To The Future!

Ethical Challenges

          In considering ethical challenges that may be relevant to the Venous Access Early Assessment Program, one challenge stands out: the assurance of applying the same consideration of care to all patients. “Each patient is unique and has life experiences that affect his or her perspective, choices, motivation and adherence” (in Mastrian and McGonigle, Chapter 5, (Mastrian, McGonigle, & Farcus, 2014, p.77). These factors may present challenges to the healthcare provider charged with fully engaging patients in healthcare decision-making. One important element of the VEAP is patient and family participation in decision-making. Achieving the goals of therapy and expediting care demands judicious use of time; truly engaging patients and families in decision-making affects the timeliness of those decisions. What if the patient specific circumstances (e.g. education level, cognitive function, etc.) interfere with the ability to move forward with the progression of care that meets the demands of efficiency? Are shared decisions truly shared in this circumstance? If not, how can this be addressed? Informatics solutions to shared decision making should account for patient education levels and/or cognitive limitations.

A somewhat parallel ethical challenge arose when considering the use of a smartphone app for patient use to track their PICC line care and maintenance. Patients who are sent home with PICC lines in place may feel overwhelmed by the responsibility of monitoring and caring for their PICC line. An app that provides tips and tricks to care and maintenance as well as the ability to input data for tracking by health care teams may enable early intervention for complications, increased patient satisfaction and compliance, and prevent readmissions. However, Beauchamp and Childress raise the question of distributive justice, which “refers to fair, equitable, and appropriate distribution (of treatment) in society determined by justified norms that structure the terms of social cooperation” (as cited in McGonigle & Mastrian, 2015, pp. 73-74). Is it ethical to develop and monitor a tool that cannot be used by those without the technology (smartphone) to support it?

Security Challenge

          The VEAP may be affected by an information security challenge. The venous access team is managing a database which contains patient information specific to PICC line placements and includes patient names and MR numbers, therefore it must be protected in order to ensure privacy. When this database was first created years ago, it was saved to a thumb drive to enable updates from whichever workstation the staff was able to access at the time allotted for the work of updating the database. While this thumb drive was encrypted to enhance security of the patient information, the IT department soon required that the database instead be maintained and backed up on a secure remote server to eliminate the possibility of inadvertently exposing patient’s sensitive health information and provide network security to the database contents.

Currently, the IT department is examining the possibility of another informatics solution: incorporating the data elements within the database into the Healthlink software and eliminating the need for the database altogether. This would bring the data under the umbrella of security provided by the Healthlink system. While enhanced security is desired, it may come at the cost of functionality. The spreadsheet that currently houses this data is easily accessible and searchable by the members of our team, and its contents are valuable in providing direction for care. If the data is merged with the Healthlink software application, a report will have to be generated in order to access it. Healthlink reports are more time consuming than simple spreadsheet searches, which is the point of contention. Ideally, the efficiency of Healthlink data retrieval will improve over time and allay this concern.

Data, Information and Technology and Venous Access: The Next 5-10 Years

          Over the next 5-10 years, continuing to strive to improve processes involved in healthcare documentation of venous access related history, assessment, and plans of care will capitalize on the power of EHR’s to support improvements in care. According to Al-Rawaifah, Aloush, and Hewitt (2015), variance in the coding systems used by different healthcare organizations complicates the mission of gathering and managing data for research. Therefore, standardized terminologies and coding systems will routinely be applied to maximize the sharing of data between organizations and across healthcare settings to promote the availability of data for research purposes. Patients will contribute to the documentation of their venous access device (VAD) related health history through the use of personal health information tools. Apps that allow for patient and family tracking of the patient’s venous access experiences in real time will serve to inform the health history and in this way contribute to a complete picture of each patient’s VAD-related health history.

Technology will advance to support the increasing patient demand for access to healthcare information and improved quality of care, as well as provider and bedside caregiver demands for efficient methods of documentation, care planning, and data retrieval. Internet access will be free and universally accessible to all regardless of setting. Patients and families will be provided with smart technology, free of charge if needed, to enable them to engage with the new paradigm of real-time recording of subjective data with regard to their VADs. Order entry, documentation, medication administration, chart review, and patient/family and staff education functions will be available via a single hand held device. Health care providers and caregivers will carry these devices equipped with voice recognition capability so that data is integrated into and accessed from the health record with maximum efficiency. The EHR will enable user-friendly report generation by authorized individuals without the need to wait in line for Information Technology service’s assistance.

The early selection of the most appropriate VAD to meet the needs of the desired therapy will be a routine occurrence. Patients and families will be meaningfully engaged in VAD related decision making through the use of shared decision support tools which serve to educate and incorporate the personal values and desires of each patient into decision making. Providers and nursing staff will be supported in efforts to optimize VAD selection through the use of clinical decision support tools. These decision support tools will undergo ongoing evaluation and iteration to incorporate the most current evidence and guidelines available.

Informatics will support the ideal care and maintenance of all types of VADs. Patients will have access to troubleshooting tips and tricks for care and maintenance in the outpatient setting at the tip of their fingers. Contact with healthcare providers will be ongoing through the uploading of patient reported health data. This will facilitate early intervention and avoid delays in assessment and treatment of potential VAD related complications.

Human factors engineering will be fully employed in all aspects of informatics related to VADs. Recognition of the limitations of human cognition and physical capacity will be the rule rather than the exception when work systems and processes are designed. Timely and accurate ordering of VADs will be seamless and eliminate the potential for human error. Software applications will deliver up to date, evidence-based, and patient specific VAD care and maintenance guidelines, in easy to access and easy to consume formats, where information chaos, overload, underload and conflict are eliminated.

Social/Political/Economic factors

          While the Patient Protection and Affordable Care Act has done much to begin to ensure equity of access to healthcare resources for all, there is still much work to do. Matthew M. Davis, in his discussion of whether healthcare is a right or a privilege, agrees: “While the PPACA certainly includes provisions designed to shift the sense of coverage from a privilege to a right, it is not clear that the U.S. health care system will achieve transformational change until the policy plane shifts from the individual to the collective.” As alluded to above, patients and providers will increasingly rely on technology and internet access to support the ideal selection, care and maintenance of VADs. Currently, socioeconomic factors related to access to these technologies influence patient and provider’s ability to participate fully. As access to data, technological tools, and information become vital to the provision of quality care, my hope is that U.S. healthcare reform will one day create a healthcare environment that supports and enables access to technological resources for all. This will be necessary to ensure equity and justice in access to quality healthcare for all.

Solutions and Committee Involvement

          The solutions I’ve proposed throughout this blog are informatics and workflow related. They impact nursing, provider, and pharmacy practice, including changes to nursing documentation and CPOE. As such, after review of proposed solutions with the Venous Access Team Unit Council and department Nursing Manager, contacting the Nursing Practice Council, the Advanced Practice Council and the Informatics Council would be good places to start in presenting ideas on an organizational scale. In addition, contact with and input from the Education and Quality Councils as well as the Council of Nursing Unit Chairs will likely be important.

Concept Map

          The concept map for my focus area has evolved throughout these six weeks with my understanding of what would be needed to address the problem of early assessment for venous access needs and how informatics concepts may be applied. Initially, I began with a fishbone diagram (below) that served to provide a visual guide for understanding how various system factors might contribute to the success of the VEAP. This visual illustrates the need to find ways to use informatics to retrieve and capitalize on patient specific data as a priority in developing the VEAP.

          Reflection upon the SEIPS model work system design for patient safety, which emphasizes the central role of people within a work system, inspired me to consider a visual which reflects this emphasis (see below). I wanted to illustrate the interdependent nature of the people involved in making safe and timely decisions regarding venous access.

          As the focus of my problem is early assessment for venous access, I constructed an algorithm (below) for decision support that illustrates the decision making necessary in choosing a device.

Coggle

Learning about clinical and shared decision support tools helped me to envision how the SEIPS model would reflect the tools and technology that contribute to the VEAP. This led to visualization of the other work system factors: people, organization, task and environment and how all of these components impact the VEAP and it’s outcomes. It then became clear that my concept map should ultimately reflect the role of the VEAP within the context of the SEIPS model work system design, rather than simply the algorithm used to establish the ideal VAD for a given patient and plan of care.

The arrows returning the processes and outcomes back to the work system indicate the iteration on the model that is necessary to generate knowledge, build on process improvement, and steadily improve patient and organizational outcomes.

Takeaways

          The SEIPS model of workflow design is just a place to start. After reading Jeff Belden’s blog entry regarding workflows, we are reminded that even seemingly simple workflows can (and do) take on increasing complexity that may be underappreciated. This is an important concept to grasp, and one of the significant takeaways for me from this course. Understanding the analysis and evaluation of work system, process, and outcomes that is required to build a foundation for knowledge and wisdom transfer has given me a greater appreciation of the underlying complexity necessary to build on existing healthcare and nursing knowledge and wisdom.

Another learning point that I leave this course with is the potential for informatics solutions to empower patients. Prior to this course, if I thought of informatics at all, I thought of it as a way to serve the healthcare system. The idea that informatics can serve and empower patients had never occurred to me.

Lastly, in one of my early blog entries, I discussed being frustrated as a new nurse by the seeming lack of ability to confer knowledge and wisdom from one generation of nursing to the next. It seemed such a waste to constantly have to reinvent the wheel – if it was reinvented at all, that is. And even now, after 22 years as a practicing nurse, I hold the same concern. However, there is light at the end of the tunnel, and I can see how informatics can provide the solution.

Looking to the future, it is difficult to imagine the specifics of my career trajectory at this point. I know a lot more about what I don’t want to do than what I’d like to do with an advanced practice nursing degree. However, I can say with confidence that informatics will be a significant part of my practice, wherever I go. And that’s not just because I won’t have a choice (as none of us will!), but because I see and embrace the power and potential informatics holds.

Thank you all for reading my blog and sharing your thoughts, it’s been an enlightening 6 weeks!

References

AL-Rawajfah, O. M., Aloush, S., & Hewitt, J. B. (2014). Use of electronic health-related datasets in nursing and health-related research. Western journal of nursing research, 37(7), 952-983. doi: 10.1177/0193945914558426

Belden, J. (2015, July 28). Workflow: Not as simple as it seems (Web log comment). Retrieved from http://toomanyclicks.com

Davis, M. M. (2013, August 13). Right, privilege – or tragedy of the commons? (Web log comment). Retrieved from http://www.rwjf.org/en/culture-of-health/2013/08/right_privilege_or.html

McGonigle, D., & Mastrian, K. G. (2015). Nursing informatics and the foundation of knowledge. Burlington, MA: Jones & Bartlett Learning.

Mastrian, K., McGonigle, & D., Farcus, N. (2015). Ethical applications of informatics. In D. McGonigle & K. Mastrian (Eds.), Nursing informatics and the foundation of knowledge (pp. 67-87). Burlington, MA: Jones & Bartlett Learning.

Informatics and Quality Measures, Workflow, and Human Factors

Visit NDNQI—are any of the collected measures relevant to your focus area? What additional measures would be relevant?

Central line associated bloodstream infection (CLABSI) is one the 18 quality indicators on the NDNQI list that relates to my focus area (Press Ganey, 2015). The CLABSI rates are monitored by unit throughout the hospital, including the peripherally inserted (PICC) lines placed by the Venous Access Team (VAT).   Total numbers of line days are measured and the infection rate is expressed as a relationship to this number.

One initiative that has been instituted to help minimize the CLABSI rate is an overall reduction in the number of line days, as discussed by one of our guest speakers, Shelly VanDenbergh. Prior to the implementation of HealthLink, the EPIC software application used at my hospital, the total number of line days for each unit was monitored manually by an infection control practitioner who physically travelled from room to room, visualized each patient, and then located and interviewed the RN regarding the plan of care. Line days can now be measured through simple data extraction from the EMR.

One of the barriers to implementation of the VEAP lies in the realm of this push to reduce line days. Overall, the message to providers is: the best way to avoid CLABSI’s is to avoid central lines in your patients. To this end, the Infection Control Committee is pushing to replace PICC lines with much shorter catheters, called Midlines. A bloodstream infection which develops while a Midline is in place does not qualify as a CLABSI, therefore there is no reimbursement risk to the organization. Unfortunately, while Midline catheters appear identical to PICC lines on physical assessment, Midlines are not safe to use in many contexts of care. The informatics challenge here includes finding ways to alert providers and nursing staff to the risks and limitations associated with Midline catheters in order to prevent patient harm.

Think about workflow related to your focus area. Whose workflow would be important to consider?

The workflow of the providers and the nursing staff are important to consider in this challenge. Changes to the provider workflow during the entering of orders for catheter placement in CPOE will serve to support the ordering of the appropriate catheter for the treatment plan, and prevent errors related to the ingrained mantra of avoiding central lines. Although nursing staff workflow will be equally important, I will focus here on the provider workflow.

Visit the AHRQ Health IT tools on workflow, choose a tool and discuss how it would be used to evaluate/plan/design workflow implications to resolve an informatics challenge in your focus area.

             The workflow assessment tool that I chose from the AHRQ Health IT website is the Use Case tool. This tool is helpful in uderstanding “how a user is aided by a system when completing a specific task”. One of the advantages of this tool is that it breaks a scenario down to a series of steps that “allow you to create an effective interaction prior to application design” (Agency for Healthcare Research and Quality, 2013).

Following are the steps listed in the tool, with specifics for use in provider workflow during catheter selection in italics:

1. IDENTIFY A PROCESS AND A SCENARIO within that process (the use case) to be analyzed.

The process is ordering of an intravenous catheter placement within the CPOE system. The scenario is ordering a Midline catheter.

2. IDENTIFY STAKEHOLDERS AND KEY PLAYERS in the use case.

Stakeholders and key players in this process are the patient, the organization, the provider, and the nursing staff.

3. DETERMINE THE GOAL(S) to be achieved from the analysis. Generally the goals of the use case revolve around identifying event triggers, alternate scenario paths or extensions, or simply just to understand the process and scenario better.

The goal is to make a safe and effective decision regarding the choice of Midline catheter for intravenous access.

4. COLLECT RELEVANT DATA that will aid in achieving the goals of the use case identified in the previous step.

Data will be collected from studies reflecting the safety and efficacy of each Midline catheters, including risks, benefits, and precautions. Data from the EMR including intravenous medications ordered, patient preference, and patient-specific limitations (e.g. history of mastectomy, history of arteriovenous fistula, etc.)

5. ORGANIZE THE COLLECTED DATA in a manner which best supports the use case goals.

The data will be represented as alerts or warnings to the provider during CPOE. Yellow warnings for precautions, or moderate risk (e.g.: Midline catheters and select antibiotic drugs, and red warnings for high risk (e.g.: Midline with vesicant drugs). Infobuttons will be used to provide further information regarding risks and links to Midline catheter organizational policy will be placed.

6. SUMMARIZE AND FORMULATE CONCLUSIONS.

Clinical decision support will be implemented to increase the safety of decision making around ordering a Midline catheter. Midline catheters will be ordered only when determined to be safe for the individual patient’s infusion plan of care.

Think about human factors and your focus area. Identify areas where humans are challenged. Where does human performance suffer? Or, where do humans get frustrated by a technology or process? How could human factors be used to improve the design of technologies and tools to better support humans in your focus area.

Human factors are described by Henriksen, Dayton, Keyes, Carayon, and Hughes as the application of information about “human behavior, abilities, limitations, and other characteristics to the design of tools, machines, systems, tasks, jobs, and environments for productive, safe, comfortable, and effective human use” (2008, p. 1-67). These factors are evident in the clinical assessment, documentation, and use of Midline catheters by nursing staff. Midline catheters visually appear identical to PICC lines, complicating the process of catheter identification. Thus, Midline catheters are commonly mistaken for PICC lines upon physical assessment. In addition, there exists a derth of knowledge regarding Midline catheters and their indication, use, and limitations, leading to unsafe practices and preventable patient complicaitons.

In the initial phase of HealthLink implementation at my hospital, Midline catheter documentation was limited reflecting the limited indication for the catheter’s use. One example is that of the option for the number of lumens being limited to one, in contrast to the number of lumens for PICC lines being one, two, or three. Now that the indication for Midline catheter placement is being expanded, the documentation must be modified to allow for an accurate reflection of the assessment. In describing how to improve the human-technology interface, Effken, McGonigle and Mastrian (2015) list three axioms (as cited in Nelson, 2003):

1. the focus on users early and continuously in interface design
2. an iterative design process that permits course correction and ongoing evaluation, and
3. the use of rigorous qualitative or experimental methods in formal evaluations

The second axiom described above reflects the necessity of revisiting processes as clinical decision-making and care recommendations evolve. Changes to practice around Midline catheter use in response to the CLABSI initiative require iteration on the processes involved in assessment and documentation of Midline catheters. Following are some potential solutions to this informatics problem.

Low Tech:

1. Labeling of dressings – consistent (all catheters), eye-catching (red?)
2. Color coding of catheter materials (PICC lines purple, Midlines yellow)
3. Patient room signs

High Tech:

1. Development of Midline-specific catheter maintenance order set. Currently the PICC line maintenance order set is used to guide care and maintenance of Midline catheters, further complicating the proper identification and use of Midline catheters. Links to educational videos may be embedded in the documentation. For example, here is a link to a corporate vendor-sponsored Midline catheter insertion and care video:https://www.youtube.com/watch?v=98ftIyS59lw  Other, organization-sponsored informational videos would be more appropriate for inclusion in the EMR.
2. Changes within the documentation of Midline catheters in EMR
   1. LDA modification to reflect multi-lumen catheters. Currently the only option for LDA entry is for single lumen Midline catheters.
   2. Attachment of link to organizational Midline policy embedded in Midline LDA.
   3. Embedding best practice alerts and evidence based practice recommendations into Midline catheter documenation. According to Tyler (2014), the volumes of medical information avaiable on specific health care topics makes it impractical for clinicians to integrate evidence and best practice without the aide of easily accessible and salient sources of information on specific subjects. Midline catheter specific evidence presented during documentation would serve to support knowledge dissemination.

So how does this all fit into my primary informatics challenge of developing a Venous Access Early Assessment Program? What have I learned that will further my efforts in developing the VEAP?

1. Data Mining. In a previous post I commented that data mining, as defined by Cummins, Pepper, and Horn (2013), would not be useful as I am not analyzing large sets of data but simply looking to extract pieces of data from the EMR to generate a patient-specific decision tree. However, I realized this week during Dr. Steege’s lecture that I may be able to use data extracted from the body of evidence around infusion related complications and best practice for venous access devices to support the development of a decision-making algorithm. This algorithm, in concert with patient-specific data from the EMR, could be used to guide providers’ decision of venous access device at the time of admission via CPOE decision support tool use.
2. Informatics Requests. You may recall that in one of my previous posts, I expressed concern for the length of time it may take to implement informatics-related changes at my hospital. Our guest lecturers this week, Nathan Whitman and Shelly VanDenbergh, emphasized the importance of cultivating a personal connection with the informatics professionals and linking requests to measures which may impact reimbursement. This advice was really useful for my application, as there may be a way to link my venous access early assessment informatics requests to CLABSI reduction.
3. Human Factors. I need to focus on making the information needed to make safe, quality, patient-centered decisions easily accessible and presented in a way that will not lead to information fatigue. I will want to capitalize on opportunities to use technology to eliminate the potential for error. For example, the classification of a patient as DVA should not be a response that may be selected by non-VAT staff. Another example may be to require over-rides by providers using CPOE to order peripheral IV’s for patients whose IV therapy requires central access.

References

Agency for Healthcare Research and Quality. (2013). Use case. Retrieved from https://healthit.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/use-case

Cummins, M. R., Pepper, G. A., & Horn, S. D. (2013). Knowledge discovery, data mining and practice-based evidence. In Nelson, R. & Staggers, N. (Eds.), Health informatics: An interprofessional approach (pp. 54-71). St. Louis, MO: Mosby.

Effken, J. A., McGonigle, D., & Mastrian, K. (2015). The human-technology interface. In D. McGonigle & K. G. Mastrian (Eds.), Nursing informatics and the foundation of knowledge. Burlington, MA: Jones & Bartlett Learning.

Henriksen, K., Dayton, E., Keyes, M. A., Carayon, P., & Hughes, R. (2008). Understanding adverse events: a human factors framework. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK2666/

Press Ganey Associates, Inc. (2015). Turn nursing quality insights into improved patient experiences. Retrieved from http://pressganey.com/ourSolutions/performance-and-advanced-analytics/clinical-business-performance/nursing-quality-ndnqi

Tyler, D. (2014). An insider’s view of the utility of a clinical information system. In D. McGonigle, B. Kirkwood, K. Mastrian, & K. L. Rich (Eds.), Nursing informatics and the foundation of knowledge. Burlington, MA: Jones & Bartlett Learning.

More on Shared Decision Support and Patient Empowerment

Last week I touched on patient-focused shared clinical decision support tools. McGonigle and Mastrian (2015) describe the consumer empowerment trend, whereby people are increasingly interested in taking control of their health. This week we look more closely at how we can support the engagement of patients, families and caregivers through the creation of shared decision support and the use of patient generated data and personal health records for venous access.

Patient and family/caregiver Input, Perspective and Engagement

Patients and families/caregivers will have the opportunity to weigh in on CVC decision making during admission and throughout hospitalization. The patient and/or family/caregiver will indicate a preference for CVC access on admission. This data, which gets integrated into the CDS tool for the provider, can be modified throughout the patient stay as needed.

In the process of developing the VEAP, I am envisioning that during the admission interview a link to a venous access shared decision tool will be offered. This tool will provide guidance for patients and families to become engaged around the risks and benefits of various types of CVC access, empower them to advocate on their own behalf, and make the best decision for their care. A good example of this type of tool is the Cornell mammogram patient decision tool included in my last post. Here is the link, again, for reference:

http://breastscreeningdecisions.com/#/

In this tool, available risk and screening evidence (data) is synthesized along with patient values to generate a summary. Similarly, I envision a tool that helps patients and/or families and caregivers to consider the risks and benefits alongside their own personal values in determining which venous access device will be right for them. Data from studies regarding the performance of various forms of short- and long-term venous access devices will be used to provide a picture of how well a certain type of venous catheter may be expected to perform for a given diagnosis and infusion plan of care. A summary, much like the one produced by the breast cancer screening tool, will be created for review with the patient’s health care provider. In this way, the patient is empowered to make an informed and personalized decision with his or her health care provider.

What technology(ies) are in use? What could be?

As I’ve mentioned in previous entries, the hospital’s EHR application is a tool that will allow us to indicate patient and family/caregiver venous access preferences at admission and throughout hospitalization via the use of the admission interview. Venous access preferences can be updated throughout the patient’s stay as their condition or plan of care evolves by updating the field associated with this data.

The Venous Access Shared Decision Tool may be used in any setting. The tool will be available as an app as well as a website, accessible with an Internet connection via a smartphone, tablet or computer. Upon admission to an inpatient environment, access to hospital supplied computers and Internet access may be needed for those without smartphones or other devices for connectivity. Outpatients will also need to have access to computers or devices with Internet access in order to use the tool.

The patient and/or their family/caregiver will be provided information about where to access the tool upon admission during the admission interview. The admission interview will be modified to include the question “Do you have a preference of venous access device during this hospital stay?”. The tool’s web address will be listed at this prompt and a check box will indicate that the RN interviewer provided the web address.

Facilitators

Technology is prevalent and accessible to many, and the number for whom it is accessible is growing. The federal government is invested in supporting health information sharing, having recently approved more than $38 million for it’s support (U.S. Department of Health and Human Services, 2015). The support from federal agencies frees up funds to be applied to IT projects that may benefit patients. Support for patients who wish to have access to their medical records is provided by Blue Button, a federally supported program which enables patients to obtain and share their health records from multiple sources, including providers, insurers, and pharmacies (The Office of the National Coordinator for Health Information Technology, 2015). These and other federally supported programs provide incentives that will ideally lead to improved health record information sharing, including venous access device history and preferences, between organizations.

Organizations are motivated to support health information technology through federal incentives for Meaningful Use. The implementation of the venous access patient decision tool supports the Venous Access Early Assessment Program in the goals of achieving the right access at the right time for each patient. Seckman (2013) describes Meaningful Use as the leveraging of “technology to improve quality, safety, and efficiency in patient care” (p. 90), which aligns with the goals of the VEAP.

Barriers

First and foremost we know that technology is not accessible to all – the “digital divide is the term used to describe the gap between those who have and those who do not have access to online information.” (McGonigle & Mastrian, 2015, pp. 288-289). In addition, McGonigle and Mastrian (2015) point out that persons with chronic diseases are less likely to have Internet access; increased age, level of education, ethnicity and income are factors common to both the digital divide and chronic disease (as cited in Fox & Purcell, 2010). In order for the shared decision support tools to function with maximal impact, patients will need to be ensured access to computers and Internet connections intermittently throughout their engagement with the health care system.

In addition, with the increasing ubiquity of EHRs, privacy and security of health information is a concern. Fears that personal health information may be subject to unauthorized access may prevent patients from using tools and accessing their health records online. Patients must feel that their health information is safe in order that they might be expected to freely participate in the sharing of their personal health information.

Finally, health literacy may be a barrier to successful implementation of a venous access shared decision tool. In order to expect that patients will benefit from participating in the decision making process around venous access device selection, patient health literacy deficits must be met. McGonigle and Mastrian (2015) indicate that at least one third of all Americans have health literacy problems (as cited in Parker, Ratzan, and Lurie, 2003). This need may be addressed through the work of the eHealth Initiative, whose work is focused on empowering individuals to better understand and act on their health needs (McGonigle and Mastrian, 2015).

References

McGonigle, D., & Mastrian, K. G. (2015). Nursing informatics and the foundation of knowledge. Burlington, MA: Jones & Bartlett Learning.

Seckman, C. (2013). Electronic health records and applications for managing patient care. In Nelson, R. & Staggers, N. (Eds.), Health informatics: An interprofessional approach. St. Louis, MO: Mosby.

The Office of the National Coordinator for Health Information Technology. (2015). Blue button connector: A way to help you find your health data. Retrieved from http://bluebuttonconnector.healthit.gov

U.S. Department of Health and Human Services. (2015). More than $38 million awarded to improve coordinated health information sharing in communities across America. Retrieved from http://www.hhs.gov/news/press/2015pres/07/20150728a.html

Informatics and Decision Support

This week we are turning our attention to the use of information (data) to support decision making in the context of the Venous Access Early Assessment Program (VEAP). In addition, we’ll cover a bit on how current and future federal initiatives impact the development of the VEAP.

What is your take away from the process of nursing information requirements?

My nursing information requirements topic describes the need for a bedside RN in the ICU to access data that was already present in the EMR in a more meaningful way in order to guide decision-making. In working to find a solution for this problem, it was clear that more thought was needed about how the end-user accessed and consumed information available in the EMR, and that changes to the way we structure informatics applications must be end-user friendly. According to Seckman (2013), usability may be complicated by poor design of human-computer interfaces or clinical decision support tools. In the example of my nursing information requirements topic, the usability of the Healthlink data that was needed to determine the best course of action in anticipating the discontinuation of tube feedings was not ideal. Enabling the organization of the necessary data into graphic form was the solution I arrived at when presented with this problem. This allowed the RN to view various data elements over time in a synthesized format that facilitated patient specific decision-making.

Think about an information need in your focus area; similar to the discussion of case studies in class, briefly outline an approach you would take to define the information and technology requirements and then to design, implement and evaluate a potential solution.

Information Need: Patient History of Venous Access

• Has the patient qualified as DVA?
• Have there been CVC’s? (see example photos below)
  • Short Term? (non-tunneled, non-PICC CVC’s)
  • Long Term? (Ports, tunneled CVC’s)

Defining Information and Technology requirements: Harvesting data from the digital health system

• Extracting ICD-9 codes assigned when Venous Access Team or provider documents CVC placement.
• Extracting Level 5 fields from the RN’s (VAT or bedside) documentation within the LDA.

Designing, implementing and evaluating a solution:

1. Begin by understanding work flows.  Are there distinct ICD-9 codes for different CVC types? Are consistent codes being applied to CVC insertions across disciplines and services.  Are these codes easy to find within the search function while documenting CVC insertions?
2. Identify any inconsistencies in documentation.  Identify variant ICD-9 codes to optimize capture all CVC procedures.  Is the level 5 DVA classification being properly assigned within the LDA?
3. Plan educational info-sessions to ensure quality data entry.  Bedside RN’s: use and intent of DVA classification in LDA.  Providers: consistent documentation of CVC insertion
4. Solicit the assistance of the Hospital Informatics Department to integrate CVC insertion history and DVA data into an algorithm that will ultimately be expressed as a data display and/or alert/reminder.  Data display would be effective in this application as it is an IT tool, triggered by patient specific information rather than user-action, that assists the clinician in making more informed decisions (Mercincavage, Sherry, & Pan, 2011).  An alert or reminder may also be useful here to pop up when a provider is entering orders for venous access, such as a PIV placement. It may be that both will ultimately be useful (Mercincavage, et al., 2011).
5. Evaluation of the process will include chart audit to identify discrepancies, which will guide iteration on the process for improvement.  Identify instances where ICD-9 code is not capturing CVC insertion.  Identify instances where patients who should be classified as DVA are not, and vice versa.

Think about the Neehr Perfect Implementing Clinical Decision Support activity from class. Are there any opportunities to integrate decision support tools in your focus area? What would those tools look like?

Clinical decision support tools will be key to the implementation of the Venous Access Early Assessment Program (VEAP). I envision the use of data displays and best practice alerts for high-risk venous access at various points during CPOE on admission and during a patient’s stay. Patients with high risk diagnoses, plans of care including vesicant or irritant medications, histories including the necessity of long- and short-term CVC placement, DVA assessment level 5, or who have expressed a preference for CVC placement on admission will have a data display flagging the need for consideration of CVC placement. Infobuttons, which are “clickable links to reference information for selected terms or phrases that appear in the EHR” (Mercincavage, et al., 2011, p. 2), will be available, providing a link to best practice guidelines and institutional policies for venous access.

What would be the goal of a CDS in your focus area?

 The goals in using these CDS tools include:

1. Getting the providers attention.
2. Providing information about best practice and institutional policy to guide a more informed provider decision.
3. Providing patient specific information to guide informed decisions. The use of “person-specific information, intelligently filtered or presented at appropriate times” (Kawamoto & Del Fiol, 2013, p. 165) is one element of a good clinical decision support tool.

Where do you think CDS would be most effective (e.g., whose decisions should they support, what types of decisions, etc.)?

 CDS implementation as part of the VEAP will be most effective in the form of:

1. Banner displays reading “VENOUS ACCESS AT RISK” in red for medication profile, diagnosis, or patient history triggering events.
2. Pop-up alerts will trigger for any patient who has a vesicant or irritant medication ordered at the time of admission, or throughout their treatment. The use of this alert is one example of the use of CDS to alert when a specific care action may present patient risk (Nelson and Staggers, et al.), making it an ideal CDS tool during medication related CPOE tasks. In addition, a pop-up alert will trigger during CPOE for PIV placements when the patient has indicated a preference for a CVC on admission.
3. Kawamoto and Del Fiol (2013) describe the utility of CDS tools which provide clinicians easy access to online reference information that applies to specific patient problems. Infobuttons will be present with both the banner and pop-up alert with a link to guidelines and best practice information on venous access device selection and organizational policy for administration of vesicant and irritant medications.

 How would they be implemented, what type of documentation would need to be done and where that documentation would be done in the EHR.

Implementing the various CDS tools includes documentation in:

1. The RN admission assessment. Patients will be interviewed to determine their preferences for CVC insertion for the anticipated stay. A question will be posed: At this time, do you wish to have a CVC placed? The discrete data collected from this response will be documented as “YES”, “NO”, or “UNSURE”. If the patient response is “YES”, this will trigger a pop-up alert as described above.
2. The provider’s History and Physical exam note. Diagnoses at high risk for difficulty with venous access (Cancer, Cystic Fibrosis, Spinal Muscular Atrophy, Sickle Cell Anemia, etc.) will be identified by ICD-9 coding within the H&P note.
3. Documentation of CVC placements. CVC placements are documented by the provider performing the procedure or the VAT. During documentation a description of the procedure is selected from a searchable menu. This selection automatically attaches the associated ICD-9 code for the procedure with the documentation. This ICD-9 coding can be extracted from the patients EMR for all encounters.

Decision Support for Patients

At this point I’d like to take a moment to point out that decision support is not only for clinicians, but a concept that can be (and is) applied to patient decision making as well. For example, the Registered Nurse Association of Ontario has developed a decision support guideline to aide patients with stage 5 chronic kidney disease in making informed decisions about their dialysis access. The SURE tool, a validated tool used to identify decisional conflict, was used as a measure to determine if decision support interventions were likely to be beneficial. If so, specific interventions were implemented, resulting in enhanced patient ability to make informed choices around their dialysis access (Murray, Thomas, Wald, Marticorena, Donnelly, & Jeffs, 2011).

I can foresee a similar process for patients with complex venous access needs. They are often faced with difficult choices, for which they are not fully prepared to cope. Identifying those who may require decisional support (those with decisional conflict), and developing evidence-based interventions to enhance their decision-making capacity may ensure that the choices they make are well informed.

Additionally, you may be interested to check out this patient decision support tool on breast cancer screening decisions developed by Cornell University:

http://bsd.med.cornell.edu/#/info

How does Meaningful Use relate to your focus area?

Meaningful use incentivizes healthcare organizations to implement EHR (Seckman, 2013). Determining the complete picture of a patient’s history of venous access is dependent on understanding the experiences they’ve had at other healthcare organizations. The history of an individual patient’s venous access is only partially told through viewing the data from my organization’s EMR. Therefore, to the extent that meaningful use impacts the broad scale adoption of EHR, it does have an impact on my focus area. In addition, phase II of meaningful use requires healthcare organizations to electronically transmit a summary of patient care for at least 10% of patients being transferred from their facility to another (Marchibroda, 2014).

How does the Federal Health IT Strategic Plan relate to your focus area?

 There are five overarching goals of the Federal Health IT Strategic Plan. The first goal is to “expand the adoption of Health IT” nationwide (United States Department of Health and Human Services, 2014). This goal relates directly to my focus area in that patient records from other healthcare organizations must be accessible and searchable in order to provide meaningful history that can be integrated into the algorithm for the VEAP.

References

Kawamoto, K., & Del Fiol, G. (2013). Clinical decision support systems in healthcare. In Nelson, R. & Staggers, N. (Eds.), Health informatics: An interprofessional approach. St. Louis, MO: Mosby.

Marchibroda, J. (2014). Health Policy Brief: Interoperability. Health Affairs. Retrieved from http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2014/rwjf414992

Mercincavage, L., Sherry, D., & Pan, E. (2011). Clinical decision support starter kit. Advancing clinical decision support.

Murray, M. A., Thomas, A., Wald, R., Marticorena, R., Donnelly, S., & Jeffs, L. (2011). Exploring the impact of a decision support intervention on vascular access decisions in chronic hemodialysis patients: study protocol. BMC nephrology, 12(1), 7.

Seckman, C. (2013). Electronic health records and applications for managing patient care. In Nelson, R. & Staggers, N. (Eds.), Health informatics: An interprofessional approach. St. Louis, MO: Mosby.ClD

The Office of the National Coordinator for Health Information Technology (ONC) Office of the Secretary, United States Department of Health and Human Services. (2014). Federal health IT strategic plan 2015-2020. Retrieved from http://www.healthit.gov

Ultrasound Guidance and Difficult Venous Access (DVA)

For this week’s blog entry we are choosing and evaluating a clinical practice guideline that applies to our area of interest.  I chose the Cincinnatti Children’s Hospital Medical Center (CCHMC) guideline –  Use of ultrasound guidance for peripheral intravenous access in the pediatric population (2012), which provides recommendations for ultrasound use in pediatric patients with difficult venous access (DVA). Stevens and Mitchell call for explicit identification of the evidence and rating of evidence and recommendations in the development of quality guidelines (2013). They also require a guideline to undergo specific development steps, including the identification of the type of supporting evidence (research or expert opinion) used to formulate each recommendation, as well as the use of a rating scale to reflect the strength of evidence used. This guideline clearly meets these criteria (see image below). Other factors which influenced my choice of guideline:

• Population – this guideline focuses on patients with peripheral venous access needs, while others were more broad, making extrapolation of recommendations challenging.

• Setting – the guideline was developed by a hospital, making translation of recommendations more applicable.

• Format – easy to read and interpret.

Guideline Modifications

Potential Harms The CCHMC’s guideline elaborates on potential benefits but does not state any potential harms. Weiner, Geldard and Mittnacht acknowlege the limitations of ultrasound guidance for vessel access, remarking on the steep learning curve required for successful use and the need for training and skill reinforcement to avoid complications such as the inadvertant cannulation of an artery (2013). This video demonstrates the process of using ultrasound technology to guide a needle into a vein.  You might notice the screen represents a total of 2.2cm depth.  The target vein is about 0.5cm in diameter – it’s easy to imagine the potential for error in such a small space! The CCHMC does reference the need for appropriate training and maintenance of competency within the Implementation Strategy section of the guideline, however I believe a description of potential harms, including inadvertant arterial perforation, nerve irritation or damage and possible increased risk of infiltration warrants some discussion in this section.

Defining Difficult Venous Access Within the CCHMC’s guideline, references are made to patients with difficult venous access (DVA) and the definition for this characterization is provided: In my last blog entry I discussed the challenge of translating expert assessment into data that may be extracted and imported to clinical decision making tools. In reflecting how I might adjust this guideline for use at my hospital, my mind returns again to the utility of quantifying the expert assessment of patient’s veins. Generating data like this will define what we mean by DVA at our organization. I was unable to discover any standardized nursing terminology while searching the NANDA Knowledge Base for terms relating to venous access.  Below are some of the existing elements and changes I would make to the Lines, Drains and Airways (LDA) nursing documentation: Fields included in existing LDA:

• Date of placement
• Time of placement
• Anatomical location and orientation
• Catheter length and size
• Method used for placement
• Number of attempts to place successfully
• Role of clinician who placed

Fields I would add:

• Techniques for vessel dilation
  • dry heat
  • moist heat
• VAT assessment of difficulty
  • 1 – tourniquet only
  • 2 – moist heat required for vein id
  • 3 – VAT attempt >1
  • 4 – ultrasound use required
  • 5 – ultrasound use employed with difficulty and/or >1 attempt w/ultrasound

The data generated from the addition of these fields will help determine whether patients should be identified as DVA and thereby qualify for application of the guideline.  It may also help bedside nurses understand which techniques may be useful in maximizing venipuncture success for each patient. Extracting this data from the EMR and using it in determining a patient’s classification as DVA will help further the goal of my Venous Access Early Assessment Program by addressing the access history factor that may qualify a patient as DVA.  Below I have updated my SEIPS chart to reflect this evolution: One thing that may be a stumbling block is the accuracy and completion of this documentation.  You can create fields for data entry, but that doesn’t mean it’s always entered, or entered accurately. I would expect that retrieval of this data will reveal only partial compliance with it’s entry. This challenge can be viewed in light of the larger context of electronic charting time commitments. McGonigle and Mastrian describe nurse’s perception that the time required to document has increased significantly (2015). With all of the demands placed on nurses at the bedside in this age of informatics, the temporary tradeoff for the rapidly expanding access to information may (ironically) be the sacrifice of compliance with accurate documentation. Some of the questions I need to consider at this point include:

• How will DVA be defined?  At this point, I think it’s probably adequate to define DVA as any patient who ranks a score of 4 or 5.
• If a patient is considered DVA during one hospitalization, does this classification always follow them in subsequent admissions?  If so, how will this data be communicated from one hospital episode to the next?

Data Mining

Cummins, Pepper, and Horn define Knowledge Discovery and Data Mining as “a process in which machine learning and statistical methods are applied to analyze large amounts of data” (2013, p. 56).  Data mining would not be useful in my problem, as I am not seeking to evaluate large data sets to draw conclusions or guide care for populations.  However, descriptive references to the plan of care in the progress notes may require the application of Natural Language Processing.  This is a method of data extraction from text (Cummins, Pepper, & Horn, 2013) that will help identify those patients whose plan of care may be for a duration of irritant or vesicant medication administration that would benefit from central access.  The use of the hospital’s HealthLink software report features will provide patient specific reports highlighting “red flags”, such as specific irritant or vesicant medications on their profile or diagnoses and co-morbidities such as cancer, cystic fibrosis or kidney failure which may indicate the need for early central access.

One challenge to obtaining data for the VEAP is the matter of the popularity of the informaticians.  At an academic medical center the size of mine, get in line!   With the rapid pace of evolution of  the EMR, the associated ongoing modifications, and high volume of requests for information, it can be months before requests for changes or reports are met.  So, one of the keys, I believe, to achieving success in generating informatics related change at your organization is …

PERSEVERANCE.

Stay tuned….

References

Cincinnati Children’s Hospital Medical Center. (2012). Use of ultrasound guidance for peripheral intravenous access in the pediatric population. Cincinnati, OH: Cincinnati Children’s Hospital Medical Center. Retrieved from http://www.guideline.gov/content.aspx?id=46457

Cummins, M. R., Pepper, G. A., & Horn, S. D. (2013). Knowledge discovery, data mining and practice-based evidence. In Nelson, R. & Staggers, N. (Eds.), Health informatics: An interprofessional approach (pp. 54-71). St. Louis, MO: Mosby.

McGonigle, D., & Mastrian, K. G. (2015). Nursing informatics and the foundation of knowledge. Burlington, MA: Jones & Bartlett Learning.

Neurocritical Care Ultrasound (Producer). (2014). Ultrasound guided vascular access- out of plane (axial/transverse) view. Available from http://www.youtube.com/watch?v=JkToLAbW8u0

NANDA International Knowledge Base.  Accessed at

Stevens, K. R., & Mitchell, S. A. (2013). Evidenced-based practice and informatics. In Nelson, R. & Staggers, N. (Eds.), Health informatics: An interprofessional approach (pp. 40-53). St. Louis, MO:  Mosby.

Weiner, M. M., Geldard, P., & Mittnacht, A. J. (2013). Ultrasound-guided vascular access: a comprehensive review. Journal of cardiothoracic and vascular anesthesia, 27(2), 345-360.

Developing the Venous Access Early Assessment Program

The Infusion Nurses Society calls for the placement of the most appropriate intravenous access device in patients who require intravenous therapy (Infusion Nurses Society, 2011). Often patients admitted to the hospital receive a short peripheral intravenous catheter when a different catheter would have provided for more reliable, satisfying and safer access. In addition, too much time passes before patients receive appropriate access for irritant or vesicant therapy, resulting in unnecessary complications. The informatics challenge I am exploring is how to choose the most appropriate device early in a patient’s hospital stay.

Collecting, Analyzing and Organizing the Data

According to Connors, Warren & Popkess-Vawter (2013), health informatics is the analysis and dissemination of stored health data through the use of technology. In gathering data to determine the most appropriate venous access for each patient early in their hospital stay, one of the informatics challenges lies in the analysis and organization of the data from the electronic medical record (EMR) into reports that can be used to guide clinical decision-making. Diagnosis, current medication list and prior venous access devices, the number of needle sticks required to place a peripheral intravenous catheter (PIV), it’s dwell time, and reason for removal will need to be extracted from the EMR for each hospital visit. This data currently is only available by manually entering each encounter within the patient’s EMR and scrolling through flow sheet entries one encounter or admission at a time. While both the EMR and the electronic health record (EHR) contain an individual’s digital form of health related data, the EMR is specific to one institution while the EHR represents the collection of this data across various facilities and agencies (Connors, Warren & Popkess-Vawter, 2013). I’ll be accessing data strictly from my hospital’s EMR, although it’s easy to imagine the utility of expanding this program and integrating data across care environments.  The expansion of this program into the realm of the EHR would enable an even more thorough understanding of patient’s venous access history and support more seamless care.

Nursing Informatics, Knowledge and Wisdom

The sub-specialty of nursing informatics is defined as a clinical health care informatics that incorporates the application of computer science and information science and provides for the management and communication of nursing knowledge and wisdom (Connors, Warren, & Popkess-Vawter, 2013). I am intrigued by this concept. As a new nurse, I recall lamenting the lack of translation of knowledge from one generation of nurses to the next – the opportunity to learn key skills and benefit from the collective wisdom of nursing was haphazard at best. The challenge here: how to find a way to record and retrieve data that represents the expert nurse’s assessment and findings, thereby making it possible to characterize and share their knowledge and wisdom. For example, while it may be possible to place a PIV for a particular patient on the first attempt, the expert nurse may have had to employ advanced techniques. The EMR would reflect that the PIV was placed in one attempt, but no data reflects the degree of difficulty as assessed by the expert nurse. Employing a scale or rating system using standardized terminologies would be useful in this context. The degree of difficulty and advanced techniques employed are an important piece of information that reflects nursing knowledge and wisdom and adds value to the overall clinical picture.

SEIPS Framework

The SEIPS model of work system and patient safety expands on the Donabedian framework of structure-process-outcome to more specifically underscore the effects of the work system, or structure, on processes and outcomes. The SEIPS model defines the work system as and inter-related network of technology and tools, organizational, environment, tasks, and people factors. This model stresses the central role of the people in the work system and how one factor within the work system can significantly impact the others. This system allows for assessment of the impacts of a work system as a whole while minimizing the focus on one element in isolation (Carayon et al., 2006). Below is a concept map of the work system for development of the VEAP. In reflecting on the challenge of developing the VEAP, the interdependent nature of the relationship between the patient, the nurse, the pharmacist and the ordering provider, will need to be considered. See below for a visual reflecting this dynamic. All of these individuals will impact the functioning of the VEAP in different ways: the patient as the recipient of services will play a role through determining personal preference of device; the nurse’s expert knowledge in the character and quality of the patient’s veins and their amenability to various forms of access; the pharmacist’s understanding of the physical properties of prescribed medications; and the provider’s knowledge of the patient’s medical condition and authority to drive the plan of care.

Barriers

One of the barriers to developing the VEAP may include resistance from ordering providers related to their concern for loss of autonomy in clinical decision-making. It will be important to educate providers about the program and stress that it’s intent is to integrate individual patient information in order to ensure awareness of the risks and benefits of various forms of venous access for each patient. This will serve to provide reassurance that this program is not intended to bypass any clinical decision making or provider autonomy, but to provide support for clinical decisions.

Organizational characteristics may also serve as a barrier to the development of the VEAP program. Carayon et al. (2006) describe teamwork, culture, collaboration, communication, and coordination as contributing to the organizational characteristics that may impact a work system. While the organizational culture at my hospital supports evidence-based change, which acts as a facilitating element for this program, collaboration among and between disciplines is strained and may present a significant barrier. Recruiting representatives from provider groups, pharmacy, administration and nursing to form the VEAP committee will be a starting point to promote collaboration and teamwork among the disciplines.

References

Carayon, P., Hundt, A. S., Karsh, B. T., Gurses, A. P., Alvarado, C. J., Smith, M., & Brennan, P. F. (2006). Work system design for patient safety: the SEIPS model. Quality and Safety in Health Care, 15(suppl 1), i50-i58.

Connors, H., Warren, J., and Popkess-Vawter, S. (2013). Technology and Informatics. In J. F. Giddens (Ed.), Concepts for Nursing Practice (pp. 443-452). Mosby.

Infusion Nurses Society. (2011). Infusion Nursing Standards of Practice (2011) (Vol. 34). Untreed Reads.

Welcome to Jen’s n764 Informatics Intravenous Access Blog

This blog will be a space for exploration of informatics issues as they relate to intravenous access in the hospital setting.