Module 4: Clinical Information Systems

Introduction

Earlier you learned that information systems include hardware, software, procedures and data and that they are used to provide the information necessary to run health care organizations. In this module we will take a closer look at the notion of information systems more specifically designed or developed for use in the clinical setting.

Reading Activities

(Australia):Hovenga, E., Kidd, M. & Cesnik, B.(1996). Health informatics: An overview. South Melbourne: Churchill Livingstone, pp.133-173; 239-250.
(US): Hannah, K. J., Ball, M. J., & Edwards, M. J. A. (1994). Introduction to nursing informatics . New York: Springer-Verlag, pp. 45-94.

Additional activities & suggested reading will be noted throughout the topical outline and are intended to facilitate your ability to participate in the discussions.
 

Objectives

After working through this module you should be able to:
i) describe the different information systems and applications that are currently used in the clinical setting.
ii) discuss the implications of the nursing minimum data set.
iii) using the nursing process as a framework for providing care, describe how clinical information systems might facilitate the provision of care.
iv) select a clinical information system and review one or two web sites and evaluate the information they provide about their system in terms of desirable features for nursing practice.

Topics

    Information systems in the clinical setting
        Electronic medical records
        Point of care systems
        Decision support systems
        Image management/communications technologies
        Telemedicine
        Computer based education for patients/clients and staff
 
    Nursing's Minimum Data Set

    Information Management in special clinical settings

        Issues related to clinical information systems
        Selection
        Usability
        Privacy, Security and Confidentiality
        Safety and workplace design
 

Information systems in the clinical setting

Early health care information systems (HIS) were made up of separate application, mostly designed to communicate information related to financial, administrative and order entry functions between hospital departments. As software and hardware have evolved, today's HIS include the functions just mentioned as well as more integrative clinical and communication functions.

Activity:
Consider how you have thought about using information sytems/computers in providing care and list what you think the current barriers and benefits are to using them in practice. Make a list of 2-3 benefits you have experienced or think might be a benefit of using computers in practice and then list 2-3 barriers to using them in practice.

Interaction:
Share your list of benefits and barriers on the Discussion Forum. Are they similar to your classmates? Where are the differences? Have you or your classmates identified unique  issues?

Suggested Reading:
Bowles, K. H. (1997). The barriers and benefits of nursing information systems. Computers in Nursing, 15(4), 191-196.

WWW:

Check out this site for a list of the different kinds of healthcare information systems. Select one and review the site using what you have learned about evaluating web sites.

http: //www.vwo.com/hcis.html

Electronic medical records

One of the first clinical information systems that comes to mind is the patient record. Electronic medical records have been evolving to provide timely, accurate patient information readily available to the health care team. Implementation of these systems has been hampered by a variety of issues including data processing capabilities, lack of standard languages, cost of hardware and software and clearly defined information structures.

Suggested reading:

Andrew, W. F., & Dick, R. S. (1995). Applied information technology: A clinical perspective, Part 1. Computers in Nursing, 13(2), 80-84.
Andrew, W. F., & Dick, R. S. (1995). Applied information technology: A clinical perspective, Part 2. Computers in Nursing, 13(3), 118-122. (Contains the IOM recommendations for an electronic medical record).

Activity:
Review the IOM recommendations for a robust electronic medical record, pp. 119-120 from part 2 of the Andrew and Dick article.

Interaction:

After reviewing the 12 attributes that the IOM recommended (cited by Andrew and Dick in the Part 2 article), where do you see the medical records that you have worked with in terms of meeting those criteria? If you are not working with electronic medical records, can you use those same criteria to evaluate a paper based record? Share 1-2 of your experiences, observations or thoughts with your classmates on the discussion forum.

Point of Care Systems

Point of care systems (POC) have evolved in the last decade or so to be the answer to timely, efficient data collection or capture. These systems can take a variety of configurations and will change dramatically as the hardware and technology get more and more compact.

The early point of care systems were simply the stationary computer terminal at the bedside or available for a cluster of patients nearby where the care was given. Today there are a several configurations that include hand held devices or laptop computers. When an organizations is considering a clinical information system, the hardware is an important consideration particularly around the hardware since it will either be something the nurse carries around with them or it will take up space in already spaced deficient patient care areas.

The goals of these systems are generally said to include:
1. decreasing the time spent in documenting patient care.
2. eliminating inaccurate and duplicate charting
3. improving the timely availability of data and information
4. improving access to the information
5. providing information and support to the clinician to help them make the best decision for care

Suggested reading:

Andrew, W. F. (1994). Point-of care-systems review. Healthcare Informatics, 11, 33-48.

Decision Support Systems

Decision support systems are aimed at supporting the clinician in decision making. Although some people would like to think that these systems can take the place of clinican's in some areas so that personnel costs can be reduced, the reality is that with current knowledge about these systems the best they can do is to support the care provider. They can provide this support in 3 different ways:

1. by providing formatting tools that help to organize, categorize and manipulate data;
2. by allowing the manipulation of the data from the formatting tools based on weightings that help to determine priorities and likelihoods of outcomes
3. by suggesting courses of action for a particular problem or issue( expert systems).

Components of a decision support system include: a knowledge base; an inference engine; a patient database; and user friendly interfaces. Integrating all of these components into a system for nurses requires an understanding of how nurses think and process information to do nursing care. Critical to to developing effective support systems is understadning the component of the system and the interface between the system and the nurse.

Suggested Reading:
Brennan, P. F., & McHugh, M. L. (1988). Clinical decision-making and computer support. Applied Nursing Research, 1(2), 89-93.

Ozbolt, J. G., Schultz II, S., Swain, M. A., & Abraham, I. L. (1985). A proposed expert system for nursing practice: A springboard to nursing science. Journal of Medical Systems, 9(1/2), 57-68.

Activity:

Thinking about decision support systems, what types of decisions, problems, issues and in what kinds of patient care situations could you see a decision support system being useful?

Nursing Minimum Data Set

Embedded within the framework of the electronic medical record is the development of a standardized language to represent nursing care and nursing. Werley suggested that the Nursing Minimum Data Set (NMDS) would facilitate comparibility across settings, populations, etc.; facilitate research; provide a framework to describe care and allow for the monitoring of trends. Health care today is strongly focused on evaluating patient outcomes for effectiveness. This activity has been difficult because different terms, phrases, etc are used interchangeably by nurses and other health care providers for the same thing.

Work on these taxonomies and classification systems has progressed to the development and testing of several systems in nursing. Example of these systems include: NMDS; Nursing Intervention Classification; Nursing Outcomes Classification; Nursing Intervention Lexicon and Taxonomy; Omaha System and Home Health Classification Method.

Suggested readings:

Werley, H. H., Devine, E. C., Zorn, C. R., Ryan, P., & Westra, B. L. (1991). The nursing minimum data set: abstraction tool for standardized, comparable, essential data.  American Journal of Public Health, 81(4), 421-426.

Grobe, S. J. (1996). The nursing intervention lexicon and taxonomy: implications for representing nursing care data in automated patient records.  Holistic Nursing Practice, 11(1), 48-63.

Whitley, V. G., & Gulanick, M. (1996). Barriers to the use of nursing diagnosis language in clinical settings. Nursing Diagnosis, 7(1), 25-32.

WWW:

http://www.nursing.uiowa.edu/nic/
Webpage with information about the Nursing Intervention Classification. Includes list of classifications.

http://www.nursing.uiowa.edu/noc/
Webpage with information about the Nursing Outcomes Classification.

Activity:

Select an activity that you have done to provide care for a patient. Is it represented in the NIC classification (refer to the website above)?  Select one of the aspects of the care (for example, explaining handwashing to the patient). Briefly outline what you would tell the patient. Ask one of your classmates to do the same thing and compare your lists. In this example how would a standardized terminology or process improve the care that the patient receives? How would it facilitate determining if handwashing was a critical element to achieving the overall outcome for a patient that needed this skill in order to get well?

Additional References

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