Informatics and Evidence-based Practice M8120 Fall 2001 Suzanne Bakken, RN, DNSc, FAAN School of Nursing…

Informatics andInformatics andEvidence-based PracticeEvidence-based Practice

M8120Fall 2001

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

InformaticsColumbia University

What’s the Problem in What’s the Problem in Practice?Practice?

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

actual practice

Ways of Knowing for Ways of Knowing for PracticePractice

• Tradition• Authority• Personal experience• Trial and error• Intuition• Logical reasoning: inductive or

deductive• Systematic inquiry

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

• 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 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

What Data Do We Need for What Data Do We Need for Evidence-Based Practice?Evidence-Based Practice?

• Information about the patient• Domain information and knowledge

(“the evidence”) from systematic inquiry and other sources

Informatics Supports:Informatics Supports:

• Building the evidence• 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

Standardized Terminologies

• Capture patient care data in a standardized fashion

• Facilitate data re-use and aggregation

• Index information resources• Facilitate information retrieval

Standardized TerminologiesSystem 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 International x x x

Nursing Outcomes Classification x

National Health Service Clinical Terms (Read) x x x

Medcin x x x

First Data Bank Pharmacy KB x x

Outcomes of Interest• Traditional

– Mortality– Morbidity– Health services utilization

• Clinical phenomena (e.g., pain, decubitus ulcers)• Patient health status• Knowledge• Caregiver• Family• Community

M8120• Strengths and weaknesses of

existing terminologies• National and international

standardization efforts related to representing concepts in computer-based

• Unified Medical Language System

Foundation for Evidence-based Practice

• Standardized terminologiesDigital 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

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

M8120• Bibliographic sources

– Primary– Cochrane Collaboration

• Diagnostic decision support systems

• Clinical practice guidelines

Foundation for Evidence-based Practice

• Standardized terminologies• Digital sources of evidenceStandards that facilitate health care data

exchange• Informatics competencies• Informatics processes that support the

acquisition and application of evidence to a specific clinical situation

Standards for Healthcare Data Exchange for EBP

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

M8120

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

Foundation for Evidence-based Practice

• Standardized terminologies• Digital sources of evidence• Standards that facilitate health care

data exchangeInformatics competencies• Informatics processes that support the

acquisition and application of evidence to a specific clinical situation

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

Basic Computer Literacy Basic Computer Literacy Skills Required for M8120 Skills Required for M8120

AssignmentsAssignments• Access and download documents from WWW• E-mail and e-mail attachments• Word-processing• Power point slide presentation

These will not be taught in M8120! Classes available on campus.

M8120 Informatics M8120 Informatics CompetenciesCompetencies

• Acquire various types of data, information, and knowledge– Retrieve EBP literature from a variety of

sources (Medline, CINAHL, CliniWeb, Cochrane Collaboration)

• Organize data, information, and knowledge– Organize literature retrieved using a

systematic approach (e.g., EndNote)

M8120 Informatics M8120 Informatics CompetenciesCompetencies

• Critically analyze and synthesize data, information, and knowledge– Prognosis– Diagnosis– Clinical practice guideline– Therapy

• Apply data, information, and knowledge in the clinical decision making and care provision process– Evidence-based practice synthesis– Assessment of practice relevance in critiques– Expected value decision making– DXplain

Foundation for Evidence-based Practice

• Standardized terminologies• Digital sources of evidence• Standards that facilitate health care data

exchange• Informatics competenciesInformatics processes that support the

acquisition and application of evidence to a specific clinical situation

Informatics-based Informatics-based ApproachesApproaches

• Patient care systems• Integration of disparate sources

– MedWeaver– Skolar and Skolar RN

• Task-specific information retrieval– Infobuttons

• Alerts and reminders related to practice guidelines• Tailored delivery of informational and educational

interventions– PatCIS– MI Heart

• Elicitation of client preferences• Expected value decision making (decision analysis)

Patient Care Systems• Electronic health records• Care management (e.g., care

plans, critical pathways)• Ancillary systems

– Laboratory– Radiology– Pharmacy

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

Elicitation and Incorporation of Elicitation and Incorporation of Client PreferencesClient Preferences

Standard gamble

Expected Value Decision MakingExpected Value Decision Making

A Simple Decision TreeA Simple Decision Tree

Operate

Do not operate

Disease present

Disease absentDisease present

Disease absent

Survive

Operative death

Palliate

Operative death U=0Operative death U=0

Survive

Survive

No cure

Cure

Cure

No Cure

No cure

Cure

p=.10

p=.90

p=.10

p=.90

p=.90

p=.10

p=.02

p=.98 p=.10

p=.90

p=.10

p=.90p=.90

p=.10

p=.01

p=.99

Try for the cure

U=2

U=20U=2

U=20

U=20

U=2

U=20

U=0

M8120• Electronic health records• Dxplain• Alerts and reminders • Expected value decision making

(Data 3.5)• Interactive health communication