Informatics and Evidence-based Practice M8120 Fall 2001 Suzanne Bakken, RN, DNSc, FAAN School of Nursing & Department of Medical Informatics Columbia University

What’s the Problem in Practice? Avoidable errors Under-utilization of services Overuse of services Variation in services Gap between “best” practice and actual practice

Ways of Knowing for Practice Tradition Authority Personal experience Trial and error Intuition Logical reasoning: inductive or deductive Systematic inquiry

What is Evidence-Based Practice? Evidence-based medicine is the practice of making medical decisions through the judicious identification, evaluation, and application of the most relevant information (Friedland, 1998)

What is Evidence-Based Practice? Traditional conceptualizations –Research utilization –Clinical trials-based –Clinical practice guidelines Application of domain knowledge to patient care –Evidence as a continuum

What Data Do We Need for Evidence-Based Practice? Information about the patient Domain information and knowledge (“the evidence”) from systematic inquiry and other sources

Informatics Supports: Building the evidence Retrieving the evidence Analyzing the evidence Applying the evidence

Foundation for Evidence-based Practice Standardized terminologies Digital sources of evidence Standards that facilitate health care data exchange Informatics competencies Informatics processes that support the acquisition and application of evidence to a specific clinical situation

Standardized Terminologies Capture patient care data in a standardized fashion Facilitate data re-use and aggregation Index information resources Facilitate information retrieval

Standardized Terminologies System Problem/Dx Interventions Outcomes NANDA Taxonomy 1x Current Procedural Terminologyx Nursing Interventions Classificationx Omaha Systemxxx Home Health Care Classificationxxx International Classification of Diseasesx SNOMED Internationalxxx Nursing Outcomes Classificationx National Health Service Clinical Terms (Read)xxx Medcinxxx First Data Bank Pharmacy KBxx

Outcomes of Interest Traditional –Mortality –Morbidity –Health services utilization Clinical phenomena (e.g., pain, decubitus ulcers) Patient health status Knowledge Caregiver Family Community

M8120 Strengths and weaknesses of existing terminologies National and international standardization efforts related to representing concepts in computer- based Unified Medical Language System

Foundation for Evidence-based Practice Standardized terminologies Digital sources of evidence Standards that facilitate health care data exchange Informatics competencies Informatics processes that support the acquisition and application of evidence to a specific clinical situation

Types and Sources of Digital Evidence Bibliographic –Primary literature –Synthesized Practice parameters –Standards of care –Practice guidelines –Disease management plans Comparative databases Knowledge bases –Diagnostic decision support systems –Pharmacy

M8120 Bibliographic sources –Primary –Cochrane Collaboration Diagnostic decision support systems Clinical practice guidelines

Foundation for Evidence-based Practice Standardized terminologies Digital sources of evidence Standards that facilitate health care data exchange Informatics competencies Informatics processes that support the acquisition and application of evidence to a specific clinical situation

Standards for Healthcare Data Exchange for EBP Data and knowledge representation Messaging Privacy, confidentiality, and security Digital library

M8120 Data and knowledge representation Messaging Privacy, confidentiality, and security

Foundation for Evidence-based Practice Standardized terminologies Digital sources of evidence Standards that facilitate health care data exchange Informatics competencies Informatics processes that support the acquisition and application of evidence to a specific clinical situation

Informatics Competencies Acquire various types of data, information, and knowledge Organize data, information, and knowledge Critically analyze and synthesize data, information, and knowledge Apply data, information, and knowledge in the clinical decision making and care provision process Use informatics-based approaches and information technologies in clinical decision making and care provision process

Basic Computer Literacy Skills Required for M8120 Assignments Access and download documents from WWW and attachments Word-processing Power point slide presentation These will not be taught in M8120! Classes available on campus.

M8120 Informatics Competencies Acquire various types of data, information, and knowledge –Retrieve EBP literature from a variety of sources (Medline, CINAHL, CliniWeb, Cochrane Collaboration) Organize data, information, and knowledge –Organize literature retrieved using a systematic approach (e.g., EndNote)

M8120 Informatics Competencies Critically analyze and synthesize data, information, and knowledge –Prognosis –Diagnosis –Clinical practice guideline –Therapy Apply data, information, and knowledge in the clinical decision making and care provision process –Evidence-based practice synthesis –Assessment of practice relevance in critiques –Expected value decision making –DXplain

Foundation for Evidence-based Practice Standardized terminologies Digital sources of evidence Standards that facilitate health care data exchange Informatics competencies Informatics processes that support the acquisition and application of evidence to a specific clinical situation

Informatics-based Approaches Patient care systems Integration of disparate sources –MedWeaver –Skolar and Skolar RN Task-specific information retrieval –Infobuttons Alerts and reminders related to practice guidelines Tailored delivery of informational and educational interventions –PatCIS –MI Heart Elicitation of client preferences Expected value decision making (decision analysis)

Patient Care Systems Electronic health records Care management (e.g., care plans, critical pathways) Ancillary systems –Laboratory –Radiology –Pharmacy

Integration of Disparate Sources

Task-Specific Information Retrieval

Tailored Delivery of Informational and Educational Interventions

Elicitation and Incorporation of Client Preferences

Standard gamble

Expected Value Decision Making

A Simple Decision Tree Operate Do not operate Disease present Disease absent Disease present Disease absent Survive Operative death Palliate Operative death U=0 Survive No cure Cure No Cure No cure Cure p=.10 p=.90 p=.10 p=.90 p=.10 p=.02 p=.98 p=.10 p=.90 p=.10 p=.90 p=.10 p=.01 p=.99 Try for the cure U=2 U=20 U=2 U=20 U=2 U=20 U=0

M8120 Electronic health records Dxplain Alerts and reminders Expected value decision making (Data 3.5) Interactive health communication