Ambulatory Care Systems

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2. Diagnosis

Treatment is diagnostic- specific. The eym,ology of the word “diagnosis” is based in its Greek roots “Dia” means “through” and “gnosis” means “knowledge.” Diagnosis is dependent on the knowledge base of the person diagnosing. Disease represents the knowledge base of physicians. Human responses to illness and health represent the knowledge base of nursing. A classification of functional health and disability terms represents a beginning step toward the elaboration of a unified health professional knowledge. These knowledge bases are displayed within classification systems specifically

 Medical classifications of diseases: World Health Organization(WHO), International Classification of Disease (ICD)

 Nursing classifications of human responses to illnesses and health: NANDA Classification of Nursing Diagnoses

 Functional Health and Disabilty: the International Classification of Functioning in Health and Disability

 Bioterrorism/ Emergency Preparedness

 Emergency Preparedness and Response

Centers for Disease Control and Prevention

 Emergency Preparedness and Response

Centers for Disease Control and Prevention

 Center for the Study of Bioterrorism and Emerging Infections

Saint Louis University

# Disease/Conditions pick lists

 Diseases and Conditions

 Brain Attack: Stroke Scales

National Institute of Neurological Disorders and Stroke

 New York Online Access to Health (NOAH)

 Easy Diagnosis

 Genomics

 Specific Genetic disorders

National Human Genome Research Institute

 Unified Medical Language System

 Unified Medical Language System

National Library of Medicine

 Standardized Diagnosis Terminologies

Nursing Diagnosis Terminologies

 Clinical Care Classification (HHCC) System

 NANDA International

 Omaha System

 Surgical Information Systems (SSM) OnlineAORN’s Information Resource for Perioperative Leaders: Document Sharing Service
3. Treatment

The term treatment is used here in lieu of interventions and nursing actions, because it expresses more precisely the broad clinical management focus of the section.

 Standardized treatment terminologies : Nursing treatment terminologies

 Clinical Care Classification (Saba, 2003)

 Nursing Interventions Classification (NIC)

 Gerontological Nursing Intervention Research Center

 Center for Nursing Classification and Clinical Effectiveness Includes: Nursing Interventions Classification

 Advanced Billing Concepts (ABC) Codes for AlternativeMedicine, Nursing and Other Integrative Healthcare
 Calculators

Martindale’s Calculators Online Part I: Nutrition

 Manuel’s Web, Nursing calculators

Pediatric Critical Care Medicine

 Drug Management


o The Centers for Disease Control and Prevention

o Vaccines and Immunizations:

o More Information on Vaccines


o Drug Enforcement Agency,

o Diversion Control: Drugs and Chemicals of Concern


o Food and Drug Administration #

o Center for Drug Research and Evaluation, Food and Drug Administration

o The FDA Safety Information and Adverse Event Reporting Program, Medwatch

o Adverse Event and Product Problem Forms, Medwatch, Food and Drug Administration

o VAERS (Vaccine Adverse Event Reporting System)

 Medscape

Subscribe free and then click on “drug information after inserting drug name in search box.

 Rxlist
 Evidenced Base Practice and Treatment Guidelines

 CDC - Centers for Disease Control and Prevention #

o Diseases and Conditions #

o Sexually Transmitted Diseases Treatment Guidelines 2006

o Tuberculosis

o Core Curriculum on Tuberculosis

 NCI - National Cancer Institute

Treatment Cancer Treatment. Select from an A-Z listing.

 NGC- National Guidelines Clearinghouse

 National Heart, Lung and Blood Institute

 Guidelines for the Diagnosis and Management of Asthma

 Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults

(Adult Treatment Panel III)

 Recommendations Regarding Public Screening for Measuring Blood Cholesterol

 High blood pressure guidelines: Joint National Commission (JNC) 7:

 Overweight and Obesity Clinical Guidelines


American Academy of Family Physicians, Clinical Recommendations


American Diabetes Association, Clinical Recommendations

 ACS- American Cancer Society

4. Outcomes

Outcomes refer to standardized nursing terminologies that either present outcomes in a structured format or data sets that may be used for evaluative purposes.

 Patient Safety

Agency for Healthcare Research and Quality (AHRQ), Web Morbidity and Mortality Rounds

Institute for Healthcare Improvement
 Nursing Outcomes

o Center for Nursing Classification and Clinical Effectiveness Includes: Nursing Interventions Classification and Nursing Outcomes Classification
 Health Plan Outcomes

Health Plan Employer Data and Information Set (HEDIS®), National Committee for Quality Assurance (NCQA) 2007 HEDIS measures


eClinicalLog is a web-based clinical encounter database which is part of an educational strategy initially designed to build data entry, analysis, and synthesis skills in nurse practitioner students.
Informatics Solution for Emergency Preparedness and Response

Monica Janine Lee

The events of September 11, 2001 and the Anthrax outbreaks made the United States realize the need for adequate protection from terrorism. The initial response by the informatics community focused on contributions toward surveillance of threat detection, however, they realized that informatics could also contribute to increasing the efficiency in disaster response.
Changes in the Federal System Affecting Emergency Preparedness and Response

Federal Responsibilities for Healthcare Providers

US Department of Health and Human Services (DHHS)- responsible for the education of healthcare professionals in preparedness for emergency

  • Centers for Disease Control and Prevention (CDC)

  • Agency for Healthcare Research and Quality (AHRQ)

  • Health Resources and Services Administration (HRSA)

Presidential Directive #8 (US Department of Homeland Security [December 17, 2003])- included healthcare providers as part of the first responders; allows the healthcare community to be eligible for funding from the DHS.

New Visibility of CDC promotes Informatics Solutions

CDC- the lead federal agency for protecting the health and safety of the people—at home and abroad, providing credible information to enhance health decisions and promoting health through strong partnerships.

 Compiles statistical information to guide actions and policies

 Dr. Julie Gerberding (director)- called for changes that would strengthen organization especially in risk communication(after the anthrax attacks)

 First-Kennedy legislation funds- supposed to be targeted to the states, but were channeled through the CDC.

-designed to upgrade the failing public health infrastructure, improve emergency communication and educate healthcare professionals in emergency planning and response.

-funding for fiscal year 2005 was reduced to the states in order to channel funds to “high risk” cities.

CDC initiatives

 National Electronic Disease Surveillance System (NEDSS)- promotes the use of data and information system standards to advance the development of efficient, integrated, and interoperable surveillance systems; major component of the Public Health Information Network (PHIN)

o To detect outbreaks rapidly and to monitor the health of the nation

o Facilitate electronic transfer of information from Clinical information systems in the healthcare system to public health departments

o Reduce provider burden

o Enhance timeliness and quality of information provided

 Health Alert Network (HAN)- funded to develop capacity at the state and local levels for continuous high-speed access to Public Health information and to broadcast information in support of emergency communications

o 1999- 33 states with 3 city/county hospitals

o Now- all 50 states plus 8 US territories

 Laboratory and Response Network- established after President Clinton issued Presidential Decision Directive 39 in 1995 (outlined national antiterrorism policies and assigned specific mission to federal department agencies)

o To ensure an effective laboratory response to bioterrorism

 Division of Public Health Surveillance and Informatics- the informatics component of CDC

o To provide and improve access to and use of public health information

Role of AHRQ in Stimulating New Informatics Solutions

AHRQ- received $5 million in support for bioterrorism research in 2001; initiated projects which focus on the use of informatics and other technologies and methods to improve linkages between personal healthcare systems emergency response networks and public health agencies.

Decision Support Systems

 Integrated Delivery System Research Network- develop a computer simulation model for citywide response planning for mass prophylaxis and vaccination during bioterrorist attacks

 Researchers at Children’s Hospital of Boston- are building decision support models that would speed up reporting and enhance rapid dissemination of relevant information

 University of California at San Francisco- reviewed and synthesized available evidence on IT needs of first responder in the event of bioterrorism (findings were published by AHRQ Publication Clearinghouse as wells as by National Library of Medicine Bookshelf)

 Joint project by Boston Children’s Hospital and Harvard University- seeks to develop a prototype database and web site to facilitate clinician reporting of trends that will be used to diagnose possible bioterrorist attacks.

Syndromic Surveillance

 Detection of a disease outbreak before the actual disease or mechanisms of transmission is identified

 MPC corporation, University of Pittsburgh and Carnegie Mellon University- have undertaken a project to develop the “real-tine outbreak and disease surveillance” (RODS) system which provides early warning of possible infectious disease outbreaks.

 Prototype electronic bed –tracking tool- project developed by the MPC corporation which focuses on the use of Information systems to track and plan for bioterrorist attacks.

Helping Clinicians Respond

 Provider training and education

 Researchers at University of Alabama at Birmingham- developed modules for continuing medical education training; helps healthcare professionals identify biologic agents.

o Six biological agents (Biosafety level 4 [most deadly]): anthrax, smallpox, botulinum toxin, tularemia, viral hemorrhagic fever and the plague

 Practice Based Research Network at the Children’s Hospital in Cincinnati- developed a system which allows electronic solicitation of data using handheld devices and wireless communications

 Researchers at Vanderbilt University Medical Center- undertook a study to determine the effectiveness and efficiency of learning programs to educate nurses volunteering in their local community Medical Reserve Corps; compares face-to-face format with online version format of learning program

Role of HRSA in Promoting Informatics Educational Solutions

Bioterrorism Preparedness Program

 Aid state, territory, and selected entities in improving the capacity of the healthcare system to respond to incidents requiring mass immunization, isolation decontamination, diagnosis and treatment.

Bioterrorism Training and Curriculum Development Program (BTCD)

 Provides continuing education and curricular enhancement for practicing healthcare providers and current students

 Designed to equip a healthcare workforce to recognize indication of a terrorist event, meet acute care needs of patients in a safe and appropriate manner, rapidly and effectively alert the public health system, and participate in a coordinated response to terrorist events.
Other Changes Affecting Emergency Preparedness and Response

Competency-Based Learning and Informatics Needs

 The American College of Emergency Physicians (ACEP)- formed a nuclear, biologic, and chemical task force to evaluate the status of bioterrorism training, identify barriers to this training and offer recommendations for effective education,

◦ Cheryl Peterson (American Nurses Association)

◦ Claudia Niersbach (Emergency Nurses association)

◦ Bettina Stopford (emergency Nurses Association)

 Kristine M. Gebbie, RN, DrPH-- published the first version of competencies for all public health workers (Center for Health Policy, 2001)

 International Nursing Coalition for Mass Casualty Education (INCMCE)- international coalition of consisting of organizational representatives interested in promoting mass casualty education for nurses.

 John Hopkins University Evidence-based Practice Center- summarized existing evidence on the effectiveness of training clinicians for public health event relevant to bioterrorist preparedness.

Informatics and the Emergency Operations Center

 Incident Management System (IMS)- used by firefighters to control disaster scenes in which there is a hierarchical chain of command led by the commander; integrated in the hospital and called Hospital Emergency Incident Command System (HEICS)

 Vanderbilt University Medical Center (VUMC)- incorporated the HEICS in 199, in preparation of an incident commander with eight direct reports: planning officer, operations officer, logistics officer, security officer, public information officer, liaison officer, safety officer, and finance officer.

 Revised organizational chart for HEICS, adding the position of information management officer and physician officer to the first line management.

Informatics and Volunteerism

 Disaster Medical Assistance Teams (DMATs)- system for organizing team that are willing to travel to other regions of the country in the event of an emergency.

 Medical Reserve Corps initiative- designed to assemble healthcare volunteers who are willing to respond at their loval levels

 National Nurse Response team- comprises 10 regionally-based teams of 200 Rns who could be called to assist chemoprohylaxis or vaccination

The National Health Information Infrastructure (NHII) in Fighting National Threats

 David J. Brailer, MD, PhD-- appointed the first national coordiantor for Health Information Technology. Charged with directing health IT within DHHS and coordinating them with those of other relevant executive branch agencies.

Vendor Applications

Monica Janine Lee

There are a wide variety of software products offered by an array of diverse vendors that nurse use to plan, document, manage and evaluate patient care. “Niche” applications focus on a discrete set of nursing functions. “Departmental” systems address a more comprehensive set of functions for a single point or closely aligned group of departments.

Current Trends

New Technologies

 key goals: to improve quality of care, mobility of caregivers and collaboration among the care team

 Currently, strong emphasis s being placed on delivering technology at the point of care via bedside terminals and wireless devices

 bedside terminal access- facilitate real-time charting and eliminate end of shift charting

 Enabling technologies- speech and handwriting recognition
Historical Perspective

 Nurse executives have not widely embraced IT as a strategic business tool since they often lacked a deep understanding of the power of IT

 The nursing profession has been largely undeserved by HCIT vendors

 In healthcare debates, nursing has been essentially invisible. This is in part because nursing is the only profession that does not charge for the services rendered

 because nursing lacks a standard nomenclature and nursing data are not codified and the direct correlation between nursing interventions and patient outcomes is difficult

 Contribution of nursing to patient care has historically been undervalued and nursing initiatives underfunded

Current Situation

 since nurse executives historically did not drive most of the her purchasing criteria or decisions, systems were poorly designed

 Nursing perceptions on nursing applications

◦ Nursing is an untapped and underserved resource in provider organizations

◦ workflow inefficiencies are not well addressed by existing solutions

◦ automation is not a high priority for nursing

◦ vendors are out of sync with nursing needs

◦ some new tools have complicated nursing practice

 Root causes of poorly designed nursing applications

◦ vendor product design process driven by non-nurses

◦ insufficient nursing representatives

◦ The HCIT industry's overall woeful lack of adequate requirements definition, functional, specification and process analysis

◦ early focus on automation of the paper chart without a full understanding of nursing processes

 Primary HCIT initiatives for patient safety

◦ Computerized physician order entry (CPOE)

◦ Bar-code-enabled medication administration (BCMA)

Vendor Response

 “next generation” clinical application that:

◦ Support multi- and interdisciplinary care

◦ Promote data integrity via data validity checks and embedded tools

◦ Provide ready access to internal standards

◦ Enable evidence-based care via automation of integrated multidisciplinary clinical pathways

◦ Collect work load management data as a byproduct of clinical documentation

◦ Support productivity management, staffing and budgeting activities

◦ support process and outcomes monitoring,management and continual improvement via standard reports and database mining

◦ Support charge capture, supply management and inventory reconciliation

◦ support for medical, disease and population management
Care Flow Diagram

 a conceptual model that represents a patient-centric, interdisciplinary, inpatient-oriented view of a clinical information system that supports a fully integrated her. It includes care components that are automated in her systems as well as in niche and departmental applications

 reflects how core care components are interrelated and how clinical data are shared among multiple care providers

Key Clinical System Nursing and Multidisciplinary Care Components

Patient Access

 patient record is initiated in the admission, discharge, and transfer (ADT) system or administration of the her

 establishes a patient record and begins the clinical and financial encounter with provider organizations nurses can access patient records for all encounters with the organization and compare clinical data across multiple episodes of care.
Admission Assessments

 physicians and other health care professionals perform initial patient assessments upon admission

 advanced clinical systems support:

◦ bringing forward select data from current and prior episodes of care in the EHR, for edit and reentry (saving data entry time)

◦ Sharing of data among MD and the care team (avoiding duplicate requests fro information and services

◦ automatic referrals based on entry of specific data

◦ prompting of nurses for care plans and/or pathways based on initial diagnosis and nursing assessment data (promoting efficiencies and standard, evidence-based care)

◦ creation of separate allergies and precautions list (promoting quality of care)


 A problem list-- common set of patient-specific problems that are maintained by the MD and care team

 Any authorized care provider can add a problem to the problem list hat is then tracked by information system
Nursing and Multidisciplinary Orders and Plans of Care

Integrated Plans of Care

◦ includes all orders for all services to be provided for a patient

◦ an integrated plan of care provides a single, patient-centric, rather than fragmented department- oriented plan of care


◦ a patient management tool used by nurses to collect,organize and display summary patient information

◦ paper environment-- includes: patient's name, medical record number, admission date, diagnosis, service, attending physician, primary nurse, age and date of birth, special needs, allergies, medical alerts and all currently active orders.

◦ Automated environment-- an electronic Kardex gathers appropriate data already in the system

Workplans-- Tasklists

◦ EHR supprot generation of work plans known as task lists, as an automatic byproduct of orders and plans of care

◦ electronic medication administration record (eMar)- list of assigned medication and nonmedication related tasks

 in an EHR, results data can be viewed over time in tabular formats and graphed for display of trends

Clinical Documentation

 with an increasing number of critical care beds and monitored patients throughout the hospital, integration of monitored data in the patient record is increasingly important to HCOs

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