1. Using Health Care Technology Systems
Churton Budd, RN, EMTP
Systems Analyst, III
Medical University of Ohio at Toledo
Information Systems division of Clinical Informatics

2. Objectives
How information technology has changed nursing and health care practice
How technology can reduce errors and improve efficiency and effectiveness
What technology applications are used in patient care
Why technology benefits nurses

3. Objectives (cont.) What obstacles to using technology exist
What concerns with privacy have emerged with information technology
What is predicted for the future of technology in health care

4. Information Systems
Integrated and complex automated systems consisting of networked computers to process data, answer questions, solve problems or make decisions
Seamless integration of information minimizing the need for multiple record keeping

5. Hospital Information Systems
An integrated information system used in healthcare to manage patient information
Collaborative framework
Electronic Medical Record (EMR)
Shared and integrated repository for patient demographics and billing information, orders, results, clinical documentation and images

6. State of the art HIS include
CPOE – Computerized physician (provider) order entry
Point of care devices
Expert and decision support systems
Integration with clinical equipment
Patient monitoring equipment (vents, pumps, monitors)
Point of care testing devices (glucose monitors)

7. Benefits of an HIS Reduce errors Streamline and improve efficient care
Lower costs
Improved revenue capture
Coordinate services
Improve quality of service
Improve patient satisfaction
Automate repetitive manual tasks
Make more efficient use of resources

8. Obstacles to adopting HIS
User resistance
Of the 2,694,540 licensed registered nurses in the United States. Only 9.1% of all RNs are under the age of 30. The average age of the RN population in the United States is 45.2 years. (
Average age of a physician is about 48
“depersonalization of care”
Resistance to change
False starts on IT adoption with immature systems
Systems becoming more user friendly
Widespread consumer use of computers
AC Nielson – 6/2004: over four out of five households (81%) now own at least one PC – up from 78% in 2003

9. Household use of computers by age group
Source - ACNielson

10. Management Information System – Executive Dashboard
Capture, integrate and report various financial and operational measures
Real time review of financial and operational health of an institution
Support management decisions
Improve patient care from the top level down

11. Clinical Information Systems
Collect, integrate and deliver information to the appropriate areas of responsibility
Results to the physician
Orders to the nurse
Inventory and par levels to central supply and pharmacy
Just in time stock
Match research candidates to clinical trials
Patient load and acuity to staff scheduling
Allows providers to have access to aggregate patient information that is otherwise difficult to acquire and manipulate in a timely manner

12. Clinical Information Systems – For the Nurse
Assess patient acuity and condition
Prepare a plan of care or maintain a critical path
Specify and track interventions
Document care
Observe and document outcomes
Improve quality control

13. Typical clinical system example
Patient with suspected pneumonia admitted
Sputum specimen sent to lab
(+) culture – physician alerted via automated alert to text pager or personal digital assistant (PDA)
Medication ordered by physician in provider order entry system – physician chooses the medication based on current clinical research results and statistical use by peers for same organism infecting same specimen source (evidence based medicine)
System does conflict checking with other meds the patient is on, does allergy check – reports to physician if any warnings allowing the physician to change med or override and document justification for doing so (patient safety)

14. clinical system example (cont.)
Pharmacy notified of medication order
Pharmacist gets notified of new order, checks availability of stock, ordered concentration and route, verifies order (patient safety)
Medication placed on electronic MAR
Medication delivered to floor stock to automated medication management system

15. clinical system example (cont.)
Nurse removes medication from floor stock (unit dose with barcode)
Nurse checks bar-coded ID band of patient and asks name (two method identification), verifies medication with barcode
5 R’s Right Dose, the Right Patient, the Right Time, the Right Medication, the Right Route
Delivers medication to patient
Completion of order in HIS triggers documentation in Nursing Information System

16. clinical system example (cont.)
Antibiotic peak and trough blood levels automatically ordered in laboratory system with draw times based on time of delivery of medication
Charge for medication sent to billing system
When blood drawn, lab system sends charge to billing system
Results reported to the physician on his text pager or PDA

17. Nursing Information System
Standardized nursing record
Reduces reporting workloads
Improves the quality of patient care
Standardized nomenclature
Standardized data collection
Standardized care planning
Standardized implementation of care
Standardized evaluation of care
Standardized documentation of care
Although a Nursing Information System would be part of a Hospital Information Systems, many HIS fall short of a Nursing Information Systems

18. Caring – can’t bill for it
Nursing is all about caring for a patient
Can’t describe what we do to care for a patient because of a lack of a standardized nomenclature
If we can’t describe what we do using standard nomenclature, how can we document what we do consistently
If we can’t document what we do consistently how can we bill for what we do
If we can’t bill for what we do, nobody can put a value on it

19. Nursing Nomenclature Nursing Minimum Data Set (NMDS):
establish comparability of nursing data across clinical populations, settings, geographic areas, and time
describe the nursing care of individuals, families and communities in a variety of settings
demonstrate or project trends regarding nursing care provided and allocation of nursing resources to patients or clients according to their health problems or nursing diagnoses
Stimulate nursing research through links to the data existing in health-care information systems
provide data and information about nursing care to influence practice, administrative, and health policy decision making.

20. Nursing Nomenclature (cont.)
North American Nursing Diagnosis Association (NANDA) – Nursing Interventions Classification (NIC) / Nursing Outcomes Classification (NOC)
NANDA Taxonomy II provides nursing diagnostic concepts that identify and code a patient's responses to health problems or life processes that explain variance in patient outcomes that is different than the variance explained by disease diagnoses.
NIC encompasses nursing interventions used in all clinical settings and is used at the point of care to document care planning and nursing practice.
NOC includes a comprehensive list of nursing outcomes, which provides a measurable way to evaluate the effect of nursing interventions on patient progress.

21. Nursing Information System
Provide the legal record of care
Support clinical decision making
Capture costs for billing, costing and/or accounting purposes
Accumulate a structured, retrievable data base for:
administrative queries
quality assurance
research
Support data exchange with internal and external systems

22. Monitoring / Data Acquisition Systems
Because so much data is collected in the critical care environment, documentation can be complex and time-consuming for the nursing staff
Data Acquisition Systems automatically integrate information directly from medical equipment such as cardiac monitors, invasive lines, ventilators, IV pumps
This greatly reduces documentation time and the potential for errors in transcribing vital signs and other readings
Using a data acquisition system nurses can confirm and automatically record key information from medical devices at specified intervals or on demand and insert those readings directly into the medical record

23. CPOE – Computerized Physician (provider) Order Entry
Match the physician's workflow with point-of-care clinical decision support powered by an interactive expert knowledge engine that displays clinically relevant information about a patient's condition along with treatment protocols to assist them in making the best possible decisions for patients
Provide adaptive order sets and treatment guidelines based on the role of the clinician, the patient's condition, and evidence- based clinical knowledge
The system revolutionizes the order entry process and produces real-time alerts when inconsistencies are detected, helping to improve quality of care.

24. Point of Care (POC) Devices
Allow clinicians to access information, enter orders, monitor patients and complete record keeping at the bedside or while mobile
There is growing evidence that access to medical information at the point of care can reduce costs, improve accuracy in diagnosis and treatment, reduce errors, and optimize workflow
Personal Digital Assistants in Medicine: Critical Data in the Palm of your Hand. Zafar A. Chaudry, UK Health Informatics Today, No. 45, Winter 2004, pp4-6.

25. POC devices Personal Digital Assistant (PDA)
In a recent survey of health care PDA users at MCO - top three ranked PDA applications used by survey respondents are:
Drug information applications (e.g. ePocrates)
Medical textbooks (e.g. 5 Minute Clinical Consult)
Personal calendar/address book/to do list/memos.

26. POC Devices – Tablet PC
Using the Tablet PC, healthcare professionals can be more productive with real-time access to patient information and other data, whether you are with a patient, a colleague, at your desk, or on the go.
Features:
Full Capabilities of Windows XP
Natural more intuitive computing – Pen and voice input
Minimal requirements on Memory and hard drive space
Grab-and-Go docking and “Instant On” – 30 seconds
Instant screen rotation
Active Pen vs passive pen
Wireless network connectivity
Extended Battery life and hot-swappable batteries

27. POC Devices (COW) Computer on Wheels (COW)
Enable nurses, doctors and other clinicians to wirelessly access real-time patient data in a convenient, secure, and cost-effective mobile computer cart
Healthcare professionals are empowered to access electronic medical records (EMR) from any wireless-enabled location within the healthcare facility.

28. Wireless Networks
Local Area Networks: WiFi – a, b, g, n
150 ft from access point
Mbps
Personal Area Networks: Bluetooth
30 ft from device / access point
700kps – 3mbs
Wide Area Networks: WiMax,EV-DO, UMTS
1 – 5 miles from antenna
2 – 75 Mbps

29. Radio frequency identification technology (RFID)
Wireless, automated, and secure
Ensures positive patient identification
Ensures the integrity of information between patient, host device, and/or Hospital Information System (HIS).
RFID wristband acts as a portable, dynamic database that carries patient information to be used and updated during the patient's stay
RFID helps to ensure that the "Five Rights of Medications Safety" are achieved, facilitating real-time confirmation of the Right Patient, Right Drug, Right Dose, Right Route, and Right Time
Unlike bar code, RFID's non-line-of-site data transmission can be read through and around the human body, clothing, bed coverings, and non-metallic materials.
RFID tags can be placed on medical devices such as pumps, monitors, carts, wheelchairs and other durable medical equipment to help locate and track these resources
RFID can help warn of wandering patients

30. RFID and medications
Some drug manufacturers have announced plans to use RFID technology to track the distribution of drugs particularly susceptible to counterfeit or diversion
FDA Guidelines on RFID
RFID will not be used in lieu of current labeling control systems and the tag will not obscure or alter any existing labeling information
The RFID tag will not substitute or interfere with a linear bar code
The tag will not contain or transmit information for health care practitioners or consumers
Tag readers will work at specific radio frequencies
Pfizer will place RFID tags on all bottles of Viagra;
Purdue Pharma will do the same with OxyContin and its new Palladone pain medication.
GlaxoSmithKline intends to use the technology in the next 12 to 18 months to protect at least one product from counterfeiting.

31. Biomedical Sensors
Camera Pill: Tiny ingestible video camera is not only less invasive than conventional tools for diagnosing bowel diseases but has now proven to be vastly more sensitive
WrisTASTM: device for continuous, passive monitoring of blood alcohol in human subjects transdermally (through the skin).  The sensor and instrumentation are contained in a wrist-mount configuration suitable for long-term wear.   It has applications in abstinence monitoring, treatment compliance, re-licensing, validation, alcohol abuse assessment, and alcohol treatment research

32. Targeted Medications

33. Telemedicine
Provides access to shared and remote medical expertise by means of telecommunications and information technologies, no matter where the patient or relevant information is located
Has the potential to improve the delivery of health care by bringing a wider range of services such as radiology, mental health services and dermatology to underserved communities and individuals in both urban and rural areas.
Help attract and retain health professionals in rural areas by providing ongoing training and collaboration with other health professional

34. Telehealth Remote monitoring of patients
Using wireless and internet technologies that are seamlessly integrated into everyday health monitoring devices such as a blood-pressure monitor, weight scale, and glucose monitors
The caregiver can track the patient's data, graph the results, monitor trends, annotate variances, set alert criteria, and send reminders and receive alerts via or pager

35. Patient Simulation / Virtual Patient
specially instrumented patient mannequin stands in for the patient, and real clinical equipment is used to make up the work environment
simulate accurately the patients responses in many situations such as anaphylaxis, septic shock and heart failure, producing 'patterns' of physical signs and corresponding monitor data. These include heart sounds, central and peripheral pulses, muscle twitches, breathing sounds and urine output.

36. Consumer Health Information
Consumers are better educated on issues of their own healthcare
Accuracy of online information often unknown
Consumer may be unable to interpret the information
However, consumers are more likely to be aware of research results and available therapies

37. Privacy / Security concerns
HIPAA 1996 – Security rule goes into affect April 2005
Threats: virus, hardware failure, data integrity, hacking / eavesdropping
Secure system should:
Allow only authorized users
Limit access to need to know
Ensure security, integrity, accountability, reliability

38. Nursing Informatics
Graves and Corcoran state that nursing informatics is:
"a combination of computer science, information science and nursing science designed to assist in the management and processing of nursing data, information and knowledge to support the practice of nursing and the delivery of nursing care".
Graves, J.R. and Corcoran, S. The study of nursing informatics. Image: Journal of Nursing Scholarship, Vol 21(4), 1989, pp

39. Nursing Informatics
"Today's nurses are identifying and developing new ways of using computers and information science as a tool to support the practice of nurses in the performance of their duties.
At the same time, computers and information science are facilitating a more sophisticated and expanded level of nursing practice.
There is an interactive and synergistic effect between nursing informatics and nursing practice
The boundaries of nursing informatics are contiguous with those of nursing and like them dynamic and constantly changing.“
Ball, M. and Hannah, K. What is informatics and what does it mean for nursing? In: Ball, M. Hannah, K. Gerdin Jelger, U. Peterson, H. (Eds.), Nursing Informatics: Where Caring and Technology Meet. New York: Springer Verlag, 1988, pp

40. Nursing Informatics
The work of an informatics nurse can involve any and all aspects of information systems including theory formulation, design, development, marketing, selection, testing, implementation, training, maintenance, evaluation, and enhancement. Informatics nurses are engaged in clinical practice, education, consultation, research, administration, and pure informatics
From the ANCC description of practice for Nursing Informatics

41. Informatics Nurse certification
baccalaureate or higher degree in nursing or a baccalaureate degree in a relevant field OR completed at least 12 semester hours in nursing informatics courses AND had 30 continuing education contact hours applicable to the specialty area within the last three years

42. Examination topics System Life Cycle Human Factors
System planning
System analysis
System design
System implementation and testing
System evaluation, maintenance, and support
Human Factors
Ergonomics
Software and user interface
Information Technology
Hardware
Software
Communications
Data representation
Security
Information Management and Knowledge Generation
Data
Information
Knowledge
Professional Practice, Trends, and Issues
Roles
Trends and issues
Ethics
Models and Theories
Foundations of nursing informatics
Nursing and health care data sets, classification systems, and nomenclatures
Related theories and sciences

43. Future trends in Healthcare Technology
New technology will allow Healthcare Information Technology to go places it has not gone before
Exam rooms
Patients homes
More information means we have a “movie” rather than a “photograph” on how patients are doing, thereby improving the quality of patient care by detecting changes in health status early

44. Leapfrog Group Healthcare purchasing association
The Founding “Frogs” : General Electric, General Motors, GTE, etc.
IOM 1999
44,000-98,000 deaths per year from medical errors
The Leapfrog Group’s Mission
Trigger a giant leap forward in quality, customer service and affordability of healthcare of all types by:
Making the American public aware of a small number of compelling and easily understood advances in patient safety
Specifying a simple set of purchasing principles designed to promote these safety advances, as well as overall customer value.

45. Healthcare IT in the future?
Genomics, nanotechnology, robotics
Community or Regional Electronic Medical Record
Disposable and unobtrusive health sensors
Expert based and evidence based decision support systems
Ubiquitous wireless access