Clinical Informatics

Clinical Decision Support and Electronic Health Records
Introduction
Information technology has revolutionized nearly every aspect of life, from how people recreate to how they work. This is no less true in the field of health care, where clinical informatics is reshaping the nursing workplace environment, how patient data is recorded and shared, and how health care is delivered. This paper will discuss clinical informatics concepts emerging in the 21st century, what evidence-based practice (EBP) shows with respect to clinical informatics, how the law figures into this issue with respect to HIPAA, privacy/confidentiality and security issues; and how patient safety, the nursing role and electronic medical records are impacted.
Clinical Informatics Concepts in the 21st Century
Controlling the flow of information to promote efficiency, security, and safety is the number one priority of clinical informatics. 21st century concepts for how this can be accomplished include training in how to find information, how to appraise information, and how to apply information. One common mistaken assumption among nurses is that having clinical informatics skills simply means to have computer literacy (Khezri & Abdekhoda, 2019). While computer literacy is a necessary component, it is by no means the full concept of informatics. In the 21st century, nurses need to know how to engage in information retrieval, the way librarians do. They need to be able to plug information into databases, pull up information from other databases, search for information manage knowledge effectively. Additionally, they have to be able to appraise information. When conducting an information search in a database, they may get a return of a thousand different references or sources of information. If they cannot process that information and appraise it well, their ability to conduct a search will be meaningless. Thus, informatics is more than just about knowing how to use a computer or how to obtain information; it is also about how to appraise information and assess its value. Keeping complete records for the purpose of electronic medical records (EMR) databases is also part of the concept because of need for continuity of care, which necessarily depends upon continuity of information (Kleib & Nagle, 2018).
Database Systems and Analytics and Their Impact on Nursing Research
Database systems require that nurses understand the concept of analytics as well. Nursing research is no different from any other kind of research in which analysis is involved. Nurses must be able to search data, appraise it, compile the relevant data, and utilize it for research purposes. Sousa, Reeder, Bondy, Ozkaynak and Weiss (2017) note that even today nurse leaders do not have adequate access to EMR. Without adequate access to EMR, nurse leader cannot engage in effective or timely decision-making (Sousa et al., 2017). Nursing research has to focus more on how to positive integrate EMR systems into nurse workplaces. One of the big questions going forward, however, is whether nurse PHDs, researchers or leaders are being prepared in the classroom to handle big data or data science (Westra et al., 2017). It appears to be the case that as technological advances are made, the need to be able to handle, process, interact with, command, and drive informational technology resources has grown—and nowhere is that seen more than in health care.
Informatics, EBP and the Law
Nursing informatics can be useful when it comes to implementing EBP for quality care (Elsayed, Hussein & Othman, 2017). However, as Effken, Weaver, Cochran, Androwich and O’Brien (2016) point out, nurses tend to be data-rich yet information-poor—meaning they have as much data as they could want at their fingertips yet they do not have the skills to retrieve or make sense of that data. One EBP to consider is the practice of mapping clinical terms to terminologies that have been standardized to help nurses better understand how to use information (Effken et al., 2016). Elsayed et al. (2017) posit that an informatics competency should be made part of the standard nursing curriculum in order to help promote the use of more EBP in the nursing field.
Nursing informatics can also be used to promote health literacy among at-risk patients (Haupeltshofer, Egerer & Seeling, 2020). By teaching older patients how to use technology to retrieve health information, nurses can increase their access to health literature and foster their health literacy. Technology thus has advantages that can be used to encourage the EBP of promoting health literacy as a means of preventive medicine. Still, this requires an informatics competency that is not as of yet being standardized in nurse education.
Nurses using clinical informatics still have to be careful, however, with respect to how information is shared. The Privacy Act of 1974 regulates how information is collected by the federal government, which means that nurses working in Veterans Affairs have to follow these regulations. Then there is also the Conditions for Coverage of Specialized Services by Suppliers, which is part of Medicare laws and requires that patient health information be confidential and private. Patients must give their written authorization before their information can be shared or forwarded. Health care facilities must protect patient information, which is why EMR must be securely maintained—and that can be a challenge, as numerous data breaches over the years have shown.
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 was implemented to regulate health care facilities with respect to how they handle health information, and HIPAA violations can lead to big fines for health care facilities. The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 likewise gives the Department of Health and Human Services the ability to regulate the use of Health IT and clinical informatics. Safety, security and quality issues are all overseen by the federal government under HITECH.
Privacy, Confidentiality and Security Issues
One of the challenges facing the field of nursing is how to keep information private in a world that has largely blurred the line between private and public. Social media has become a platform for people to take their private lives and make them public. Confusion persists as to how “public” social media really is, and some believe that because they have their own profile pages and determine which friends get to see it that the forum is somehow still private. They believe they have a right to air private grievances on these formats even though the information may be obtained in a semi-public manner. Sharing patient information on social media is prohibited of course but it can still be the case that nurses might discuss their work lives on social media without giving up any strictly confidential information about patients. But should they be able to do even this, or should every aspect of their work be confidential the way top level security officers in the government apparatus are prohibited from discussing any aspect of their work? The issue of right to privacy and confidentiality is one that receives less focus in America than the issue of security (Drolet, Marwaha, Hyatt, Blazar & Lifchez, 2017).
Privacy and confidentiality are still big issues and HIPAA violations can be costly, particularly if a large database is hacked and records stolen or publicized. End users in health care have to be especially careful to make sure they are not falling for phishing scams and that they are protecting passwords. EBP with respect to this area shows that end users of Health IT are the number one weakness in any information technology system: unless they are vigilant in protecting passwords and steering clear of phishing schemes, they can cause big financial damage to their facility (Nahm et al., 2019).
Patients have the right to privacy and their health information is thus protected by law to ensure that their data is not compromised. Nurses must respect this right when using clinical informatics and they must know that they cannot forward patient information on unless the patient provides written permission. They must be aware of the risks that end users pose to patient information. If they are not practicing EBP with regard to password protection (never writing down passwords on post-its, changing passwords periodically, never sharing passwords, and never providing access information to others), they are putting their patients at risk. These processes should be standardized using best practices. Confidentiality is a major issue in health data and patient trust should never be violated.
Informatics and Patient Safety
Patient safety has also been a top concern when it comes to informatics as well. Thus, the Food and Drug Administration Safety and Innovation Act (FDASIA) of 2012 was implemented with the purpose of overseeing how Health IT is used to provide remote access to patient information in the service of patient care. The FDASIA provided a path for the FDA and the Department of Health and Human Services to develop a framework for regulating informatics in the health care field with specific focus on mobile applications used by patients. However, one of the problems currently facing this area is that some state and federal laws are in conflict with one another, similar to how the state and federal laws are in conflict with one another on the issue of marijuana legalization.
The 21st Century Cures Act was passed in 2016. It aims in part to promote the leverage of social media in treatment delivery and to enhance the usage of digital medicine through greater implementation, training, and integration into established systems. Informatics relates to both processes and thus to patient safety because in each patient health information is used to either facilitate the treatment process or to provide information via digital technology.
Because digital technology is now playing such an important role, particularly in the way telehealth is enabling nurses to provide care, there is a need to understand how informatics support patient safety. Telehealth enables patients to overcome time and space barriers to care, but patient information should be just as protected in telehealth as in face-to-face care delivery formats.
Nurses also have to deal with some of the negative aspects of technology in the workplace, such as alarm fatigue. Alarm fatigue can be caused by too many alarms going off repeatedly, leading to stress and burnout for nurses (Cho, Kim, Lee & Cho, 2016). Proper management of alarm systems is needed to ensure that nurses’ health is cared for just as much as patient health. This can be achieved by ensuring that different alarms are set with different sounds and that nurses know which alarm sounds are most important and which are not indicative of immediate attention required. By managing alarms, a unit can be better equipped to respond to patients. However, without healthy and alert nurses, patient safety can be compromised as well.
With respects to EMR, the impact on nursing is quite significant, as EMR provides a way for nurses to record data easily, to share it, to retrieve it, and to keep documentation trails current. EMR provides access to patient records in a safe and secure manner, but it does require that nurses have basic informatics skills. As EMR are now a norm in nursing, it is helpful if nurses have training prior to entering the field, where they will be expected to be able to use databases and informatics systems routinely and without much trouble.
Technology and the Nursing Role
Technology is now a part of the nursing industry and nurses, young and old, are expected to be able to utilize it with dexterity and understanding. Technology plays a vital role because it facilitates the following of standards and promotes patient health and safety. It also reduces the risk of nurse errors being committed, as the protocol for how to care for patients has been standardized and written into the database entry systems that nurses use when administering to a patient. Before they can sign out of a system and leave a patient’s room they must go through a series of steps that ensure quality care is being delivered. This is one way in which technology is impacting the nurse’s role and helping to improve the nursing industry.
Technology is helping nurses to address some of the modern challenges that the industry faces today, such as nursing shortages and access to care obstacles. Nursing shortages are a major problem, but with technology nurses can better manage patient information, provide mobile services, implement telehealth, allow patients to schedule their appointments online, and enable patients to access their care plans through patient portals. All of these technological advances can free up nurses to address other issues such as more immediate patient care needs.
Collaborative care can also be better accomplished through the application of technology in nursing. Specialized care providers can interact with front-line nurses using digital communications technology, can receive updated forms or information from databases to which they are granted access with patient permission. This can lead to more holistic care practices and to patient-centered care being provided. The better able clinicians are to communicate using electronic health records systems the more likely patients are to reap the benefits. Technology is thus being integrated across the board to facilitate top level quality care for patients.
While technology in the workplace can have its drawbacks, such as the potential risk of alarm fatigue or burnout, the fact remains that nurses in the 21st century are living in a digital age. They must conform to the standards now being implemented as a result of technological innovations. The utility of technology is simply too great for the nursing field to allow these opportunities to pass by.
EMR and the Future
Clinical decision support is made possible by EMR, and the utility of EMR in the future of nursing is significant. Patient data can now be gathered into one database, where multiple clinicians can access the data and provide input to ensure adequate clinical support in decision making for patient care. In the US, EMR implementation has been incentivized by way of legislation. Some of the medical breakthroughs that EMR has facilitated include: automated drug monitoring and allergy alerting with dosage error detection software that can reduce medication errors in health care facilities, for example. But there are other tools that EMR can offer as well.
For instance, clinicians can be supported in diagnosis by EMR, as databases can be equipped with scoring tools and probability calculators that provide nurses and physicians with information that is mined from a patient’s record and used to aid the care provider in the diagnosis of symptoms. Treatment decisions can likewise be facilitated in this regard. EMR can also come with clinical parameters that provide clinicians with a way to be notified when a patient’s critical health levels are reached. For instance, if a patient has a history of hypertension, the clinical decision support system can be engaged to notify care providers when parameters in the patient’s records are reached, suggesting that the patient is at risk (Kharbanda et al., 2018).
EMR-linked clinical decision support can also facilitate the decision process for ordering diagnostic testing for patients. Too much testing can be a waste of time, energy and resources and it can cause strain on the patient’s health. It is far better to order the right diagnostic tests from the start rather than try a wide range of tests. To that end, EMR can help in the process of determining what tests should be conducted based on the information within the EMR. As software can be programmed to check for parameters that will then indicate which tests should be run, there is little need for clinicians to be able to sift through the data. Instead, they can rely on the system to search the data and indicate what the evidence suggests.
This will help in the future of nursing as more and more time can be freed from having to try various diagnostic tests. The EMR software will facilitate the decision making process and allow nurses to engage in a more one-to-one interactive manner with patients. It is often the case that nurses have to spend more time engaging with data and technology, which places time constraints on their ability to engage with patients. When that time is freed up due to streamlining technology that does a lot of the work of data analysis for the clinicians, nurses can then dedicate more of their time to interacting with patients, providing them with information and helping them to understand their health issues. They can address patient concerns in this manner and provide the kind of quality support and care that patients need.
Conclusion
Technology is changing the way that health care is provided in the 21st century. Information technology, EMR, telehealth, and communications systems are just some of the ways in which nursing is adapting. Collaborative care, continuity of care, and reduction of nursing errors are some of the ways in which technology can help improve the nursing field. Telehealth allows time and space obstacles to be overcome and patient quality care can be improved by way of clinicians using EMR for clinical decision support. Patient data and patient safety must be concerns, however, as patients have a right to know that their health information is being protected at all times. Facilities that do not take care to protect patient data can be fined under HIPAA. Nurses play a big role in this regard as they are end users of the technology and must safeguard passwords and beware of phishing schemes, which are used to steal access into systems. Technology thus offers a great deal of support for nurses in today’s industry, but it also comes with risks, from patient data being stolen to nurses’ own health being burdened via alarm fatigue. Proper understanding of technology and its utility is required.
References
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