HIMSS Nursing Informatics Quarterly Webinar. Using IT to Support Evidence-Based Nursing Practice at the Point of Care

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1 HIMSS Nursing Informatics Quarterly Webinar Using IT to Support Evidence-Based Nursing Practice at the Point of Care Wednesday, June 27, :30pm central

2 Judy Murphy, RN, FACMI, FHIMSS Vice President, Information Services Aurora Health Care, Milwaukee, Wisconsin Phone:

3 Objectives Define evidence-based nursing practice. Outline the method used for developing Referential Knowledge in evidence-based nursing research. Identify the process used for translating Referential Knowledge into Executable Knowledge content in an electronic health record. Describe how Executable Knowledge is deployed at the point of care. ACW Knowledge-Based Nursing Project 2007

4 Health Care Environment Rising health care costs Increased transparency of quality results Experiments with pay for performance Nursing shortage Clinical information overload ACW Knowledge-Based Nursing Project 2007

5 So why invest in nursing? ACW Knowledge-Based Nursing Project 2007

6 Rising Health Care Costs Inefficient, ineffective use of limited, valuable resources (nurses!) Redundancy of work Access to information Information overload Wasted time Impact on nurse sensitive outcomes ACW Knowledge-Based Nursing Project 2007

Increased Transparency of Quality Results CMS Hospital Quality Incentive Project Achieve progress toward the 2007 Center goal for of Medicare being in the & Medicaid top 20% (CMS) for all Medicare

7 Increased Transparency of Quality Results CMS Hospital Quality Incentive Project Achieve progress toward the 2007 Center goal for of Medicare being in the & Medicaid top 20% (CMS) for all Medicare Premier (CMS) CHF pay-forperformance measures and in the upper quartile CHF Measures: for all Premier clinical performance Measures: measures by achieving above median performance for each one of these measures by year-end LVF assessment LV assessment ACE-inhibitor medication (LV Systolic Dysfunction) ACE-Inhibitor use during IP stay Detailed discharge instructions including weight, activity, diet, followup, medications & instructions if symptoms worsen Atrial fibrillation patients are treated with Warfarin Smoking cessation advice counseling Readmission rate Top performer Bottom performer Mortality ALOS ACW Knowledge-Based Nursing Project 2007

8 ACW Knowledge-Based Nursing Project 2007

9 Experiments in Pay for Performance Requires rapid and ongoing improvement in our processes and their impact on outcomes Requires ability to capture data for process and outcomes measurement Must identify how nurses influence outcomes ACW Knowledge-Based Nursing Project 2007

10 Workforce Shortages ACW Knowledge-Based Nursing Project 2007

11 Clinical Information Overload Thousands of professional journals Tens of thousands of articles published each month 10,000 new Randomized Clinical Trials introduced in literature each year Dramatic increase in healthcare research, including nursing research ACW Knowledge-Based Nursing Project 2007

12 ... Facing the Facts While 64.5% of nurses report needing information weekly or more often, only 26.7% have received training in using tools to access evidence, and only 11% actually search for information from evidence. (Pravikoff, Pierce, and Tanner, 2005) Nurses draw on experience rather than research evidence in day to day decision making. Nurses need information in real time at the point of care if we are to influence their actions and the care the patient receives. ACW Knowledge-Based Nursing Project 2007

13 ... In Contrast Evidence-Based Nursing Practice calls for nurses to question their practice looking for reliable evidence to improve specific outcomes rather than doing things as they have always been done. The goal is to achieve the highest levels of patient safety and health care outcomes. National Quality Forum, 2003 ACW Knowledge-Based Nursing Project 2007

14 How Can Technology Help? Information systems designed to capture nurse process and outcomes variables are essential to nurses having the data to make a convincing case that nurses ensure patient safety and high quality care. Aiken, April 2004, AONE ACW Knowledge-Based Nursing Project 2007

15 The Advisory Board Company, ACW Knowledge-Based Nursing Project 2007

16 The question is What is the best way to do the dissemination to facilitate use and acceptance by nurses at the point of care? and how to incorporate Push vs. Pull opportunities ACW Knowledge-Based Nursing Project 2007

17 Aurora/Cerner/UWMilwaukee Partnership Identify nursing actions that contribute to best outcomes from evidence in research literature, in Aurora research, and from Aurora current practice. Embed evidence-based content into automated care planning and documentation tools to influence clinical decision making at the point of care. Evaluate the impact and add to the body of evidence. Shorten the time from research to practice. Aurora Nursing expertise and care delivery setting Cerner Application Solutions, Knowledge Tools UWM Research expertise ACW Knowledge-Based Nursing Project 2007

18 Knowledge-based Nursing Initiative Goal Identify Best Nursing Knowledge Develop and Use Referential Knowledge Develop and Use Executable Knowledge Determine and Improve Nurses Contribution to Patients Outcomes through the Enhanced Use of Clinical Information Systems ACW Knowledge-Based Nursing Project 2007

19 Knowledge-based Nursing Initiative Process Select phenomenon of concern Activity/Exercise Medication Generate Referential Knowledge Gather evidence Research articles National guidelines Existing patient care documents (IPOCS, order sets, teaching records, protocols, etc) Quality measures/indicators Standards from professional organizations Review literature Analyze each reference Make evidence table with ranked strength of evidence Synthesize evidence Transform to Executable Knowledge Patient Assessments Nursing Diagnoses Nursing Interventions Nurse-Sensitive Outcomes Using standardized classification systems (e.g., NANDA, NOC, NIC, Omaha systems Using standardized languages (e.g., ICNP, SNOMED) Integrate Knowledge into Automated Systems (EHR) Integrated Plans of Care Documentation Alerts and Reminders Links to referential knowledge ACW Knowledge-Based Nursing Project 4/06

20 5. Add to Nursing Evidence 1. Generate Referential Knowledge 4. Evaluate Impact Through Outcome Evaluation & Research Knowledge-based Nursing Initiative Cycle 2. Transform to Executable Knowledge 3. Integrate into Automated System (EHR) ACW Knowledge-Based Nursing Project 2007

21 Evidence-Based Decision Support Process using EHR Integrated Healthcare System Executable Knowledge Referential Knowledge Electronic Health Record (EHR) System (Care Planning/Documentation/ Decision Support) Clinical Knowledge Management Patient Assessment Nursing Diagnosis` Nursing Intervention EHR Repository Nurse- Sensitive Outcome Research QI Care Mgt Standardized Language Management (CMT, SNOMED-CT, ICNP) Data Warehouse ACW Knowledge-Based Nursing Project 2007

22 Gathering & Displaying Referential Knowledge Research Question Study aim or purpose; Explanatio n of why study was done Research Design Brief summary of key aspects of study design: 1. Study design (RCT, case/contro, cohort, qualitative, etc.) 2. Sample size & population characteristic 3. Measures used (validity /reliability noted) 4. Data analysis used Inclusion/Exc lusion criteria noted Variable/ Measures Major independe nt & dependent variables; Structure, process, outcome variables; Definition s Key Findings Key findings reported by researchers (identify findings that apply to ACW work) Study Conclusion Author summary of study summary points Level of Evidence (M & F) Evidence Grade I- VII - refer to M & F reference Application Diagnosis/ sensitive Patient Assessment Nursing Nursing Nurse- Diagnosis Problem Intervention Sensitive ID Outcome Outcome Key Key findings Study findings applicable reported apply to for nursing outcomes, patient. intervention including assessment s indicated metric, as reported by the study calculations by the findings for metric, author or definition for indicated outcome by the variable, study predictors if finding concluded Indicate if explicit in study what aspect of nursing problem is affected by the study findings (e.g. knowledge deficit, adherence, or therapeutic regimen; Utilize standard nursing language but do not be limited if n/a Future Conside rations Parking lot for ideas triggere d by study that merit futher explorat ion or discussi on Topic Cue Column to capture key topics in citation (Sortin g topics for later use) * Level of Evidence: Utilize Melnyk & Fineout- Overholt (2005) Rating I ~ VII ACW Knowledge-Based Nursing Project 2007

23 Synthesis Step Assessment Problem Identification Interventions Outcomes Medication History/Reconciliation - Functional/Cognitive/Mental/Sensory - Typical routine - Previous experience - Med & dosing facts - Medication Refill plan Medication Knowledge - Frequency, dosing, name, purpose, self adjustments, side effects, special instructions, when to call/who to call, - Health literacy Medication Behaviors Medication complexity - # Drugs - Instructions - # Doses/frequency - Special instructions Barriers: - Pt. perceived - Provider determined - Access - Cost - Transportation Medication Problems - Omissions - Dosing/timing - Wrong reasons - Not renewing - Side effects - No refill plan Med Knowledge Deficit Med Knowledge Non- Adherence Self-Care Deficit Knowledge Deficit Ineffective coping Medication Adherence effective ineffective Support system in place or not Patient s Belief regarding their Condition & Meds Ineffective Therapeutic Regimen Barriers Identified Source of Med. Problems identified Barrier specific Self-administer meds Provide patient education Medication Knowledge adequate for plan Home based med plan Reduce or eliminate barriers Patient s results Med knowledge adequate for plan Self administration of medications effective Med Complexity simplified to extent possible Reduced Barriers Reduced or eliminated med. problems ACW Knowledge-Based Nursing Project 2007

24 Posting Synthesized Knowledge on Web ACW Knowledge-Based Nursing Project 2007

25 Transforming the Knowledge from Referential to Executable Referential Knowledge Generation Referential Knowledge Synthesis Actionable Knowledge Tools Design Knowledge Development Team Executable Knowledge Tools Build Outcome Evaluation & Research Current State Data Identify standardized clinical terms. Refine PoC Gather current evidence (literature) Identify any required outcome indicators Gather current state clinical data Gather current state CIS data; begin gap analysis Create Evidence Table (1) & Tool Comparison (2) w/ translation to nursing process Develop Summary Synthesis Table w/ Key Recommendations (3a) Create draft Synthesis Document (3b) Complete Search Strategy Document (4) Create draft Clinical Process Workflow (5) Identify draft Outcome Indicators for PoC (10) Validate with AHC clinical nurses Review w/ team Revise & complete final Synthesis Document (3b) & Clinical Process Workflow (5) Sign-Off Aurora Forward practice recommendations to ASNA Practice Council Create Clinical Spreadsheet (6) Develop Standardized Clinical Terminology Table (7) Complete CIS gap analysis Post evidence & tool comparison table on CKM web (1a, 2a) & UWM website (1b, 2b) Convert Synthesis Document & post on CKM web (3c) & UWM web (3d) Cerner Design orders, plans, rules/alert, documentation screens - Cerner Build Clinical Spreadsheets Build content w/ links Complete concept mapping in CMT Validate content/design - Screen Builds (8a) Sign-Off Roll out EK content 9a Collaborate Determine final Outcome Indicators for PoC (10) Develop outcome retrieval & analysis plan --Outcome Metrics Table (11a) & AHC s (11b) Pilot Test w/ Clinicians Aurora Identify differences between Cerner builds & current forms/function in CIS Build & modify screens to embed content as applicable Validate Aurora Screen Builds (8b) Roll out EK content at point of use (9b) Outcome Data ACW Knowledge-Based Nursing Project 2007

26 Moving the Knowledge into Practice ACW Content Aurora Practice Council Is Standardization Still Needed? Yes Aurora Standardization Groups Content Is Yes Nursing Approval Needed? Nursing Research Content No No Paper Forms Existing Paper IPOC Content IS Work Team Aurora Expert Best Practice Review Prototype or Design Document Review Production Implementation Cerner Database (Aurora) Extract Oracle Data Warehouse Data Mining for ACW or other Research Data to Premier Data to CMS ACW Knowledge-Based Nursing Project 2007

27 Process for Integrating & Standardizing Existing Paper IPOC Content All Sites/Regions ACW Content Reconcile Duplicates and Variances Base Content for Review Aurora s Standardized Care Plan Research Aurora Expert Best Practice All Sites/Regions Edit out or include as Notes Non Actionable Items Non Informative Items ACW Knowledge-Based Nursing Project 2007

28 Example #1 of Executable Knowledge Tools Medication Adherence Process Flow Assessments leading to Problem Identification - Evidence Links and Referential Information Addition and Customization of Plan of Care - Evidence Links and Referential Information Documentation of Interventions - Evidence Links and Referential Information ACW Knowledge-Based Nursing Project 2007

30 Example #1 of Executable Knowledge Tools Medication Adherence Assessments leading to Problem Identification - Evidence Links and Referential Information ACW Knowledge-Based Nursing Project 2007

31 Newly admitted patients will have tasks for completion, accessible via the Patient Access List (PAL).

32 Screen for Medication Adherence issues on admission. Right click in field to access option to review Reference Text indicated with (ref) at the end of a question.

33 The user can click on the hyperlink to access additional referential information. Reference text will assist the clinician in asking evidence based questions to obtain accurate information for assessment.

34 Hyperlink from previous slide.

35 Second question with detail to document specific information is conditional to response of Inaccurately on first question. Response of Inaccurately triggers alert for problem notification. Response of Effectively with assistance or Ineffectively triggers alert for problem notification.

36 Alert appears after the documentation is completed and signed by the clinician. The problem is automatically added to the Problem List at this time. If the clinician desires to change the status or remove it, this will need to be done in the Problem List.

37 Problem defaults as Active.

38 Example #1 of Executable Knowledge Tools Medication Adherence Addition and Customization of Plan of Care - Evidence Links and Referential Information ACW Knowledge-Based Nursing Project 2007

39 Selecting the problem will lead to display of plan/s that are associated to the problem.

40 Plan is not yet initiated on the patient. Outcomes are pre-selected and displayed at the top of the plan. The plan of care can be selected and pulled in for review and customization.

41 Some interventions are pre-selected and others are left for the user to select as appropriate.

42 Evidence link at the plan level.

43 Evidence link to from plan takes clinician to referential information about potential interventions to support Medication Adherence.

44 Evidence links from interventions.

45 Evidence links on reminder notes.

46 Plan signed, ready for implementation.

47 Tasks are generated from the plan of care and populate the PAL and Task List.

48 Example #1 of Executable Knowledge Tools Medication Adherence Documentation of Interventions - Evidence Links and Referential Information ACW Knowledge-Based Nursing Project 2007

49 First Intervention in Process Flow for Medication Adherence is to Assess Functional Status

50 Second intervention in Medication Adherence Process flow is to assess the Patient s Perception of their Chronic Illness and ability to manage it, identifying knowledge needs.

51 Reference text provided to support clinician assessment.

52 Evidence Link to provides additional referential information.

53 Key intervention to begin path toward improving Medication Adherence. Pertinent history results available for nurse review to provide context for focused assessment. Evidence Link & Referential information available

54 Reference text provides the clinician with a summary of information supporting Medication Adherence Assessment key factors. Evidence link to provides additional referential information

55 Referential information providing further explanation of evidence supporting Medication Adherence Assessment.

56 Conditional fields direct the clinician to explore detail in specific areas.

57 Completion of Assessment

58 Education history (knowledge needs and teaching completed) provided to assist clinician with current needs and follow-up teaching.

59 Chronic Illness education topic list.

60 Documentation of discharge planning done with patient to assist with support of medication adherence at home.

61 Clinician can document other education in same session if appropriate. Outcomes documented here will be indicated as met or not met on the Plan of Care.

62 Outcomes documentation from Intervention documentation reflected in Plan. Top row displays most recent outcome status. Expand rows for detail of previous documentation.

63 Non-scheduled Interventions are documented in the plan.

64 Non-Scheduled Intervention documentation Variance Reason and Action documentation

66 Other EBNP that we re automating: Activity Tolerance Risk for Falls and Post-Fall Skin Integrity - Screening for Risk with Braden Skin Score - Pressure Ulcer Prevention Protocol - Standard Plan of Care for Potential/Actual Skin Breakdown Risk for Delirium and Delirium Depression Moderate Sedation Monitoring Fluid Overload Venous Thromboembolism Discharge Readiness Risk for Infection peripheral and central lines Risk for (and Actual) Infection urinary tract ACW Knowledge-Based Nursing Project 2007

67 Acknowledgments Norma Lang, UW & Aurora Distinguished Professor, Project Director Aurora Health Care Cerner Corporation University of Wisconsin- Milwaukee Sue Ela Mary Hagle Mary Hook Judy Murphy Philip Loftus Beth Johnson Flo Mielcarek Lynn Germanson Amy Olson Nancy Kalivoda Patrick Falvey Kathy Skowland Mary Cieslak-Duchek Paul Gorup Charlotte Weaver Roy Simpson Karen Berg Deb Wentzel Sharon Massa Tera Watkins Nancy Fahey Mindy Yin Cindy Stafford Lori Stafford Fran Pivoka Gerald McGinnis Sally Lundeen Mari Akre Amy Coenen Tae Youn Kim Karen Marek Rachel Schiffman Beth Ann Swan Lenore Wilkas Beth Fahlberg Maureen Greene Woi Hyun Hong Julie Larsen ACW Knowledge-Based Nursing Project 2007

68 ACW Knowledge-Based Nursing Project 4/06

69 If you re looking for what differentiates the Aurora Nurse from other nurses - this is it Suzanne Williamson, RN Staff Nurse, Aurora Medical Center-Lakeland ACW Knowledge-Based Nursing Project 2007

70 Questions? ACW Knowledge-Based Nursing Project 2007

Driving Patient Care with Evidence-based Professional Practice Mary L. Hook, PhD, APRN, BC

Automated Care Planning: Driving Patient Care with Evidence-based Professional Practice Mary L. Hook, PhD, APRN, BC Program Objectives: Review the basic tenets of professional nursing. Describe how to