1. 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

2. 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

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

4. 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)

5. 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

6. Informatics Supports: Building the evidence Accessing/retrieving the evidence Analyzing the evidence Applying the evidence

7. 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

8. 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

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

10. “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

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

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

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

14. 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

15. 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

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

17. 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

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

19. Integration of Disparate Sources

23. Task-Specific Information Retrieval

25. Tailored Delivery of Informational and Educational Interventions

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

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

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

40. 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

41. 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)

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

43. 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

44. PalmCIS Palm interface to WebCIS Web-based approach

45. 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 http://www.columbia.edu/itc/hs/nursing/m8120/