Evidenced-Based Practice Using Your Palm Pilot and Other Technology November 20, 2001 Suzanne Bakken, RN, DNSc, FAAN School of Nursing & Department of Medical Informatics Columbia University

Purpose Overview of informatics framework for evidence-based practice PDA products and resources PDA projects at Columbia University –Entry to Practice Program –Nursing Informatics Subspecialty –PalmCIS

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

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

Informatics Supports: Building the evidence Accessing/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

Motivation Costing and reimbursement for nursing services Education of students Documentation of nursing contributions to patient care outcomes Development of nursing knowledge Support for evidence-based practice Inclusion of nursing terms in computer-based systems including decision support systems

“The very elements of nursing are all but unknown” Florence Nightingale in Notes on Nursing, 1859

“If we cannot name it (nursing), we cannot control it, practice it, research it, teach it, finance it or put it into public policy.” N. Lang, 1991

Standardized Terminologies Diagnoses/judgments –NANDA Taxonomy II –Georgetown Home Health Care Classification –Patient Care Data Set –Omaha System –International Classification of Nursing Practice

Standardized Terminologies Interventions –Nursing Interventions Classification –Georgetown Home Health Care Classification –Patient Care Data Set –Omaha System –International Classification of Nursing Practice

Standardized Terminologies Outcomes –Nursing Outcomes Classification –Georgetown Home Health Care Classification –Omaha System –International Classification of Nursing Practice Goals –Patient Care Data Set

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 Clinical Termsxxx Nursing Outcomes Classificationx Medcinxxx First Data Bank Pharmacy KBxx

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

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

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

Informatics-based Approaches Integration of disparate sources –MedWeaver Task-specific information retrieval –Infobuttons Tailored delivery of informational and educational interventions –PatCIS

Integration of Disparate Sources

Task-Specific Information Retrieval

Tailored Delivery of Informational and Educational Interventions

PDA Products Pharmacy knowledge bases Prescription writing Medication calculators Other sources of evidence Clinical documentation

PDA Projects at Columbia University Entry to Practice Program Nursing Informatics Subspecialty PalmCIS

Accessing/Retrieving Evidence: ETP ePocrates medication knowledge base ePocrates infectious disease knowledge base Future – PDA interface to WebCIS through PalmCIS project

Building and Examining Knowledge from Practice: ETP Clinical Encounter Documentation and Analysis How –Documentation of individual encounters Pick list of subset of nursing diagnoses and interventions Look-up database of other diagnoses, interventions, and definitions –Based on standardized terminology (Home Health Care Classification) –Upload to central database for aggregation and analysis Why –Examine individual practice –Aggregate comparisons –Tie to required clinical competencies

Documenting Encounters with HHCC Diagnosis: Chronic pain (Q45.2) Interventions Pain control – Assess (Q47.0.1)  Pain control – Perform (Q47.0.2)  Pain control – Teach (Q47.0.3)  Medication Administration – Perform (H24.0.2) Competency (observed, supervised, independent)

Informatics Competencies Just-in-time for PDA-specific computer literacy competencies Informatics for Evidence-based Practice (3 units)

Nursing Informatics Subspecialty Courses –Informatics for Evidence-based Practice (3 units) –Interactive Health Communication (3 units) –Informatics residency –Medical informatics elective Incorporation of informatics competencies throughout NP curriculum Clinical encounter documentation –Similar to ETP plus ICD and CPT codes

PalmCIS Palm interface to WebCIS Web-based approach

Conclusion Much potential Many products available Fit with workflow Issues with memory, real estate, and synchronization approaches Slides and set of links available on Informatics for Evidence-based Practice Web Page