Evidenced-Based Practice Evidenced-Based Practice Using Your Palm Pilot and Using Your Palm Pilot and

Other TechnologyOther Technology

Evidenced-Based Practice Evidenced-Based Practice Using Your Palm Pilot and Using Your Palm Pilot and

Other TechnologyOther Technology

November 20, 2001

Suzanne Bakken, RN, DNSc, FAANSchool of Nursing & Department of Medical

InformaticsColumbia University

PurposePurpose

• 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 What’s the Problem in Practice?Practice?

• Avoidable errors• Under-utilization of services• Overuse of services• Gap between “best” practice and

actual practice

What is Evidence-Based What is Evidence-Based Practice?Practice?

What is Evidence-Based What is Evidence-Based Practice?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 What Data Do We Need for Evidence-Based Practice?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:Informatics Supports:Informatics Supports:Informatics Supports:

• Building the evidence• Accessing/retrieving the evidence• Analyzing the evidence• Applying the evidence

Foundation for Evidence-based Foundation for Evidence-based PracticePractice

Foundation for Evidence-based Foundation for Evidence-based PracticePractice

• 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

MotivationMotivation• 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 TerminologiesStandardized Terminologies

• Diagnoses/judgments– NANDA Taxonomy II– Georgetown Home Health Care

Classification – Patient Care Data Set– Omaha System– International Classification of Nursing

Practice

Standardized TerminologiesStandardized Terminologies

• Interventions– Nursing Interventions Classification– Georgetown Home Health Care

Classification – Patient Care Data Set– Omaha System– International Classification of Nursing

Practice

Standardized TerminologiesStandardized Terminologies

• Outcomes– Nursing Outcomes Classification – Georgetown Home Health Care

Classification– Omaha System– International Classification of Nursing

Practice

• Goals – Patient Care Data Set

Standardized TerminologiesStandardized Terminologies

System Problem/Dx Interventions Outcomes

NANDA Taxonomy 1 x

Current Procedural Terminology x

Nursing Interventions Classification x

Omaha System x x x

Home Health Care Classification x x x

International Classification of Diseases x

SNOMED Clinical Terms x x x

Nursing Outcomes Classification x

Medcin x x x

First Data Bank Pharmacy KB x x

Types and Sources of Digital Evidence

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 Standards for Healthcare Data Exchange for EBPData Exchange for EBP

• Data and knowledge representation• Messaging• Privacy, confidentiality, and security• Digital library

Informatics CompetenciesInformatics CompetenciesInformatics CompetenciesInformatics 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 Informatics-based ApproachesApproaches

• Integration of disparate sources– MedWeaver

• Task-specific information retrieval– Infobuttons

• Tailored delivery of informational and educational interventions– PatCIS

Integration of Disparate Integration of Disparate SourcesSources

Task-Specific Information Task-Specific Information RetrievalRetrieval

Tailored Delivery of Tailored Delivery of Informational and Educational Informational and Educational

InterventionsInterventions

PDA ProductsPDA Products

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

PDA Projects at Columbia PDA Projects at Columbia UniversityUniversity

•Entry to Practice Program•Nursing Informatics Subspecialty

•PalmCIS

Accessing/Retrieving Evidence: Accessing/Retrieving Evidence: ETPETP

•ePocrates medication knowledge base

•ePocrates infectious disease knowledge base

•Future – PDA interface to WebCIS through PalmCIS project

Building and Examining Knowledge from Building and Examining Knowledge from Practice:Practice:

ETP Clinical Encounter Documentation and ETP Clinical Encounter Documentation and AnalysisAnalysis• 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 Documenting Encounters with HHCCHHCC

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 CompetenciesInformatics Competencies

•Just-in-time for PDA-specific computer literacy competencies

•Informatics for Evidence-based Practice (3 units)

Nursing Informatics Nursing Informatics SubspecialtySubspecialty•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

PalmCISPalmCIS

•Palm interface to WebCIS•Web-based approach

ConclusionConclusion•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/