Evidence and Practice in Informatics

This week, we are going to look at how informatics is related to evidence and practice through an example encountered within my population program. As I mentioned in my first post, the focus area of this blog is program coordination.

Hospital and system accreditation programs are simply an outside organization assembling current evidence based practice and creating practice guidelines for a target population. That organization then sets criteria for the hospital to show that it has implemented, or has a plan to implement, these best practices. My dad used to say the certification and accreditation business was one of the most brilliant entrepreneurial endeavors. There is no product to make. Set a high standard in an Industry and have companies pay you a lot of money to tell them when they have achieved that standard. However, as we look at an accrediting organization this week, There is no doubt that there is a lot of research and technology that goes into supporting evidence based practice.

In my particular program which is a Chest Pain Center accreditation with Percutaneous Coronary Intervention (PCI) and Resuscitation Center, the American College of Cardiologists (ACC) sets mandatory, recommended, and innovative essential components to meet. Outcomes are documented and tracked throughout the set time between certifications. The time between certifications is relatively short due to the constantly changing nature of clinical evidence.  Accreditation of population based programs is in the very definition of Meaningful use.  Meaningful use is using certified electronic health record (EHR) technology to:

  • Improve quality, safety, efficiency, and reduce health disparities
  • Engage patients and family
  • Improve care coordination, and population and public health
  • Maintain privacy and security of patient health information

The current version is described as an operational model merging the latest scientific evidence with process improvement initiatives for the care of the patient suspected of having a myocardial infarction.  It combines evidence-based science, quality initiatives, ACC/AHA guidelines and clinical best-practices to produce the most effective care delivery model for LOW-RISK, Non ST Elevated Myocardial Infarction-Acute Coronary Syndrome (NSTE-ACS), ST Elevated Myocardial Infarction (STEMI) and Resuscitation. The focus of the current version is to optimize resource utilization and to improve patient outcomes. This version was engineered by a team of over 50 nationally recognized healthcare leaders with specialties in emergency and observation medicine, interventional cardiology, hospitalist, executive administration, social work, nursing, information technology, and governmental policies. The Electronic platform provided by the Chest Pain Center Accreditation Service website is a very well organized platform.  As this format has evolved through the versions, the site is set up in a way that meets the five goals of the Federal Health IT strategic plan.

One area that could be improved upon to meet the share goals of the Federal Health IT Strategic Plan would be the ability to connect directly to the electronic health record of my organization. All submissions of patient data and proof of compliance are entered manually by me. All patient data is entered in discrete drop-down format which is what gives that platform the ability to produce reports comparing almost every relationship of the data entered. The downside to that when dealing with humans, is that not every case falls into the options provided. Although labor-intensive, the consistent platform of the ACC can collect data from all healthcare organizations that are contributing patient data to this platform. Until standard terminologies are adopted throughout the country and coded throughout the world either by legislation or by consensus of the world’s healthcare leaders, the pool of data they can be drawn from at any given time to contribute to the pool of knowledge we’ll be limited. Standardization of terminologies or a more complete coding system that includes the variable naming of similar phenomenon Will need to be in place before patient generated health data can be pull directly into these larger databases.

You’re probably wondering when I was going to get to that picture that met your eyes when you first arrived. This diagram gives a visual for the System Engineering Initiative for Patient Safety (SEIPS), which is a work model. The United States Institute of medicine (IOM) had seen the benefit of bringing engineering systems into healthcare to improve patient safety.  As you can see, the work system to process outcomes could be applied very broadly at the strategic level or could be very focused. In the example I want to use today, I will take one process from the mandatory essential components of a chest pain program and look at it closer inside the work system. I think this example will also show how the same system can be applied throughout nursing practice.  This model can be initiate by an inquiry of a bedside clinician. For example, “Hey new chest pain coordinator, do we really have to get an ECG with every troponin draw?”  When a practice question is raised it is really asking the question of rationale. What was driving this action to take place to begin with? Is the action creating value for this patient? What are the obstacles to implementing the practice in the current setting.  In this case, the practice was driven by the accreditation service as an evidenced based best practice. Specifically in this version of accreditation, the timing of serial electrocardiograms (ECGs) where at least two ECGs are used to exclude dynamic changes and are performed at specified time intervals or at the conclusion of serial markers meaning a blood draw for troponin T. These may be timed with serial troponins. Serial Troponins are time sensitive draws.   As both cereal troponins and serial ECGs are preferred to identify changes, it makes sense to compare the process of each.  Lets look at this process using the SEIPS model.

This process of serial ECGs should be look at with two separate people in the center of the model: the respiratory therapist and the physician. First, we will look at the respiratory therapist as the person in the center of the work system model. Currently at my organization,the respiratory therapists are tasked with conducting all inpatient ECGs in addition to their other duties. The organization element in the model would be the organizations agreements with respiratory therapy department to collect revenues associated with ECGs. The organization has also agreed to be a chest pain center which recommends serial ECGs on rule out chest pain patients. The technology and tools available are ECG machines without Wi-Fi capability to transmit that produce paper copies only. The paper copies are then placed in the patient’s hard chart at the unit clerk station. The contents of the hard chart are scanned in buy medical records with varying consistency but usually after discharge.  The environment element what include the staging location of the ECGs that are available in relation to where the patients are. In our hospital, chest pain patients maybe in an observation unit, in MedSurg units as overflow patients, or in critical care areas. All of the elements together that were just described I have a lot of variability throughout a shift.

Now, let’s place the physician in the person element.  In this focus process, the physician has ordered ECGs to be timed with the troponin draw which is every three hours. He or she is tasked with reading the ECGs with the rationale that serial ECGs will identify changes in a chest pain patient for risk stratification. The organization’s decision to purchase this type of ECG machine could be included in the organizational element as well as the Technology and tools. The technology and tools Element will be the same is the respiratory therapist which will affect the environment element for the physician as here she will have to walk to the location of the patient hard chart to read the timed ECGs.

In contrast is the process for serial troponin levels.  Patients not having a central IV catheter have timed labs drawn by phlebotomists. When the labs are resulted they are immediately entered into the electronic medical record. In the electronic medical record, new result flags appear and the results are compared to a reference range for normal results. If the results are outside normal ranges, inappropriate icon is shown along with the results to attract the attention of the healthcare staff assign to that patient. When critical values are reached, a phone call to the nursing staff is also prompted.  The physician can view lab results from any computer in the hospital that he or she is logged into. The technology of bringing timely lab results to the physician adds value to the action of the lab draw to the patient as action can be taken in a timely manner.

By collecting data on these actions, measurements can be made and compared. Several solutions to the obstacles that are preventing the value of serial ECGs from reaching the patient. Factoring into the organizational element is the chest pain program having a steering committee that is multidisciplinary and includes decision-makers at the executive level. Larger costs Solutions can be proposed at this committee such as improving technology tools to include scanners on the units that allow the hard copy ECG to be scanned into the electronic medical record as soon as it’s obtained. Another is to purchase ECG machines with Wi-Fi transmitting capabilities that would send the results directly to the electronic medical record to be read by the physician from any computer. If time and money are limiting factors to those solutions the other element boxes would be looked at for workflow changes. One recommendation that I’ve already made is to stop ordering serial ECGs with the time troponins until of those ECGs can bring value to the patient. An ECG is already taken at the same time as the first lab draw because of on set or presentation of the chest pain patient.

Informatics technology can bring evidence based practice to the bedside in ways that weren’t achievable prior. I stated at the beginning how accreditation services are designed to bring evidence-based practice to population programs. The program coordinator  has the task of guiding the implementation of those practices and then providing measurable proof of the implementation.

Our hospital uses Elsevier clinical practice model.  Clinical practice guidelines, are used to build nursing care plans the trigger documentation requirements in the electronic medical record as well as educational goals they can also be documented.  Assessment tools can be built into flow sheet rows, that when populated, calculator score, and trigger best practice alerts. One example of clinical decision tools are in the form of a HEART score for chest pain risk stratification. Another clinical decision aid is in the use of order sets. Best practices and protocols are  placed together in an easy to use bundle of orders for the physician open. In the chest pain program, order sets are used to guide the recommended timing of the troponin lab draws as an example.

By collecting patient generated health data (PGHD) in the framework of the existing medical health record or placing new specific data points into the electronic health record to be collected,practice based evidence can be both retrospective or prospective research (Stevens, et al., 2018). Retrospective can be beneficial in gaining knowledge about how our actual practice has affected or is affecting outcome goals. When those are compared to the evidence based best practices, opportunities can be identified for improvement.  Prospective can be set up in order to measure changes in practice just like in the nursing process. But it doesn’t need to be used to always find the gap. Sometimes it can be used to find key elements that the research cannot find because of ethical or other limitations to controlled research is structured buy capturing specific elements of real life, relationships can be built. I think of the model that the authors of Crucial Conversations use in their research. They look for what they call positive deviants. In the healthcare world it would be studying organizations and programs that are highly successful and analyzing the data defined relationships between Measure data and measured outcomes to build evidence for the actions they contribute to the success of those organizations.

References linked into text except below:

Stevens, K. R., Horn, S. D., Kean, J., Deshmukh, V. G., Mitchell, S. A., & Nelson, R. (2018). Evidence-Based Practice, Practice-Based Evidence, and Health Informatics. In R. Nelson, & N. Staggers, Health Informatics an Interprofessional Approach (pp. 50-51). St. Louis, MO: Elsevier.

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4 Comments

  1. Eric your clinical focus area is definitely complex and I can see how the use of technology through informatics systems makes it possible to gather all the data from multiple sources, calculate scores and compare them to benchmarking data points, and finally to disseminate the data in order to maintain or improve performance. What I find surprising is that you have to manually enter all of the patient data information! That must be a very long and tedious process. I can see the implication for getting all of the information to be in an electronic format so that a system could pull the data points electronically and compile them for you. This would obviously be quite complex at it would require all the patient documents to come from an electronic health record.

    As you stated in your more recent blog post, you mentioned that the time between certifications is quite short. I imagine that an electronic system that could pull data points from your patient information would make this process more efficient and help you have more time to analyze your data and make changes before the next certification. It seems that the hospital might be inclined to implement your proposal, the ability to connect directly to your institution’s EHR to pull data if it meant they could gain accreditations more readily as you would have time to make changes and improve in key areas prior to the next certification term. Your proposed tool would definitely align with the concept of “building a culture of electronic health information access and use” that is discussed in the Federal Health IT Strategic Plan (“Federal Health,” 2015). Nelson & Staggers (2014) discuss that information system that is implemented in hospitals should have evidence-based practice support in addition to meeting regulations and requirements of accreditation groups as well as federal government policies.

    If you decided to incorporate a whole new subset of the EHR to help your healthcare system organize and pull data from your patient charts, these are some things to consider. Recent legislation of Health Information Technology for Economic and Clinical Health (HITECH) Act helps to promote adoption and meaningful use of new health IT. With this legislation, there have been grants set aside to help support new health IT programs within hospitals and other organizations, I’m uncertain of the requirements of these grants but it could help ease the cost of implementing a new tool into your healthcare organization (Nelson & Staggers, 2014, p. 261). I know that it may be a stretch to get a federal grant to help fund a smaller hospital health IT infrastructure but it is encouraging to see the support healthcare organizations are getting from the federal government to update our tools and incorporate necessary technology to improve our workflow and improve patient safety. Thanks for your post and I look forward to reading future posts regarding your clinical focus area and the technology that could improve its process!

    Federal Health IT Vision and Mission (2015). The Office of the National Coordinator for Health Information Technology. Retrieved from https://dashboard.healthit.gov/strategic-plan/federal-health-it-strategic-plan-vision-mission-principles.php

    Nelson, R., & Staggers, N. (2014). Health informatics: an interprofessional approach. (1st ed.) St Louis, MO: Elsevier Mosby.

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  2. Eric, this was a very informative post on how informatics can assist with collecting data for your program to monitor (and hopefully improve) patient outcomes. Now that we are a few weeks into this class, I have also had the chance to learn and reflect on health informatics and how technology can generate knowledge that leads to improved healthcare practices and patient outcomes.

    I liked your ideas for improving the process of obtaining ECG readings (either by increasing scanning capabilities within more areas of the hospital or by purchasing wi-fi capable ECG transmission devices) and thought the Staffers and Nelson Systems Life Cycle Model (SLCM) would be beneficial for helping you and your team decide if either of these routes were feasible and how to proceed with implementing them. Nelson and Staggers discuss this model in Chapter 2: Theoretical foundations of health informatics. The revised model would be more appropriate for your project because it has a few more steps that would apply to your needs scenario. The 8 steps are: analyze, plan, develop or purchase, test, implement or go-live, maintain and evolve, evaluate, and return to analyze. I found this model to be extremely helpful when considering various challenges and project ideas for my own focus area and hope you find it as helpful as I did.

    I also enjoyed reading your discussion on the need for questioning current practices and their rationale. I feel that many healthcare providers don’t question their healthcare practices enough and believe their hesitancy is only slowing down our ability to re-examine what we do and improve how we care for patients. Questioning current practices as a method of improving them is a concept that I have only more recently become familiar with as I learn more about evidence based practice (EBP) and how these practices are created and implemented within various clinical settings.

    As healthcare practices become more patient centered, it makes sense that our clinical decisions involve patient specific criteria along with EBP concepts. According to Nelson and Staggers, “the field of informatics and the concept of evidence-based practice (EBP) intersect at the crucial junction of knowledge for clinical decisions with the goal of transforming healthcare to be reliable, safe, and effective.” (Nelson & Staggers, 2014). When I read this statement, it became clear to me that we can only make the strides we want to make as a healthcare system if we are able to gather crucial data, transform this data into information, and gain knowledge through interpretation and understanding of what the data means. By applying this knowledge into our practice, we are able to gain wisdom, which is defined as “the appropriate use of knowledge in managing or solving human problems”. (Nelson and Staggers, 2014). The Nelson Model is a great way to visualize this concept and can be viewed in chapter 2 of our text. Through the application of wisdom in our clinical decision making, we can
    improve patient outcomes and the overall health of our population.

    Lastly, your examples of how the SEIPS model applies to improving outcomes at the systems level helped me understand how various aspects of a system can impact outcomes. The article by Carayon et al. discussed the need to consider the concept of balance when assessing current needs / challenges / barriers or when implementing changes because some negative elements within a system can seem impossible to overcome and yet, by focusing on positive elements that are available or possible, improvements to a system can still be made. This idea made me think of your scenario regarding the need for timed ECG’s and how this information can get to providers in a more timely manner, allowing this data to impact patient care. Your negative barriers are having an ECG machine that currently only prints hard copies and patients being located in a different area than the physician, making it difficult to update the provider on the information in an efficient manner. Your initial thought of, “why are we taking serial ECGs if they are not being seen in time to impact the patient’s care” followed by the idea of adding additional scanning equipment or obtaining wi-fi capabilities are all ways of looking at positive elements that could overcome the negative element. An additional suggestion (and probably what you are already currently practicing) would be to make copies of the ECG and have a currier (nursing assistant, health unit coordinator, or ER technician for example) hand-deliver them to the provider once available so they can view them quicker and make better clinical decisions in conjunction with the labs as a result.

    As we continue through this course, I am excited to learn how we can impact healthcare once we are providers by finding and implementing more ways to utilize health informatics in our specialty areas. I never realized how much of an impact we can make by using informatics and that by doing so, we can positively impact patient care on a broader scale.

    References:
    Carayon, P., Hundt, A. S., Karsh, B., Gurses, A. P., Alvarado, C. J., Smith, M., & Brennan, P. F. (2006). Work system design for patient safety: the SEIPS model. Quality and Safety in Health Care,15(Suppl_1), I50-I58. doi:10.1136/qshc.2005.015842

    Nelson, R., & Staggers, N. (2014). Health Informatics: an interprofessional approach. St. Louis, MO. Elsevier Mosby.

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  3. Eric,
    Great blog posts! Something I thought you did a really nice job with in your blog is that it seems like you did a lot of reflective learning when writing the blog. You made connections between the assigned reading and applied them to practice in the best way it makes sense to you to enhance your learning on the particular topic. I liked your personal definition of informatics and how you stressed a couple times throughout your posts that the technology needs to bring some kind of value to the user.
    Your second blog was very informative. In thought it was interesting that we are all learning the same materials assigned from class, most of us with little or no experience in informatics, but we apply it to our different areas of interest. It is very informative reading your blog and your implementation of the content. I thought it was interesting that in your facility respiratory therapists are assigned with the duty of conducting ECG’s. Even more shocking, I am surprised the ECG was not automatically uploaded to the EHR, for physicians to review from their work area. Frequent ECG, I think that is an interesting concept for the chest pain protocol, and do definitely do not do that at my organization or at least on the unit I work on. I would really like to know how much of an impact on patient outcomes serial ECG have. I liked your stance on questioning a process if it does not bring meaning or change outcomes for the patient. Great job Eric!

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  4. Program coordination is an area that I am indirectly familiar with. As a inpatient bedside nurse, I have had encounters with population specific programs but am not the most familiar with the origin of these programs. I look forward to learning more about your vision for program coordination in blog posts to come.

    Data collection from multiple sources and organization of that data is a complex process. I would imagine that the manual entry of patient data and proof of compliance results in a large use of your time. I think it is great how you identified technology, specifically EHRs, as a tool to help with the efficient transfer of this data. As you recognize, technology has the capability to sort and analyze this data once submitted.

    Additionally, I appreciated your application of the SEIPS model for serial troponins and ECGs. I have found it especially cumbersome to have ECG paper copies. This process frequently results in communication delays between the nurse and provider. In the new age of having Wi-Fi (literally everywhere) having the capability for a Wi-Fi transmitting ECG would be an efficient way to sync and send data to the physician and other care providers.

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