Using Technology to Support Evidence Based Practice Dawn Dowding1,2, PhD, RN 1. Columbia University School of Nursing, New York, USA 2. Visiting Nurse Service of New York, New York, USA

Overview What is evidence based practice? Health Information Technology (HIT) How can HIT support EBP for nurses? Issues and Challenges Discussion NYONEL Annual Leadership Conference, 20 March 2017

Evidence Based Practice NYONEL Annual Leadership Conference, 20 March 2017

Traditional Implementation Time consuming Resource intensive NYONEL Annual Leadership Conference, 20 March 2017

Types of Health Information Technology NYONEL Annual Leadership Conference, 20 March 2017

How can HIT support EBP Info Buttons Bakken et al: 2008. Integrating evidence into clinical information systems for nursing decision support. International Journal of Medical Informatics:77, 413-420 NYONEL Annual Leadership Conference, 20 March 2017

How can HIT support EBP Decision Support Integration of evidence with characteristics from individual patients to provide advice or guidance during decision making Can be in a variety of formats Can support different ‘types’ of decision integrate evidence (ideally from high-quality research) with the characteristics of individual patients, in order to provide health care professionals (including nurses) with advice during decision-making can provide information and advice in a variety of formats, including paper-based guidance, more structured formulations such as decision algorithms and computerized systems Note that it is NOT providing facilities for clinicians to search for information online

How can HIT support EBP Dashboards Electronic Ventilator-Associated Pneumonia dashboard. Zayfudin et al, 2009. Implementation of a Real-time Compliance Dashboard to Help Reduce SICU Ventilator-Associated Pneumonia With the Ventilator Bundle, Arch Surg, 144(7):656-662 NYONEL Annual Leadership Conference, 20 March 2017

Dashboards NYONEL Annual Leadership Conference, 20 March 2017

Can Implementing an EHR improve outcomes? EXAMPLE: Study Aims: To examine the impact of the introduction of the EHR on nursing sensitive patient outcomes Interrupted time series design NYONEL Annual Leadership Conference, 20 March 2017

Key Findings Individual variation across different hospitals KPHC Implementation Individual variation across different hospitals Hospital 2 KPHC Implementation Firstly we analysed the data for each hospital facility in the study. We found a lot of variation in the impact of KP HealthConnect across hospital facilities for both process and outcome measures – which is illustrated by the data in this slide. This data is for the % of patients who had their risk of falling documented; the data in the first graph comes from a hospital where the introduction of KP HealthConnect had no impact on the frequency with which risk of falling was documented. In contrast the data in the second graph illustrates a hospital where the introduction of KP HealthConnect was associated with an improvement in documentation.

Key Findings Dowding D et al. The impact of an electronic health record on nurse sensitive patient outcomes: an interrupted time series analysis. Journal of the American Medical Informatics Association. 19: 615-620, 2012 NYONEL Annual Leadership Conference, 20 March 2017

Does Clinical Decision Support Improve Outcomes? Depends on the system/decision2 Impact on practitioner performance (e.g. improved adherence to guideline recommendations) Reminder systems for preventive care Computer-assisted drug ordering and dosing Impact on patient outcomes – 30% of studies Drug ordering/drug dosing Preventive care and disease management 2 Jaspers MWM et al. (2011) Effects of clinical decision-support systems on practitioner performance and patient outcomes: a synthesis of high-quality systematic review findings. JAMIA:18;327-334 NYONEL Annual Leadership Conference, 20 March 2017

Do dashboards improve quality of care?3 If used: Can improve appropriate prescription of antibiotics Increased compliance with evidence based care guidelines (specifically increased compliance with the ventilator bundle) Increased documentation of health screening information Improvements in time to report in radiology Other mixed benefits – clinicians able to find information more effectively, improvement in communication and information sharing 3Dowding et al. (2015) Dashboards for improving patient care: review of the literature. International Journal of Medical Informatics: 84;87-100 NYONEL Annual Leadership Conference, 20 March 2017

So… HIT systems can support EBP through: Improved documentation Provision of guidance to clinicians on appropriate interventions Feedback on adherence to EBP guidelines/intervention BUT There are issues and challenges with implementation… NYONEL Annual Leadership Conference, 20 March 2017

Issues and Challenges “I don’t know what the other nurses do, but that is how I do it, ah, I do my vital signs, assess them from head to toe and then when I am done at least I sit down and then do all my charting for all of them” “I put down of course, the meds I have to give and the time I have to give it. I’m not going to remember it, you know, that this patient is going to have 1400 or 1600 med without, you know without having some type of notes to look at” Dowding D et al. Nurses’ use of an integrated electronic health record: results of a case site analysis. Informatics in Health and Social Care. August 14:1-17. 2014 . NYONEL Annual Leadership Conference, 20 March 2017

Issues and Challenges “I end up almost engineering the answers, because you think ‘oh I can’t put that because it’s going to say” “and they’ll (the experienced nurses) know that’s the most suitable algorithm, because they’ve worked them for ages, so they know most of the algorithms anyway … . and they hardly need to read them even, ‘cause they are very familiar with them.” Dowding et al. Experience and nurses’ use of computerized decision support systems. Studies in Health Technology and informatics, 2009;146:506-510 NYONEL Annual Leadership Conference, 20 March 2017

Issues and Challenges NYONEL Annual Leadership Conference, 20 March 2017

Discussion Points Fit between technology and nurses’ work Role of usability testing evaluation prior to implementation ‘One size fits all’ may not be appropriate Need for informatics expertise – structured information, coding, retrieval, analysis Social and organizational factors important How do we include patient’s values and beliefs? How do we integrate patient generated data into HIT systems? NYONEL Annual Leadership Conference, 20 March 2017

NYONEL Annual Leadership Conference, 20 March 2017