health it talk for pediatric nurses

การใช้เทคโนโลยีสารสนเทศ

ในการปฏิบัติการพยาบาลเด็ก

และการเรียนการสอน

นพ.นวนรรน ธีระอมัพรพนัธุ์

ภาควิชาเวชศาสตรช์มุชน

SlideShare.net/Nawanan

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Objectives• Examples of Health IT Use in

Various Settings• Health IT in Nursing• Health IT in Mobile Devices• IT for Education

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2003 M.D. (First-Class Honors) (Ramathibodi)2009 M.S. in Health Informatics (U of MN)2011 Ph.D. in Health Informatics (U of MN)

• Lecturer, Department of Community MedicineFaculty of Medicine Ramathibodi HospitalMahidol University

[email protected]/Nawanan

Who I Am

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• Expert on IT Use in Nursing• Expert on IT Use in Pediatrics• Expert on Mobile Health Apps• Expert on e-Learning• Ramathibodi IT Person

Who I Am Not

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Part 1: Health IT Use in Various Settings

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1.1 Health & Health Information

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Let’s take a look at these pictures...

9Image Source: Guardian.co.uk

Manufacturing

10Image Source: http://www.oknation.net/blog/phuketpost/2013/10/19/entry-3

Banking

11ER - Image Source: nj.com

Healthcare (on TV)

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(At an undisclosed nearby hospital)

Healthcare (Reality)

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• Life-or-Death• Difficult to automate human decisions

– Nature of business– Many & varied stakeholders– Evolving standards of care

• Fragmented, poorly-coordinated systems• Large, ever-growing & changing body of

knowledge• High volume, low resources, little time

Why Healthcare Isn’t Like Any Others

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Back to something simple...

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To treat & to care for their patients to their best abilities, given limited time & resources

Image Source: http://en.wikipedia.org/wiki/File:Newborn_Examination_1967.jpg (Nevit Dilmen)

What Clinicians Want?

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• Safe• Timely• Effective• Patient-Centered• Efficient• Equitable

Institute of Medicine, Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy

Press; 2001. 337 p.

High Quality Care

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Information is Everywhere in Healthcare

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“Information” in Medicine

Shortliffe EH. Biomedical informatics in the education of physicians. JAMA. 2010 Sep 15;304(11):1227-8.

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WHO (2009)

Components of Health Systems

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WHO (2009)

WHO Health System Framework

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1.2 Health IT & eHealth

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(IOM, 2001)(IOM, 2000) (IOM, 2011)

Landmark IOM Reports

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• To Err is Human (IOM, 2000) reported that: – 44,000 to 98,000 people die in U.S.

hospitals each year as a result of preventable medical mistakes

– Mistakes cost U.S. hospitals $17 billion to $29 billion yearly

– Individual errors are not the main problem– Faulty systems, processes, and other

conditions lead to preventable errorsHealth IT Workforce Curriculum Version 3.0/Spring 2012 Introduction to Healthcare and Public Health in the US: Regulating Healthcare - Lecture d

Patient Safety

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• Humans are not perfect and are bound to make errors

• Highlight problems in U.S. health care system that systematically contributes to medical errors and poor quality

• Recommends reform• Health IT plays a role in improving patient

safety

IOM Reports Summary

25Image Source: (Left) http://docwhisperer.wordpress.com/2007/05/31/sleepy-heads/ (Right) http://graphics8.nytimes.com/images/2008/12/05/health/chen_600.jpg

To Err is Human 1: Attention

26Image Source: Suthan Srisangkaew, Department of Pathology, Facutly of Medicine Ramathibodi Hospital

To Err is Human 2: Memory

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• Cognitive Errors - Example: Decoy Pricing

The Economist Purchase Options

• Economist.com subscription $59• Print subscription $125• Print & web subscription $125

Ariely (2008)

16084

The Economist Purchase Options

• Economist.com subscription $59• Print & web subscription $125

6832

# of People

# of People

To Err is Human 3: Cognition

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• It already happens....(Mamede et al., 2010; Croskerry, 2003; Klein, 2005; Croskerry, 2013)

What If This Happens in Healthcare?

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Mamede S, van Gog T, van den Berge K, Rikers RM, van Saase JL, van Guldener C, Schmidt HG. Effect of availability bias and reflective reasoning on diagnostic accuracy

among internal medicine residents. JAMA. 2010 Sep 15;304(11):1198-203.

Cognitive Biases in Healthcare

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Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003 Aug;78(8):775-80.


31Klein JG. Five pitfalls in decisions about diagnosis and prescribing. BMJ. 2005 Apr

2;330(7494):781-3.

“Everyone makes mistakes. But our reliance on cognitive processes prone to bias makes treatment errors more likely

than we think”


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• Medication Errors– Drug Allergies– Drug Interactions

• Ineffective or inappropriate treatment• Redundant orders• Failure to follow clinical practice guidelines

Common Errors

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Why We Need ICT in Healthcare?

#1: Because information is everywhere in healthcare

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#2: Because healthcare is error-prone and technology

can help

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#3: Because access to high-quality patient

information improves care

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#4: Because healthcare at all levels is fragmented &

in need of process improvement

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Health InformationTechnology

Goal

Value-Add

Tools

Health IT: What’s in a Word?

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Hospital Information System (HIS) Computerized Provider Order Entry (CPOE)

Electronic Health

Records (EHRs)

Picture Archiving and Communication System

(PACS)Screenshot Images from Faculty of Medicine Ramathibodi Hospital, Mahidol University

Various Forms of Health IT

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mHealth

Biosurveillance

Telemedicine & Telehealth

Images from Apple Inc., Geekzone.co.nz, Google, HealthVault.com and American Telecare, Inc.

Personal Health Records (PHRs) and Patient Portals

Still Many Other Forms of Health IT

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• Guideline adherence• Better documentation• Practitioner decision making or

process of care• Medication safety• Patient surveillance & monitoring• Patient education/reminder

Documented Values of Health IT

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• Master Patient Index (MPI)• Admit-Discharge-Transfer (ADT)• Electronic Health Records (EHRs)• Computerized Physician Order Entry (CPOE)• Clinical Decision Support Systems (CDS)• Picture Archiving and Communication System

(PACS)• Nursing applications• Enterprise Resource Planning (ERP)

Some Hospital IT - Enterprise-wide

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• Pharmacy applications

• Laboratory Information System (LIS)

• Radiology Information System (RIS)

• Specialized applications (ER, OR, LR, Anesthesia, Critical Care, Dietary Services, Blood Bank)

• Incident management & reporting system

Some Hospital IT - Departmental Systems

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The Challenge - Knowing What It Means

Electronic Medical Records (EMRs)

Computer-Based Patient Records

(CPRs)

Electronic Patient Records (EPRs)

Electronic Health Records (EHRs)

Personal Health Records (PHRs)

Hospital Information System

(HIS)

Clinical Information System (CIS)

EHRs & HIS

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Computerized Provider Order Entry (CPOE)

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Values

• No handwriting!!!• Structured data entry: Completeness, clarity,

fewer mistakes (?)• No transcription errors!• Streamlines workflow, increases efficiency

Computerized Provider Order Entry (CPOE)

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• The real place where most of the values of health IT can be achieved

– Expert systems• Based on artificial intelligence,

machine learning, rules, or statistics

• Examples: differential diagnoses, treatment options

(Shortliffe, 1976)

Clinical Decision Support Systems (CDS)

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– Alerts & reminders• Based on specified logical conditions• Examples:

– Drug-allergy checks– Drug-drug interaction checks– Reminders for preventive services– Clinical practice guideline integration

Clinical Decision Support Systems (CDS)

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Examples of “Reminders”

49Image Source: https://webcis.nyp.org/webcisdocs/what-are-infobuttons.html

Some Other CDS - Infobuttons

50Image Source: http://www.hospitalmedicine.org/ResourceRoomRedesign/CSSSIS/html/06Reliable/SSI/Order.cfm

Some Other CDS - Order Sets/Checklists

51Image Source: http://geekdoctor.blogspot.com/2008/04/designing-ideal-electronic-health.html

Some Other CDS - Abnormal Lab Highlights

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External Memory

Knowledge Data

Long Term Memory

Knowledge Data

Inference

DECISION

PATIENT

Perception

Attention

WorkingMemory

CLINICIAN

Elson, Faughnan & Connelly (1997)

Clinical Decision Making & CDS

53Image Source: socialmediab2b.com

IBM’s Watson

54Image Source: englishmoviez.com

Rise of the Machines

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• CDS as a replacement or supplement of clinicians?– The demise of the “Greek Oracle” model (Miller & Masarie, 1990)

The “Greek Oracle” Model

The “Fundamental Theorem” Model

Friedman (2009)

Wrong Assumption

Correct Assumption

Proper Roles of CDS

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The “Human Factor”• Alert fatigue

Unintended Consequences of Health IT

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Workarounds

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Hospital A Hospital B

Clinic C

Government

Lab Patient at Home

The Big Picture: Health Information Exchange (HIE)

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Health IT in Nursing

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What Do Nurses Do?

• Patient monitoring & patient care• Nursing assessments, care-planning,

nursing interventions, and other clinical & administrative works

• Medication administration• Shift handover• etc.

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Where Is Information in Nursing?

• Nursing assessments & documentation• Care-planning• Nurses’ Notes• Kardex• Guides for nursing procedures• Clinical knowledge• Communication with patients

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Where Are “Errors” in Nursing?

• Poor handwriting• Inappropriate care-planning

– e.g. failure to recognize fall risks, suicidal risks• Medication errors• Communication gaps (e.g. between shifts)• “Too much work, too many interruptions”• Limited clinical knowledge & skills

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Health IT in Mobile Devices

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Resources on Mobile Nursing Apps

• http://www.capella.edu/blogs/cublog/10-apps-for-nurses-in-online-nursing-programs/

• http://mobihealthnews.com/22123/apples-top-11-iphone-apps-for-nurses/

• http://www.unboundmedicine.com/products/nursing_central

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IT for Education

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How Can We Use IT for Education?

• To put teaching materials online• To let students search online resources• To allow interactive self-study (e.g. learn at

one’s own pace, quizzes, etc.)• To track student’s self-study & progress• For interactions outside classroom• To enable collaborative work• To “flip the classroom”

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Flipped Classroom

• http://ctl.utexas.edu/teaching/flipping-a-class

• http://www.washington.edu/teaching/teaching-resources/engaging-students-in-learning/flipping-the-classroom/

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• Expert on IT Use in Nursing• Expert on IT Use in Pediatrics• Expert on Mobile Health Apps• Expert on e-Learning• Ramathibodi IT Person

Who I Am Not

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Questions?

health it talk for pediatric nurses

Health & Medicine