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
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
What’s the Problem in
Practice?
•
•
•
•
Avoidable errors
Under-utilization of services
Overuse of services
Gap between “best” practice and actual
practice
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)
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
Informatics Supports:
•
•
•
•
Building the evidence
Accessing/retrieving the evidence
Analyzing the evidence
Applying the evidence
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
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
“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 Terminologies
• Diagnoses/judgments
– NANDA Taxonomy II
– Georgetown Home Health Care
Classification
– Patient Care Data Set
– Omaha System
– International Classification of Nursing
Practice
Standardized Terminologies
• Interventions
– Nursing Interventions Classification
– Georgetown Home Health Care
Classification
– Patient Care Data Set
– Omaha System
– International Classification of Nursing
Practice
Standardized Terminologies
• Outcomes
–
–
–
–
Nursing Outcomes Classification
Georgetown Home Health Care Classification
Omaha System
International Classification of Nursing Practice
• Goals
– Patient Care Data Set
Standardized Terminologies
System
NANDA Taxonomy 1
Problem/Dx
Interventions
Outcomes
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
First Data Bank Pharmacy KB
x
x
x
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 Data
Exchange for EBP
•
•
•
•
Data and knowledge representation
Messaging
Privacy, confidentiality, and security
Digital library
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
Informatics-based Approaches
• Integration of disparate sources
– MedWeaver
• Task-specific information retrieval
– Infobuttons
• Tailored delivery of informational and
educational interventions
– PatCIS
Integration of Disparate Sources
Task-Specific Information Retrieval
Tailored Delivery of Informational
and Educational Interventions
PDA Products
• Pharmacy knowledge bases
• Prescription writing
• Medication calculators
• Other sources of evidence
• Clinical documentation
PDA Projects at Columbia University
• Entry to Practice Program
• Nursing Informatics Subspecialty
• PalmCIS
Accessing/Retrieving Evidence: ETP
• ePocrates medication knowledge
base
• ePocrates infectious disease
knowledge base
• Future – PDA interface to
WebCIS through PalmCIS project
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
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)
Informatics Competencies
• Just-in-time for PDA-specific
computer literacy competencies
• Informatics for Evidence-based
Practice (3 units)
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
PalmCIS
• Palm interface to WebCIS
• Web-based approach
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/