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.