1. Clinical Decision Support Systems Paula Coe MSN, RN, NEA-BC NUR 705 Informatics and Technology for Improving Outcomes in Advanced Practice Nursing Dr. Charlotte Seckman Weber, S. (2007) A qualitative analysis of how advanced practice nurses use clinical decision support systems. Journal of the American Academy of Nurse Practitioners. 19. 652-667

2. Objectives  Explain study design and methods  Discuss grounded theory reflections of APN’s  Describe clinical decision support systems and technology  Explore themes derived from interviews  Implications for advanced practice nurses

3. Background  23 english-speaking, nationally certified APN’s (13-CNS and 10-NP’s)  Urban Medical Centers, Midwest, USA  Qualitative research method with semi structured interview  23 individual (1:1) interviews, approximately 1 hour  19 questions with interview guide  Free time to relate and discuss and relate stories  Pattern and use of clinical decision system in their practice

4. Clinical decision making systems  Interactive computer based system intended to identify and solve problems and make decisions.  Assist physicians and other healthcare professionals with decision making tasks at the point of care:  Diagnose  Treat  Link health observations with health knowledge  To influence health choices by clinicians for improved health care and patient outcomes

5. Can you describe any clinical decision making systems that are currently being used in your area?

6. APACHE III Acute Physiology and Chronic Health Evaluation  Measures the severity of disease for adult patients admitted to intensive care units  Point score is calculated from 12 routine physiological measurements such as:  blood pressure, temperature, heart rate  During the first 24 hours after admission, information about previous health status, and some information obtained at admission  Unit standard of practice: completion on admission and every 24 hours in critical care

7. Purpose of the Study  Grounded theory to reflect the experiences of advanced practice nurses (APN’s) working as critical care (CC) NP’s, CNS using clinical decision making system  How CC APN’s use the APACHE III system?  Degree of system utilization  Factors that enhance/detract from system utilization  Decisions appropriately assisted through technology use  Indicate the utility of system use in healthcare  Enable designers to create systems to be used and benefit all types

8. Core variable of system use  Forecasting decision outcomes  Voluntary process employed to forecast the outcomes of patient care decisions in critical care prior to actual decision making  Four user constructs identified  Categories described  Relationships identified

9. Forecasting Decision Outcomes  System learning experiences  Understanding system technology*  Create inferences from system data  Compare system derived data  Levels of trust in data

10. Subjects understanding of system technology  Positive responses  Clinical signs = system data  Increased clinical experience  Older age  Educated about the technology  Beyond current scope of immediate decisions  Chances of survival  Integrated data into clinical decision making  Negative responses  Less clinical experience  Newer APN’s  Data entry experiences  Patient needs and wants to be considered  Family and support system input  “No need to predict patients response before it occurs”

11. How do you feel about using a computerized decision support tool to assist you in making decisions about patient care?

12. Inferences from system data  Participants derived beliefs and values associated with system use, based on style of learning and understanding  Positive responses associated with: Comparing Applying Forecasting  Negative responses associated with: Decreased use of system Data entry only no use at all

13. Comparing Data  Clinicians observed the correlation to actual vs predicted events  System predicted mortality then clinicians allowed re- evaluation and questioning of decision making  Use data for including in Plan of Care  Collaboration with MD’s  Trust = Use

14. Trusting Data  Verifying data entry before “believing” data and system predictions  Double checking RN data entry  Decision to share system data with patients and family members  RN and MD developed rapport  Understanding patient preferences  Patient/Family request for objective data  Inappropriate use by third party payors

15. Factors influencing decision making satisfaction  Technical knowledge of how and why the system is to be used  Patient acuity level  # of times patient experiences aligned with professional clinical judgment  Lack of computer skills/ease of use  Classroom and hands-on experiences

16. Describe your feelings related to sharing system data with patient and families?

17. Decision Making  Confirm or substantiate APN clinical judgments  Life sustaining treatments or withdrawal  Level of Care aggressiveness  Transfer out/in to ICU  Mortality  Sharing data with family members  As specifically requested  Aids in objective data and decision making for family in difficult situations  Situations of uncertainty  Ethical Decisions

18. Summary  Ability to forecast decision outcomes prior to making decisions  Medical treatment  Family members with objective data  Experiences impacting use of the system  Positive experiences led to increased use  Trust  Education

19. Please share your views about using a clinical decision making system to make decisions about patient care?