Medical Informatics Standards Applicable to Emergency Department Information Systems: Making Sense of the Jumble

The adoption of medical informatics standards by emergency department information systems (EDISs) is not universal, despite obvious benefits. Clinicians and administrators looking to obtain an EDIS need to know exactly what the various standards can do for them and how the systems they depend on can be integrated and extended. In addition to the standard methods for systems to communicate (chiefly Health Level 7 [HL7]) and those required for submission of claims (Current Procedural Terminology [CPT]-4, International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM], and X12N), there are several other available standards that are clinically useful and can greatly improve the ability to access and exchange patient information. Major advances in the Unified Medical Language System of the National Library of Medicine have made the patient medical record information standards (Systematized Nomenclature of Medicine [SNOMED], Logical Observation Identifiers, Names, and Codes [LOINC], RxNorm) easily accessible. Detailed knowledge of the arcana associated with the technical aspects of the standards is not needed (or desired) by clinicians to use standards-based systems. However, some knowledge about the commonly used standards is helpful in choosing an EDIS, interfacing the EDIS with the other hospital information systems, extending or upgrading systems, and adopting decision support technologies.     

Computerized clinical decision-support in respiratory care

Computers were initially used in health care for billing and administrative functions. More recently computers have been used to present clinical information such as laboratory results and pharmacy orders. Many medical informatics researchers believe that the ultimate goal of the "electronic health record" should be to advance computerized clinical decision-support. This report considers the challenges of developing electronic-health-record systems and integrating them into useful computerized decision-support systems and presents a "pyramid of progress" concept that involves 5 steps: (1) to gather electronic health data into a standardized and coded format, (2) to validate the quality of that electronic health data, (3) to optimize presentation of electronic health data and explore computerized decision-support, (4) to develop and share computerized knowledge bases that are based on clinical evidence as well as consensus, and (5) to tailor and to implement the computerized strategies so that they fit into the workflow process of patient care. This report discusses 3 examples of successful computerized clinical decision-support (use of antibiotics, laboratory alerting, and ventilator management) and discusses strategies essential to making computerized clinical decision-support more widely available and useful.     

Health informatics

Health informatics is the development and assessment of methods and systems for the acquisition, processing and interpretation of patient data with the help of knowledge from scientific research. This definition implies that health informatics is not tied to the application of computers but more generally to the entire management of information in healthcare. The focus is the patient and the process of care. The apparent information overload and the imperfection of medical decision making motivate the use of information systems for medical decision support. Health informatics provides tools to control processes in healthcare, acquire medical knowledge and communicate information between all people and organisations involved with healthcare. Although the development of medical information systems may often lag behind the available possibilities, the technological state of the current medical information systems is better than it is generally held to be. Health informatics should help healthcare professionals to provide better and more cost-effective care and enable healthcare systems to be more efficient and to adapt better to our patients' needs. Health informatics may reshape the way we deliver care to meet the demands of the future.     

History and Trends in Clinical Information Systems in the United States

Purpose: To provide a synopsis of issues about clinical information systems for nurses not schooled in nursing informatics.
Organizing construct: The past, present, and future of clinical computing, including major factors resulting in the early hospital information systems (HIS) and decision support systems (DSS) in the United States, current advances and issues in managing clinical information, and future trends and issues.
Methods: Literature review and analysis.
Findings and Conclusions: The first HIS and DSS were used in the late 1960s and were focused on applications for acute care. The change from fee-for-service to managed care required a change in the design of clinical information systems toward more patient-centered systems that span the care continuum, such as the computer-based patient record (CPR). Current difficulties with CPR systems include lack of systems integration, data standardization, and implementation. Increased advances in information and technology integration and increased use of the Internet for health information will shape the future of clinical information systems.     

Decision Support Technology in Knowledge Translation

Information technologies, and specifically clinical decision support systems (CDSSs), are tools that can support the process of knowledge translation in the delivery of emergency department (ED) care. It is essential that during the implementation process, careful consideration be given to the workflow and culture of the ED environment where the system is to be utilized. Despite significant literature addressing factors contributing to successful deployment of these systems, the process is frequently problematic. Careful research and analysis are essential to evaluate the impact of the CDSS on the delivery of ED care, its influence on the health care providers, and the impact of the CDSS on clinical decision-making processes and information behaviors. The logistical and educational implications of CDSSs in the ED must also be considered. The specialty of emergency medicine must actively collaborate with other stakeholders in the design, implementation, and evaluation of CDSSs that will be utilized during the delivery of care to our patients.     

Information Technology Principles for Management, Reporting, and Research

Information technology holds the promise to enhance the ability of individuals and organizations to manage emergency departments, improve data sharing and reporting, and facilitate research. The Society for Academic Emergency Medicine (SAEM) Consensus Committee has identified nine principles to outline a path of optimal features and designs for current and future information technology systems. The principles roughly summarized include the following: utilize open database standards with clear data dictionaries, provide administrative access to necessary data, appoint and recognize individuals with emergency department informatics expertise, allow automated alert and proper identification for enrollment of cases into research, provide visual and statistical tools and training to analyze data, embed automated configurable alarm functionality for clinical and nonclinical systems, allow multiexport standard and format configurable reporting, strategically acquire mission-critical equipment that is networked and capable of automated feedback regarding functional status and location, and dedicate resources toward informatics research and development. The SAEM Consensus Committee concludes that the diligent application of these principles will enhance emergency department management, reporting, and research and ultimately improve the quality of delivered health care.     

A study of the informatics literacy of clinical nurses in Taiwan

The purpose of this study is to identify the essential components for informatics literacy for clinical nurses working in Taiwanese hospitals. We developed a framework to explore the critical informatics literacy factors that clinical nurses should understand to be proficient in performing their professional duties. Survey methodology was used and the participants were senior administrators of nursing and other personnel in charge of implementing nursing information systems for 84 regional hospitals and medical centers. A total of 50 valid questionnaires was returned, with a 59.5% response rate. In summary, the results of the Taiwanese study are divided into three factors: informatics knowledge, informatics skills, and computer attitudes. A total of 58 questions was used for the measurement of initial nursing informatics literacy, and 49 items were considered to be the most required informatics literacy skills specifically for clinical nurses.     

Disparate Systems, Disparate Data: Integration, Interfaces, and Standards in Emergency Medicine Information Technology

As part of the broader informatics consensus initiative sponsored by Academic Emergency Medicine, this report addresses the issues of integration, interfaces, and data standards and how they are relevant to information management in emergency medicine. The purpose of this report, and the workgroup that contributed to its content, is to provide emergency physicians and other stakeholders in the emergency informatics community a sense of direction as they design, build, and/or choose systems. Problems are identified, strategies to address these problems are discussed, and consensus recommendations are provided.     

Time for TIGER to ROAR! Technology Informatics Guiding Education Reform

Information Technology (IT) continues to evolve and develop with electronic devices and systems becoming integral to healthcare in every country. This has led to an urgent need for all professions working in healthcare to be knowledgeable and skilled in informatics. The Technology Informatics Guiding Education Reform (TIGER) Initiative was established in 2006 in the United States to develop key areas of informatics in nursing. One of these was to integrate informatics competencies into nursing curricula and life-long learning. In 2009, TIGER developed an informatics competency framework which outlines numerous IT competencies required for professional practice and this work helped increase the emphasis of informatics in nursing education standards in the United States. In 2012, TIGER expanded to the international community to help synthesise informatics competencies for nurses and pool educational resources in health IT. This transition led to a new interprofessional, interdisciplinary approach, as health informatics education needs to expand to other clinical fields and beyond.In tandem, a European Union (EU) - United States (US) Collaboration on eHealth began a strand of work which focuses on developing the IT skills of the health workforce to ensure technology can be adopted and applied in healthcare. One initiative within this is the EU*US eHealth Work Project, which started in 2016 and is mapping the current structure and gaps in health IT skills and training needs globally. It aims to increase educational opportunities by developing a model for open and scalable access to eHealth training programmes. With this renewed initiative to incorporate informatics into the education and training of nurses and other health professionals globally, it is time for educators, researchers, practitioners and policy makers to join in and ROAR with TIGER.     

Technology and informatics competencies

Health care information technology has the potential to achieve clinical transformation. Nursing students and faculty must be able to use these tools effectively to use data and knowledge in their practice. This article describes informatics competencies for four levels of nurses (beginning nurses, experienced nurses, informatics specialists, and informatics innovators). Recent activities to include informatics competencies in program outcomes are also described in relation to the clinical nurse leader, doctorate of nursing practice, and baccalaureate essentials documents.     

RN, CIO: an executive informatics career

The Chief Information Officer (CIO) position is a viable new career track for clinical informaticists. Nurses, especially informatics nurses, are uniquely positioned for the CIO role because of their operational knowledge of clinical processes, communication skills, systems thinking abilities, and knowledge about information structures and processes. This article describes essential knowledge and skills for the CIO executive position. Competencies not typical to nurses can be learned and developed, particularly strategic visioning and organizational finesse. This article concludes by describing career development steps toward the CIO position: leadership and management; healthcare operations; organizational finesse; and informatics knowledge, processes, methods, and structures.     

Towards an evaluation framework for information quality management (IQM) practices for health information systems – evaluation criteria for effective IQM practices

Rationale, aims and objectives Poor information quality (IQ) must be understood as a business problem rather than systems problem. In health care organization, what is required is an effective quality management that continuously manages and reviews the factors influencing IQ in health information systems (HIS) so as to achieve the desired outcomes. Hence, in order to understand the issues of information quality management (IQM) practices in health care organizations, a more holistic evaluation study should be undertaken to investigate the IQM practices in health care organizations. It is the aim of this paper to identify the significant evaluation criteria that influence the production of good IQ in HIS. Methods Six selected frameworks and best practices both from health informatics and information systems literature have been reviewed to identify the evaluation criteria from the perspective of human, organizational and technological factors. Results From the review, it was found that human and organization factors are of greater significance in influencing HIS IQ. Our review depicts that there is still shortage in finding a comprehensive IQM evaluation framework. Thus, the criteria from the frameworks reviewed can be used in combination for more comprehensive evaluation criteria. Integrated IQM evaluation criteria for HIS are then proposed in this study. Conclusions Poor IQ is the result of complex interdependency within sociotechnical factors in health care organization and lack of formal and structured IQM practices. Thus, a feedback mechanism such as evaluation is needed to understand the issues in depth in the future.     

Lessons Learned for Collaborative Clinical Content Development

Background

Site-specific content configuration of vendor-based Electronic Health Records (EHRs) is a vital step in the development of standardized and interoperable content that can be used for clinical decision-support, reporting, care coordination, and information exchange. The multi-site, multi-stakeholder Acute Care Documentation (ACD) project at Partners Healthcare Systems (PHS) aimed to develop highly structured clinical content with adequate breadth and depth to meet the needs of all types of acute care clinicians at two academic medical centers. The Knowledge Management (KM) team at PHS led the informatics and knowledge management effort for the project.

Objectives

We aimed to evaluate the role, governance, and project management processes and resources for the KM team’s effort as part of the standardized clinical content creation.

Methods

We employed the Center for Disease Control’s six step Program Evaluation Framework to guide our evaluation steps. We administered a forty-four question, open-ended, semi-structured voluntary survey to gather focused, credible evidence from members of the KM team. Qualitative open-coding was performed to identify themes for lessons learned and concluding recommendations.

Results

Six surveys were completed. Qualitative data analysis informed five lessons learned and thirty specific recommendations associated with the lessons learned. The five lessons learned are: 1) Assess and meet knowledge needs and set expectations at the start of the project; 2) Define an accountable decision-making process; 3) Increase team meeting moderation skills; 4) Ensure adequate resources and competency training with online asynchronous collaboration tools; 5) Develop focused, goal-oriented teams and supportive, consultative service based teams.

Conclusions

Knowledge management requirements for the development of standardized clinical content within a vendor-based EHR among multi-stakeholder teams and sites include: 1) assessing and meeting informatics knowledge needs, 2) setting expectations and standardizing the process for decision-making, and 3) ensuring the availability of adequate resources and competency training.     

Where's the Beef? The Promise and the Reality of Clinical Documentation

Physician-generated emergency department clinical documentation (information obtained from clinician observations and summarized decision processes inclusive of all manner of electronic systems capturing, storing, and presenting clinical documentation) serves four purposes: recording of medical care and communication among providers; payment for hospital and physician; legal defense from medical negligence allegations; and symptom/disease surveillance, public health, and research functions. In the consensus development process described by Handler, these objectives were balanced with the consideration of efficiency, often evaluated as physician time and clinical documentation system costs, in recording the information necessary for their accomplishment. The consensus panel session participants and authors recommend that 1) clinical documentation be electronically retrievable; 2) selection and implementation be evidence-based and grounded on valid metrics (research is needed to identify these metrics); 3) the user interface be crafted to promote clinical excellence through high-quality information collection and efficient charting techniques; 4) the priorities for integration of clinical information be standardized and implemented within enterprises and across health and information systems; 5) systems use accepted standards for bidirectional, real-time clinical data exchange, without limiting the location or number of simultaneous users; 6) systems fully utilize existing electronic sources of specific patient information and general medical knowledge; 7) systems automatically and reliably capture appropriate data that support electronic billing for emergency department services; and 8) systems promote bedside documentation and mobile access.     

护理信息能力内涵研究进展

为应对信息密集化的工作环境对护理工作者的挑战,需准确界定护理信息能力内涵从而提高护理工作者的护理信息能力。本文在文献研究的基础上,运用信息学理论和护理学理论对护理信息能力内涵进行分析,总结得出护理信息能力内涵为:护理工作者或护生为了在护理工作中提供更优质、更安全、更高效的护理服务,通过各种护理信息活动体现出来的知识、技能、能力和态度的整合,具有动态发展性和层次性。从层次结构的角度把护理信息能力分为:个体、组织、国家三个层次。     

基于认知任务分析的急诊信息系统设计与实施

本研究采用认知任务分析的方法分析急诊临床工作中的关键环节并指导急诊信息系统的设计和实施。首先进行本院急诊信息系统的现况调查, 形成初步的调研报告, 整理急诊信息系统建设中需要解决的关键问题; 然后采用认知任务分析的方法确定急诊临床工作的关键环节并生成任务分析报告, 提出改善急诊临床工作效率和保障患者安全方面对于急诊信息系统建设的核心需求; 最后完成急诊信息系统的设计。结果显示, 本院现有急诊信息系统存在众多需要完善和改进的方面, 在透彻分析急诊临床工作关键环节对于信息系统建设的核心需求的基础上, 完成了新的急诊信息系统的搭建, 可更好地服务于急诊临床。急诊独特的临床需求需要有针对性的良好的信息系统设计, 通过认知任务分析搭建了充分适应急诊临床实践需要的信息系统。     

Electronic information exchange between emergency departments and poison control centers: A Delphi study

Context. The US emergency departments and poison control centers use telephone communication to exchange information about poison exposed patients. Electronically exchanged patient information could better support care for poisoned patients by improving information availability for decision making and by decreasing unnecessary emergency department telephone interruptions. As federal initiatives push to increase clinical health information exchange (HIE), it is essential to assess the readiness of US poison control centers. We conducted a nationwide Delphi study to determine consensus on legal, operational, and clinical considerations that are important for electronic information exchange between emergency departments and poison control centers. Materials and methods. A national panel of US experts (n =?71) in emergency medicine and poison control participated in a Delphi study, September–December 2010. Panelists rated statements describing concepts related to implementation, adoption, or potential outcomes of electronic information exchange between emergency departments and poison control centers. The statements reflected panelist responses to initial open-ended questions and literature-based concepts. Results. A total of 71 panelists agreed to participate. The response rate for each round ranged from 0.73 to 0.77. Most (114/121) statements reached consensus. Seven statements failed to reach consensus. Panelists indicated that user involvement in the design of systems and tools is important. Workflow integration, safety, evidence of benefit, and outcomes are high-importance issues. Discussion/conclusions. Future research and development related to electronic information exchange should address high-importance issues: safety, patient outcomes, workflow integration, and evidence of benefit. It should also address key barriers: initial and ongoing costs associated with electronic information exchange, the absence of software and tools to facilitate exchange, and the need for training. Users should be involved in the design of an electronic information exchange process, and the process should support, not replace, verbal communication.     

Using Data from Hospital Information Systems to Improve Emergency Department Care

The ubiquity of computerized hospital information systems, and of inexpensive computing power, has led to an unprecedented opportunity to use electronic data for quality improvement projects and for research. Although hospitals and emergency departments vary widely in their degree of integration of information technology into clinical operations, most have computer systems that manage emergency department registration, admission-discharge-transfer information, billing, and laboratory and radiology data. These systems are designed for specific tasks, but contain a wealth of detail that can be used to educate staff and improve the quality of care emergency physicians offer their patients. In this article, the authors describe five such projects that they have performed and use these examples as a basis for discussion of some of the methods and logistical challenges of undertaking such projects.     

Embedded Guideline Information without Patient Specificity in a Commercial Emergency Department Computerized Order-entry System

Background: Clinical practice guidelines and computerized provider order entry (CPOE) have potential for improving clinical care. Questions remain about feasibility and effectiveness of CPOE in the emergency department (ED). However, successful implementations in other settings typically incorporate decision support functions that are lacking in many commercially available ED information systems.
Objectives: To compare acute coronary syndrome (ACS) guideline compliance before and after implementation of a locally implemented ACS guideline, first on paper and then in a commercially available ED information system without patient-specific clinical decision support.
Methods: Clinical data were abstracted retrospectively on patients seen before and after introduction of paper and, subsequently, CPOE versions of ACS guideline-based order-sets. Order-set use was determined. Risk category assignments were made retrospectively using guideline criteria and compliance with the guideline regarding β -blockers, heparin, and aspirin was determined. Association between order-set use and compliance was determined.
Results: The authors found increasing use of order-sets over the period of study. However, there was poor association between the order-sets used and risk stratification category. Some association between ED β -blocker use and use of CPOE order-sets was found, but there was no improvement in overall compliance with any of the guideline recommendations.
Conclusions: Adherence to an ACS guideline did not improve with implementation of a commercial ED information system without provision for patient-specific decision support. This suggests that the lack of patient-specific decision-support functionality in most current ED information system products may hamper progress in the development of effective decision support.     

临床护士资讯素养的研究现状

面对21世纪信息化、网络化的迅速发展,资讯素养已经成为现代公民生活所必须的基本素质.资讯素养是临床护理人员需要具备的重要能力.文章阐述了资讯素养的涵义及其在护理实践中的研究现状和在护理教育、护理管理、临床护理的应用现状.为加强护理人员资讯素养能力的培训,提高护士信息索取和利用能力,以期提高护理质量提供参考依据.