Using Informatics in the Clinical Setting NURS-6015, Section 3, Information and Healthcare Technologies Applied to Nursing Practice June 12, 2011 Using Informatics in the Clinical Setting Information technology, the interpretation and management of information using computers to analyze data, is not a new concept. Computers assist people day-to-day, from simple budgeting using a home computer, to larger management of government budgets and programs. The healthcare industry, especially nursing, has been slow in embracing available technology (Simpson, 2005).
Daily, nurses gather data, turn their data into information, and, analyze the information using evidence-based medicine to provide patient care. Computers provide an effective and faster way to process information, share the knowledge derived from the information, and add evidence to the nursing role (Hebda & Czar, 2009). The purpose of this paper is, to evaluate the use of informatics in my clinical area and suggest areas of improvement. Streamlining Paperwork Paperwork will always be a part of any health care industry.
As informatics evolves, we will undoubtedly find ways to omit paper records altogether. However, there are many times when providing paperwork is necessary: in discharges from hospitals or urgent care settings, visit summaries after office appointments, and for consents requiring signatures. Paperwork is also necessary, when attending meetings where discussion of reports, management of the department, and consideration of future needs of the work area or patients include many participants.
Of course, all of this information will undoubtedly end up in a database. In my clinical setting, we have electronic medical records (EMR’s), interoffice email, and instant messaging which alleviates the clutter of paperwork. Many times, before nurse planning meetings, our administrative assistant will make copies of the agenda items, and distribute them prior to the meetings. All of us have this information in our email accounts. However, when it comes time to meet about these items, we need the printed document to participate and take notes.
The nurse informaticist needs to be the leader in implementing the use of tools that are cost effective, streamline care and coordination: all without the inconvenience of clutter (American Nursing Association, 2008). One proposal is to have an overhead of the data or reports we are discussing, and participants can take notes they deem pertinent, without the waste of many paper printouts going into the trash. Communication Most people believe communication is generally two or more people talking, or people writing and receiving letters (Dobkin & Pace, 2006).
With the increasing use of informatics, primarily EMR’s, communication is evolving. In the clinical setting, we have many patients who can access many parts of their EMR online. They review lab results, send and receive messages to and from their healthcare team, and review topics concerning their diagnoses. In 2004, a part of President Bush’s State of the Union address, concerning EMR’s, made it clear that integration of a fully functioning EMR should be in place and operable by 2014 (Speedie & Davies, 2006, Suppl).
Currently, the company for which I work strives to deliver information to providers, staff and patients, which are evidence-based. By providing evidence-based care, and utilizing an EMR, the nurse can provide sound care, plan patient outcomes, receive alerts for medication management, health maintenance, and the healthcare team has current information available day or night. This is especially important in the management of patient care where multiple parties are responsible for the health and well-being of the patient (HIMSS Nursing Informatics Awareness Task Force, 2007).
Having worked for this company for ten years prior to their implementation of the EMR, I know we are moving forward in communication ability. A few years ago, after taking seriously, nurses being involved in the implementation of EMR’s, we have realized positive changes: duplication of information, medication errors related to allergies, and delay in reconciling information after hospital stays has been reduced. Clinical Resources Decision Support Tools Making decisions for patient care, as nurses, is a daily undertaking.
Now, more than ever, we encounter patients who bring information to us pertaining to their disease processes. Many times, the patient searches the Internet, looking for the answer they want to have about their health, and not the accurate answer. Management of information is critical for the nurse and, thus, the patient in order to provide quality care (Boyd & Catt, 2007). I am fortunate to work within a system of evidence-based practice and evidence-based care. Decision support tools are available for most patient needs.
Discussing reliable versus unreliable information with the patient makes the discussion easier with these tools. Patients also have access to a medical encyclopedia at the website from which they access their medical record. Unfortunately, reliable links to health information, for patients who crave more knowledge, are not available here. Having additional information links for the patient, can corroborate the information they already have, thus providing peace of mind. Seeing patients for various colds, sinus, throat and ear concerns, is a daily assignment in our clinical setting.
Standing orders for procedures, tests, and medications are available for the nurses, which are in place, because of evidence-based practice, care, and medicine. A patient, after nurse assessment for example, who meets the criteria for sinusitis treatment, receives education and medications where appropriate. The clinicians, using support tools for these purposes, delegate testing, diagnosis of the condition, and medication ordering. Decision tools regarding medications pop up on a screen to aid in choosing the appropriate treatment based on the patient’s current allergies, medications, and company formulary.
Finally, any prescription ordered, gives an alert if there is potential for an adverse outcome, for instance, regarding impairment in renal function. Informatics Aiding Patients Contribution to Patient Safety Now, more than ever, patients are becoming active participants in their health. Gone are the days where a patient would not dream of challenging a doctor’s word and patients were not consumers of health information. Patients have become consumers of health information as the Internet provides a potentially unending vat of information.
Clinicians are challenged by the scale of power leaning toward the patient (Wald, Dube, & Anthony, 2007). Informatics can assist the health care team in providing a patient with reliable resources based on their individual health needs. Nurses must engage the patient Internet consumer in accessing reliable data while not alienating or downplaying their efforts in being a participant to their health care (Hebda & Czar, 2009). Keeping the patient safe is a primary advocacy role of the nurse, and information technology adds another layer to patient supervision and education.
In my clinical setting, we have many resources and guidelines that we use to identify patient needs. Many of these guidelines have resources, other than the clinicians who write them, for our regional use. Many times, patients will call wanting to try a new medication, procedure, or a friend has made a recommendation to them regarding a particular health topic. Research shows that EMR’s have a positive effect on patient safety (Parente & McCullough, 2009). At our fingertips, in the clinic, we have the patient’s EMR, and a mass of information to assist in educating the patient.
One size does not fit all, and a patient calling because a friend told her a candy bar diet is the best weight loss program in the world, needs some intervention. While this is extreme, a diabetic patient may not take into account their dietary needs in general. When a patient voices interest and determination in starting a dangerous diet, the information the informatics team provides us with, helps to move the patient in a healthier direction. Summary Informatics is here to stay, and nurses should rejoice. Never before has so much information been available to nurses, and provided by nurses.
Communication is paramount to patient safety, and knowledge of current evidence-based plans of care will give the nursing community the voice it needs to maintain all aspects of patient care (HIMSS Nursing Informatics Awareness Task Force, 2007). Education of the patient begins with education of the nurses who disseminate information daily. EMR’s are only one part of the bigger picture of informatics. Having the clinical tools to further nursing practice and patient education can result in better patient outcomes, patient satisfaction, and nursing satisfaction.
Patients trust nurses to answer the unanswerable, find the information they cannot find, and validate their feelings regarding their state of health. Maintaining the informatics community, by nurses owning a part of the community, will strengthen our ability to care for our patients and their families by using evidence-based medicine and plans. References American Nursing Association. (2008). Nursing informatics: Scope and standards of practice. Silver Springs, MD: Nursebooks. org. Boyd, G. , & Catt, D. (2007, April). Talking IT through. Emergency Nurse, 15(1), 8-11. Retrieved from http://emergencynurse. rcnpublishing. o. uk/ Dobkin, B. , & Pace, R. (2006). Communication in a Changing World. New York, New York: McGraw-Hill. Hebda, T. , & Czar, P. (2009). Handbook of informatics for nurses & healthcare professionals (4th ed. ). Upper Saddle River, NJ: Prentice Hall. HIMSS Nursing Informatics Awareness Task Force. (2007). An emerging giant: Nursing informatics. Nursing Management, 38(3), 38-42. doi:10. 1097/01. NUMA. 0000262 926. 85304. a6 Parente, S. , & McCullough, J. (2009). Health information technology and patient safety: Evidence from panel data. Health Affairs, 28(2), 357-360. doi:10. 1377/hlthaff. 28. 2. 357 Simpson, R. (2005).
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