate realize the importance of system design that emphasizes ease of use and available help functions. Special needs of the elderly Good resources for learning more about the needs elderly users can be found at www.aarp.org/olderwisewired Accessibility to persons with disabilities W3C/WAI establish guidelines and promote technologies to increase accessibility of the www to persons with physical and cognitive impairments. Use-centered design While nurse information undoubtedly learn the importance of user-centered design during

their education, nowhere is this more important than in designing applications for patients and consumers.

Some research Areas Related to Consumer and Patient Computing

Ferguson (terra incognita of online consumer health) He advocates ethnographic examination of patient-doctor online communication. Gustafson Advocates for various levels of evaluation studies of e-health systems based on the type of service offered. Schwitzer Believes that there has been inadequate evaluation of the merits of one type of decision support over another in multimedia decision-support applications. Greenberg, DAndrea and Lorence Advocate research into search technologies to help consumers to search more effectively and to evaluate quality of what they find. Kaplan and Brennan Noted 3 particular areas of research: 1. Defining whether the user is a patient, consumer, or client, and whether the definitions make difference and whether the term might change with circumstances 2. Determining how the roles of the patient/consumer/client and health care providers are changing, and with what implications 3. Examining what the term empowerment means, and what effect it might have on care.

DECISION SUPPORT FOR CONSUMERS

Health Related Decision Making Decision making itself is a complex, perceptual, cognitive and social process. The talents and limits of humans as decision makers, particularly in the face of substantial uncertainty are well known and well described in the work of human information processing theorists. Stressors, such as anxiety, time pressure and lack of knowledge lead these efficient processes to deteriorate in such a way as to lead to suboptimal or even incorrect decision processes. Health-related decision making is complicated because the substance of the problems and choices is itself complex and exceeds the knowledge and education of most laypersons. Health-related decision making is complex because it generally involves more than a single person. Two key groups must be considered 1.)the family members of the person facing a health crisis, 2) in need of health information and the health care delivery team Family members hold values, beliefs and attitudes that implicitly or explicitly influence the health choices of an individual.

The healthcare industry holds clinical care standards, values and attitudes about patients responsibilities for their care and organizational or personal traditions that may interfere with the persons right to self-determination and self-care. Healthcare decision making is challenging because it involves uncertainty, taxes human information processing capabilities, deals with subject matter that is unfamiliar to the involved person and there are multiple constituencies that must be served.

Shared Decision Making and Informed Choice Shared decision making is also known as a relationship or collaborative decision making which empowers patients to choose among the options available to their in consultation with clinicians using their personal values to frame the choice among alternatives. Related to shared decision making is the concept of evidence-informed choice. Informed Consent-has been an established practice that involves the patient acknowledging that they have received adequate information to assent the care that is recommended by the clinician. Informed Consent is a passive process that simply requires that a patient has knowledge of the treatments and the probable outcomes. Evidence informed choice-sets a much more rigorous standard that requires that patients both receive and understand information that enables them to evaluate risks and benefits of alternative options, examine how they value the benefit versus the risks, and then use that information collaboratively with their clinicians to decide on the optimal course of action consistent with the joint values of clinicians and patients. Decision support technology is a key tool to enable a higher level of understanding and evaluation of alternatives available to the patient and thus servers as a key to achieving informed choice by insuring that information regarding courses of treatment is comprehensively and uniformly communicated. A major determinant of choice and decision making is the context provided by the values held by an individual.

Patient Preferences

 Von Neuman and Morgentern (1964) = first proposed the personal values and

attitudes that drive individual choice could be understood through mathematical formulations.
Ledley and lusted (1999) = introduced the concepts of mathematical reasoning to

medical decision-making, with particular attention to decision-making under uncertainty.

Raiffa (1968) = explicated decision analytic strategies that brought the treatment

of the personal preference and uncertainty into a form accessible in an interpersonal interview.
Sonnberg and Pauke 1986; Pauker, Pauker n and MacNiel, 1981= demonstrated

the feasibility of using decision analysis to better understanding treatment choices that are complicated by the multiple uncertainties and personal values.
Domain Analysis and Normative Decision Theory= two main branches of

decision theory, both help make patient preferences accessible for clinical decision- making.
Multiattribute utility theory (MAUT)= provides the mechanisms for qualifying the

subjective value of health states and therefore can be useful to patient who must make health care decisions.

Alternate Meaning of the Term Preferences The distinction between preferences as formulation of values

vis- a vis= a set of healthcare related entities become important when one

examines how computers could be assisted in eliciting patient preferences.

(Donabedian, 1968) =provides a useful heuristic for sorting out the various

references about which individual may developed preferences.

(Sainfort and Booske,1996)= individual may established preferences about

structural aspect of healthcare, such as belonging to a health maintenance organization.

Preferences= to represent an individuals fi9nal choice of one option from many

possible treatment options.

 (Barry et al., 1995)= he finally decides on surgical intervention as his final choice of

tr4etment.
Moore and Kramer (1998)= used the term Preferences to identify those features

of cardiac rehabilitation programs deemed most desirable by patient

Henry and Holzemer (1995) = identified preferences as patient specific inputs to

the care process.

Challenges to using patient preferences for health- related decisionmaking

(O connor et al., 1999; Eraker, Krischtk and Beker, 1984) = the value of

understanding and using patient preferences in healthcare decision making is well organized.
Gerteis et al., 1993= actually doing so can represented a daunting challenge to

patient.

Patents assessment of desirability of health sate or attitude tow3ard the risk can

vary substantially depending on the frame (POSITIVE ORN NEGATIVE) in which the information is presented.
In a classic study, one half of participants were asked their preference given a set

of survival probabilities POSITIVE FRAME and NEGATIVE FRAME the other onehalf were given the complementary set of mortality probabilities NEGATIVE FRAME Challenges to Using Patient Preferences for Health-Related Decision-Making The value of understanding and using patient preferences in healthcare decisionmaking is well recognized (OConnor; Eraker; Kirschtk, and Becker, 1984) actually doing so can present a daunting challenges to patients. Imagining what a future health state could be like and determining the desirability of that future state is a complex cognitive task.

Skilled interpersonal interaction can lead to an accurate assessment of an individuals preferences but the fragmented, time-limited nature of the contemporary health encounters leaves little opportunity to conduct the intense, interpersonal exploration. The determination of preferences is subject to a number of biases that result in departures from assessments that would normally be expected from rational, fully informed patients. Framing effect is the most pervasive potential form of bias in preference elicitation. Patients assessment of the desirability of a health state or their attitude toward risk can vary substantially depending on the frame in which the information is presented. One-half of the participants were asked for their preference given a set of survival probabilities (positive frame) and the other one half were given complementary set of morality probabilities 9negative frame) that conveyed the identical outcome prediction. Those who were basing their decision on survival data preferred the treatment in question less often than those who were basing their preference on morality data. Under traditional models of care which are still in common practice, patients and clinicians both presumed clinicians pre-eminence in decision making and frequently patients prefer to defer to the judgement of the clinician. PREFERENCE ASSESSMENT- an iterative, cognitive process designed to help a person understand and clarify personal values, healthcare situations, treatment options and likely outcomes, and elicit statements of preference. An INTERACTIVE ANALYSIS PROCESS is used to help an individual focus on the key components of a decision problem. RULAND (1998) demonstrated that the staff nurses can be trained to effectively elicit patient priorities regarding the focus of care, and that such elicitation can lead to improved satisfaction with care. Interactive computer system can assist in meeting the challenges inherent in accessing and employing patient preference in health care practice.

Computer packages that focus on elicitation and values clarification may serve to help patient think about complex, abstract issues such as the desirability and future states. Multimedia display use sounds, pictures and full-motion video to help patients envision future health states with greater clarity. Automated preference elicitations method eliminate the possibility of bias or variability A human interviewer and the preference obtained through automated means can be precise through the use of interactive feedback methods such as graphical displays. COMPUTER TECHNOLOGY can store and communicate assessment data gleaned through a human or computer directed analysis. The inclusion of preference information in the patients EHR allows for consideration of patients preferences at each stage of his or her treatment. An EHR is an immature field, most decision- support system application currently are standalone and their output is not integrated into care provider information system.

EFFICACY OF DECISION AIDS Decision aids for providing information regarding treatment option and health states leading to the elicitation of patient preferences have been developed to provide assistance to patients who are facing complex healthcare decisions. The goal is for decision aids to support and enhance patients ability to choose a course of treatment that is consistent with their values along each of these dimensions while simultaneously yielding optimal clinical outcomes. The Ottawa Health Research institute (OHRI) has developed a set of evaluation measures and instrument that can be used by implementers of DSS to assess their system performance along the dimensions of choice predisposition, decisional conflict ,regret ,acceptability ,knowledge ,realistic expectations, values preparation for decision-making and decision self-efficacy. Randomized control trials (RCT) that helped to provide patients make specific and deliberative choices among option by providing information on the options and outcomes relevant to a patient health.

Decisions aids have no effect on the retrospective satisfaction with the treatment decision made. The decision aids that provided more detailed information and allowed for a finer granularity of preference assessment improved both decision comfort level and knowledge.

POINTS OF DECISION SUPPORT SYSTEM INTERVENTION DSS have have been introduced at several type of intervention points. DSS are narrowly targeted to providing the patient with a level of information adequate to allow them to make informed choices and participate in the shared decision process. An emerging application of computer-based DSS is in the area of chronic disease management. The success of the management of chronic disease is characterized by the need to timely monitor patients status and their compliance with the treatment protocols over an extended period of time. The computer-based DSS can function as an intelligent disease management agent ,which can be used to remotely acquire and transmit health indicator such as heart rate and weight and can be used to prompt patients when it is time to take their medicine or perform physical therapy activities. Screening teat are used to identify latent disease. There is the potential harm ,in that psychological health may be affected by increased stress and the treatment option in the case of a false or misleading result may cause harm to the physical health of the patient. DSS has been demonstrated to be effective at assisting patients with assessment of the individual risk of having the latent disease along with understanding of the implications of the result of the test as viewed through the patients values. Computer based DSS have great potential to provide the information and reinforcement that is required to achieve changes in the chain of decisions that define an undesirable behaviour.

Acute disease decision support system

The degree of comprehensiveness of the DSS is tailored to meet the specific characteristic of the disease with regard to the level of decision that the patient is going to be called on to participate in. Types of characteristic require increasing levels of information presentation and decision support Alternatives differ greatly in their outcomes ,complications or side effects, Alternatives require trading off long term and short term outcomes. A choice or choices may result in a small chance of a grave outcome. There are any small differences in the outcomes of treatment alternatives.

It is particularly important, in this case for the DSS to provide a structured method of the joint examination of the patients preferences that result. The comprehensive health enhancement support system (CHESS) is a health promotion and support network application that operates as a module-based computer system for in home or healthcare setting use.

Chronic Diseases Management Decision Support System Computer-based DSS, have the capability to enable the patient to better monitor and treat these disease resulting in increased lifespan and QOL. The primary difference between DSS that support chronic disease from those that support singular treatment acute diseases in their extension to handle symptom management. The primary components of chronic disease DSS are: 1. Assessment-used to measure the patients health state along the key dimension to the current health state of the patient. 2. Information-used to provide information and guidance that is customized to the current health state of the patient. 3. Communication-provides an integrated mechanism for communicating with the clinician.

Email interfaces are provided that allow patients to end their health status along with any questions or comments that they have to their clinician and thus serve as a portal into the healthcare provider . Computer Link provided participants with access to an integral set of computer utilities targeting the needs of homebound patients and their family caregivers. Communication service included several public/private options:

1. An unrestricted public bulletin board, which allowed users to post by name anonymously anything that was on their minds for open, ongoing discussion. 2. Private Electronic mail, through which users could send and receive their own private electronic mail, including messages from the nurse responding to their personal healthcare inquiries. 3. Question/Answer area, in which answer to question posed anonymously by nurse moderators. PLWA choosing to analyze a decision problem using the Computer Link would first make modem access to computer Link from the home based computer terminal and then select the option Make a Decision from the opening menu. English language prompts guide the analysis. 29 PWLAs involved in the computer network experienced used the decision support tool 195 times over the course of the experiment, each session lasting less than 10 mins.

Decision Making To Promote Health Behaviour Change According to Glanz and coulleages, these proposed changes fall into three broad categories;

1. Individual change 2. Interpersonal change 3. Community change

4 Theories for individual change:

1. Health belief model 2. Stages and change model 3. Stress and coping model of change These theories focus in the individual and imply that change or the lack of it can be explained by individual characteristics.

The 3 Theories of; 1. Interpersonal health Behaviour are social cognitive 2. Social support theory 3. Patient provides communication These focus on the interaction of two or group of individual and how these interactions can promote change.

4 theories of Community or Group Intervention; 1. Community Organization 2. Diffusion of Innovation 3. Organization change 4. Communication Theory These models are helpful for leaders who want to make change in organization

Informatics and the Emergency Operative Center IMS Incident Management System -1st used by fire fighters to control disaster scenes in a multijurisdictional and ---interdepartmental manner. -calls for hierarchial chain of command led by the incident manager or commander. -also called HEICS (Hospital Emergency Incident Command System).

1999

- the VUMC (Vanderbit University Medical Center) incorporated the HEICS system in preparation for Y2K. -they adopted the organizational structure of an incident commander with 8 reports: o Planning officer o Operations officer o Logistics officer o Security officer o Public information officer o Liaison officer o Safety officer o Finance officer -For those emergencies caused by an IT threat, increased coordination is necessary between the HEOC and the IMEOC (Information Management Emergency Operations Center). During non-technology-related incidents, IT tools are needed to promote effective and efficient communication during times of crises. Furthermore, advanced modelling tools would be a helpful addition to the tool set, given that some data are known prior to an event ( like when medications from the Strategic National Stockpile should arrive).

Informatics and Volunteerism Healthcare volunteers are a necessary component of mass casualty events but also create challenges. Some states (like Colorado and Texas) offer their nurses the opportunity to volunteer when they renew their nursing licensure.

DMATs Disaster Medical Assistance teams - a system for organizing teams that are willing to travel to other regions of the country in the event of an emergency. -members of the teams are federalized or made temporarily workers of the federal government, which the assumes the liability for their services (when activated).

Medical Reserve Corps Initiative was designed to assemble healthcare volunteers who are willing to respond at their local levels; 2004. -this 2 year old program is part of the larger Citizens Corps Federal Program. NNRT National Nurses Response Team -will compromise 10 regionally based teams of 200 RNs who could be called on to assist in chemoprophylaxis or vaccination. American Red Cross has a long history of volunteerism during disaster and has education requirements for nurses depending on what roles they will play in disaster relief. Characteristics of a National Volunteer Nurses Database: Verification of licensure (can be multiple states) Record of continuing education Records of certifications Organization/s volunteering for Activation instructions Prior emergency response experience Security clearance level

The National Health Information Infrastructure (NHII) In Fighting National Threats David J. Brailer, MD, PhD was appointed as the 1st national coordinator for heath information technology.

Review the following:

International Perspectives Critical Care Applications The Role of Technology in the Medication Use Process Community Health Applications For the Lab (InformaticsTheory)