PolicyPolicy• is defined as a course of action that

guides present and future decisions. • Healthcare policy is established on

local, state, and national levels to guide the implementation of solutions for the population’s health needs.

• is defined as a course of action that guides present and future decisions.

• Healthcare policy is established on local, state, and national levels to guide the implementation of solutions for the population’s health needs.

Healthcare Policy and Nursing Informatics as a Specialty

• 1992- ANA recognized NI as a specialty. • 1980 - The term NI first appeared in the

literatureNursing Informatics• combination of nursing, information, and

computer sciences to manage and process nursing data into information and knowledge for use in nursing practice.

• NI-a specialty that integrates nursing science, computer science and information science to manage and communicate data, information, and knowledge in nursing practice.

• NI- facilitates the integration of data, information, and knowledge to support patients, nurses, and other providers in their decision-making in all roles and settings.

Healthcare Policy Impact onNursing Informatics Practice

Nursing Shortage and Nursing Informatics

• 2002 - HRSA’s National Center for Health Workforce Analysis found that a shortage projected for 2007 had already occurred by 2000.

• The Bureau of Labor Statistics (BLS)- is predicting registered nurse positions will increase more than 600,000 between 2002 and 2012. To cover these new positions and replace retiring nurses 1.1 million more nurses are needed by 2012.

• It is obvious this shortage will negatively impact the outcomes of patient care.

1. Schools and colleges of nursing have shortened program lengths and instituted accelerated programs for those who already hold a baccalaureate degree

2. The American Association of Colleges of Nursing (AACN) reports that in 2003 nearly 16,000 qualified applicants were turned away from entry-level baccalaureate programs primarily due to lack of faculty to supervise students.

3. Nursing organization is advocating for increased federal funding to expand programs and increase loans, scholarships, and incentives to attract more young people into nursing.

4. American Academy of Nursing (AAN) focused efforts on decreasing the demand side of nursing practice.

5. More efficient systems, including IT systems, must be created that will support care and lighten the work load of nurses.

• In 2002 the AAN Commission Workforce launched a multiphase project to develop IT that will help support nurses in their day-to-day work, thereby reducing the demands of their jobs.

• Bradley - indicated that technology solutions should improve existing care processes and outcomes, increase access through the use of portable and hand held devices, incorporate Internet capability to overcome distance barriers of care and improve access to knowledge acquisition.

• also suggested that technological devices should be developed that would “optimize the working life span” of those individuals currently in nursing.

• Sensmeier and colleagues - added that wireless technology and personal digital assistants could support nurse’s workflow by providing information at the point of care.

• These authors also advocate for using bar-coding of medications, use of speech recognition, and fine-tuning the user interface of systems to support nurses.

Health Insurance Portability and Accountability Act (HIPAA)• is intended to improve public and private health

programs by establishing standards to facilitate the efficient transmission of electronic health information

• IT must be designed to comply with Title II of the act known as administrative simplification,

• requires the DHHS to establish:national standards for electronic healthcare transactions; for national identifiers for providers, health plans, and employers; and for the security and privacy of health data.

National Agenda for Using Nursing Informatics

• The DN, HRSA, is responsible for setting national policy to guide the preparation of the nursing workforce, including preparation in the area of NI.

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Five assumptions considered by NACNEP to be a basis for all further discussion of NI initiatives:

Five assumptions considered by NACNEP to be a basis for all further discussion of NI initiatives:

• Learners are students, faculty, and clinicians.• NI must be considered within an interdisciplinary

context of partnerships and collaboration.• Efforts should target disadvantage and

underserved populations.• Initiatives should be responsive to other

government funding priorities.• Collaboration among federal agencies and

between federal and private entities is necessary.

Telehealth and Nursing Informatics

Telehealth and Nursing Informatics

Telehealth

-the use of electronic information and telecommunication technologies to support long distance clinical healthcare, patient and professional health-related education, public health, and health administration.

Influences on the Adoption of Technology

• In an optimally acute care bar coded environment, a nurse would scan his or her bar code identification badge at the beginning of each medication administration time, the patient’s bar code identification band, and the intended drug’s bar coded label with a bar code scanner.

Department of Veterans Affairs (VA) in Topeka, Kansas

• the first healthcare facilities to adopt bar code technology

• resulted in a 74% improvement in errors caused by the wrong medications being administered,

• 57% improvement in errors caused by incorrect doses being administered

• 91% improvement in wrong patient errors, and• almost a 92% improvement in wrong time errors

between 1993 and 1999.it is important for nurses to understand that technology

is a “tool” to assist them, not replace cognitive thought processes or basic nursing principles.

Computerized Prescriber Order Entry (CPOE)

barriers that lead to ineffective communication of medication orders: illegible handwritinguse of dangerous abbreviations and dose designations, and verbal and faxed orders.

CPOE • a system used for direct entry of one or more types

of medical order by a prescriber into a system that transmits those orders electronically to the appropriate department

Advantages1. Can improve quality, patient outcomes,

and safety by a variety of factors such as: increasing preventive care by encouraging compliance with recommended guidelines, identifying patients needing updated immunizations or vaccinations, and suggesting cancer screening and diagnosis reminders and prompts.

2. Can improve drug prescribing and administration by improving antibiotics or their dosages

3. Errors of omissions would be reduced, such as failure to act on results or carry out indicated tests.

4. Handwriting and interpretation issues would be eliminated.

5. Fewer handoffs if the CPOE system will be linked to information systems in ancillary departments which would eliminate the need for staff members to manually transport orders to the pharmacy, radiology department, and labs, resulting in fewer lost or misplaced orders and faster delivery time.

6. Eliminate the need for staff members in those departments to manually enter the orders into their information systems, reducing the potential for transcription errors.

7. Access to pertinent literature sources would enable ready access to updated drug information.

8. Offer a variety of solutions to help reduce the cost in providing healthcare and making more appropriate utilization of service.

9. Reductions in hospitalizations and decreased lengths of stay can be obtained from automated scheduling of follow-up appointments to reducing unnecessary diagnostic tests.

10. Costs associated with the use of transcription notes would be eliminated as well by using an electronic patient record system.

11. Lastly, there is a patient and user satisfaction.

Disadvantages1. Is not analogous to purchasing software

off the store shelf and it involves far more resources than spending money on a software package.

2. Hospitals need a minimum infrastructure to support its use such as a fiber-optic backbone network; time, space, and manpower to provide adequate staff education and development; and workstations and high-speed Internet access.

3. Unsafe prescribing practices and medication errors are still possible with these systems.

• Errors may occur due to the lack of integration between a CPOE system and the organization’s pharmacy system. Instead of medication orders electronically transferred to the pharmacy, orders would be printed on paper, which would then require order entry by another individual.

4. Errors in monitoring patient’s response to therapy can occur if the laboratory system is not interfaced with medication order entry system.

5. Error-prone process in communicating medication orders due to complex and time consuming order entry processes.

6. Computer issues such as error messages, frozen screens, slow access to information, and other issues lead to problems of accessing critical patient or drug information as well as adding to prescriber frustration.

7. Medication errors such as wrong patient error, when the wrong patient is selected from a menu list of similar patient names; wrong drug errors, when the medication is selected from a list due look-alike similarity in either the brand or generic name or orders intended for laboratory levels that are filled as medications can occur.

Bar Code-Enabled Point-of-Care Technology

BPOC can improve medication safety through several levels of functionality.1. At the most basic level, the system helps to verify that the right drug is being administered to the right patient at the right dose by the right route and at the right time. •On admission, patients are issued an individualized bar code wristband that uniquely identifies their identity.

• When a patient is to receive a medication, nurses scans their bar coded employee identifier and the patient’s bar code wristband to confirm their identity.

• Prior to medication administration, each bar coded package of medication to be administered at the bedside is scanned.

• The system can then verify the dispensing authority of the nurse, confirm the patient’s identity, match the drug identity with their medication profile in the pharmacy information system, and electronically record the administration of the medication in an online MAR.

2. Increased accountability and capture of charges for items such as unit-stock medications.

3. Up-to-date drug reference information from online medication reference libraries.

4. Customizable comments or alerts (e.g., look-alike/sound alike drug names) and reminders of important clinical actions that need to be taken when administering certain medications (e.g., respiratory intubation is required for neuromuscular agents).

5. Monitoring the pharmacy and the nurse’s response to predetermined rules or standards in the rules engine such as alerts or reminders for the pharmacist or nurse.

6. Reconciliation for pending or STAT orders (i.e., a prescriber order not yet verified by a pharmacist).

7. Capturing data for the purpose of retrospective analysis of aggregate data to monitor trends (e.g., percent of doses administered late and errors of omission).

8. Verifying blood transfusion and laboratory specimen collection identification.

Negative Effects1. Nurses were sometimes caught “off guard” by the

programmed automated actions taken by the BPOC software.

2. The BPOC seemed to inhibit the coordination of patient information between prescribers and nurses when compared to a traditional paper-based system.

3. Nurses found it more difficult to deviate from the routine medication administration sequence with the BPOC system.

4. Nurses felt that their main priority was the timeliness of medication administration because BPOC required nurses to type in an explanation when medications were given even a few minutes late.

5. Nurses used strategies to increase efficiency that circumvented the intended use of BPOC.

• Omissions: After the patient’s bar code armband and medication have been scanned, the dose is inadvertently dropped onto the floor.

• Extra dose: An extra dose may be given when there are orders from the same drug to be administered by a different route.

• Wrong drug: In situations when the nurse has difficulty in scanning medication and proceeds to scan the medication twice.

• Unauthorized drug: An order to hold a medication unless a lab value is at certain level such as an aminoglycoside (i.e., elevated gentamicin drug level).

• Charting errors: Distinguish the indication for the administration of the medication (Tylenol 650 mg every 4 hours as needed for pain or fever).

• Wrong dosage form: Certain drug shortages may force a pharmacy to dispense a different strength or concentration (mg/mL) other than what is entered in the BPOC software.

Automated Dispensing Cabinets

• The ADC is a computerized point-of-use medication-management system that is designed to replace or support the traditional unit-dose drug delivery system.

• The devices require staff to enter a unique log n and password to access the system using a touch screen monitor or by using finger print identification. Once logged into the system, the nurse can obtain patient-specific medications from drawers or bins that open after a drug is chosen from a pick list.

The rationales behind the wide acceptance of this

technology

• Improving pharmacy productivity• Improving nursing productivity• Reducing costs• Improving charge capture• Enhancing patient quality and safety

Unsafe practices• The lack of pharmacy screening of medication order

prior to administration, which negates an independent double check of the original order.

• Choosing of the wrong medication from an alphabetic pick list

• High-alert medications placed, stored, and returned to ADCs are problematic.

• Storage of medications with look-alike names and/or packaging next to each other in the same drawer or bin

• The development of “workarounds” for effective or inefficient systems can be devastating to patient safety.

“Smart” Infusion Pump Delivery Systems

• are primarily used to deliver parenteral medications through IV or epidural

• The delivery of an incorrect dose of a medication or incorrect rate of infusion of an IV solution can cause an error when programming the infusion pump.

• The common denominator in many of these and other cases was a single wrong entry or button pressed.

• The use of a ‘smart” infusion pump, programmed with patient and drug parameters, would have been able to recognize the error before the infusion even began since a practitioner would no longer have to rely on memory to determined correct dosing, or on keystroke accuracy to ensure correct programming.

Need for Healthcare Data Standards

• Data standards include “methods, protocols, terminologies, and specifications for the collection, exchange, storage, and retrieval of information associated with healthcare applications, including medical records, medications, radiological images, payment and reimbursement, medical devices and monitoring systems, and administrative processes”.

• Healthcare - is fundamentally a process of communication.

• The need for health information exchange – use electronic information and management systems.

• Data standards reduce the level of ambiguity in the communication of data so that actions taken based on the data are consistent with the actual meaning of data.those standards having to do with the structure and content of health information, it may be useful to differentiate data, information, and knowledge.

• Data are the fundamental building blocks on which healthcare decisions are based, are collection of unstructured, discrete entities (facts) when data are interpreted within a given context and given meaningful structure within that context, they become information when information from various contexts is aggregated following a defined set of rules, it becomes knowledge and provides the basis for informed action.

Healthcare Data Interchange Standards

Healthcare Data Interchange Standards

• Data interchange standards- format of messages that are exchanged between computer systems, document architecture, clinical templates, user interface and patient data linkage.

Major organizations involved in the development of data interchange standards

• Institute of Electrical and Electronics Engineers (IEEE)

• National Electrical Manufacturers Association (NEMA)

• Accredited Standards Committee (ASC) X12N/Insurance

• National Council for Prescription Drug Programs (NCPDP)

Institute of Electrical and Electronics Engineers

• The IEEE has developed a series of standards known collectively as P1073 Medical Information Bus (MIB)which support real-time, continuous, and comprehensive capture and communication of data from bedside medical devices such as those found in intensive care units, operating rooms, and emergency departments.

• 802.11 – most widely known standard, referred as the Wi-Fi

National Electrical Manufacturers Association• NEMA in collaboration with the American College of

Radiologists (ACR) and others, formed the DICOM (Digital Imaging Communication in Medicine Standards Committee) develop a generic digital format and a transfer protocol for biomedical images and image-related information.

• Joint NEMA, COCIR/JIRA and Security and Privacy Committee (SPC) issued a white paper which provides a guide for vendors and users on how to protect medical information systems against viruses, Trojan horses, denial of service attacks, Internet worms, and related forms of so-called “malicious software”.