RUNNING HEAD: Final Nursing Informatics Project

Nursing Informatics

Delaware Technical and Community College

Final Nursing Informatics Project

Alyssa Shoemaker

November 23, 2018

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INTRODUCTION

Nursing informatics is an important concept for the future of healthcare. Social and

professional networking can improve the use of healthcare informatics processes. Personally, using the

app technology is easy for me and is always a great resource for information. I think there is an app for

basically anything you ever need or could want. I do have apps on my computer which makes it kind

of hard for me to use or to understand how to use them. I am personally familiar with Google Drive in

which we have used in previous courses for the nursing program. I think it is amazing that we can

enter information and then it saves and the next person opens up and sees what I have added. We also

have used a cloud like this for doing the bed ahead assignments at work, although I am not quite sure if

it was Microsoft OneDrive or another application. Of course, I am familiar with the Apple Icloud

which makes it great to store photos without taking up storage on your phone. I liked the Universal

Keyboard Shortcuts diagram in our book. I actually wasn't too familiar with all of those.

I think social and professional networking can improve nursing informatics in many ways. I

remember when the internet took forever because it was a dial up modem. Now, technology has come

so far with the network connection speed. Certain web browsers that I use most often are Internet

Explorer, Firefox, and Chrome. I most certainly use Google to find most of my answers or things that I

am looking for. I feel like the top hits on Google are always what I am looking for. I do think my

email needs to become more advanced with finding spam. I get about 50 emails a day and only one or

two are things that I actually need to read. The rest are either ads or spam. I feel like hacking into

accounts has been made easier and more technology needs to be available to protect against this. I

actually just received a notification today that someone tried to login to my Facebook account in Ohio.

Luckily, their technology has alerted me. It would be so easy for someone to login to my accounts and

find a lot of protected information because the use of computers for storing information like passwords,
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bank accounts, etc is so prevalent.

Medication errors are a serious problem in healthcare and informatics play an important role in

improving this process. Having the correct medications and knowing any adverse effects with other

prescribed medications is key in planning for the discharge process so that the patient can continue the

correct medication administration at home. Another important part of informatics and healthcare is the

use of electronic networks and the electronic medical record. With the use of these records, there are

some ethical and legal concerns that have come to light along with privacy issues. I have also taken a

look at the workflow process in which we currently use at my place of my employment and ways it can

be improved upon. With all this research combined, I have developed a policy for implementation of

the discharge process.

MEDICATION ADMINISTRATION

I have researched about the medication administration process. I have found two articles

relating this to the nursing process. Informatics plays an important role in medication administration.

Medication errors remain a serious health care problem in the US which result in approx. 7,000 deaths,

cause harm to 1.5 million people, and cost the hospitals billions of dollars each year (Huynh et. al.,

2016). This study used an iMedTracker on an Ipad which recorded live medication administration

process observations. The data collected was taken from an actual hospital setting which provided

realistic results. It compared an RN completely focusing on medication administration workflow

(unbundled) vs. an RN completeing medication administration along with other patient care

responsibilities during the care episode (bundled). The bundled vs. unbundled medication

administration processes seemed to be related to the RN's level of experience (Huynh et. al., 2016).

The outcome was that bundled workflow is not desireable due to higher incidence of task switching and

task switching often increases physical activities that can result in cognitive slips and mistakes that lead
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to performance error (Huynh et. al., 2016). Without the use of informatics, this study wouldn't have

been possible. The other article is about the effect of bar code technology on the safety of medication

administration. Technology has come a long way since paper charting. This decreases the risk for

medication errors by using different types of technology and incorporating it into the nursing practice.

This study conducted a before and after of implementing a bar code eMAR. They observed 14,041

medication administrations and reviewed 3082 order transcriptions and observers noted 776 nontiming

errors in med admin on units that did not use the bar code eMAR versus 495 of the same errors on units

that did use it (NEJM, 2010). They concluded the use of the bar code eMAR substantially reduced the

rate of errors in order transcription and in medication administration as well as potential adverse drug

mistakes (NEJM, 2010). This is a very important piece of improving medication safety and should be

widely used throughout the world.

ELECTRONIC NETWORKS

Technology has come a long way in recent years. Electronic health records are now being

widely used and are extremely beneficial for transferring and sharing patient data. A new concern is

with the ethical use of genomic information and electric medical records. A recent trend is combing

DNA biorepositories with Electronic Medical Record (EMR) systems to enhance clinical care and

research (Amer, K., 2015). They are using patient’s blood and DNA sequencing and preserving it for

future research. Some ethical, safety, and privacy issues are being addressed now.

An example of an electronic network is the eMERGE Network which collects genetic

materials from patients to develop large-scale, genetic research studies (Amer, K., 2015). This

Genomic data can be used for disease identification and to develop individualized treatment plans by

combining the traditional information in the patient’s medical record with the patient’s genetic and

genomic information and comparing treatments for patients having similar medical problems (Amer,
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K., 2015).

In provision 8 of the Code of Ethics for Nurses, the nurse collaborates with other health

professionals and the public to protect human rights, promote health diplomacy, and reduce health

disparities (American Nurses Association, 2016). Research is crucial for reducing health disparities.

New medications can be made or medications can be approved upon and patient care can be improved

through research as well.

ETHICAL ISSUES

Ethically, the patient would not object to having the blood used for research and that the

sample is not identified with the patient (Amer, K., 2015). There are currently inconsistent practices

with storage, identification of samples, and informed consent from patients (Amer, K., 2015). An EMR

ethical concern are the risks associated with breaches of confidentiality (Amer, K.,).

In provision 3 of the Code of Ethics for Nurses, the nurse promotes, advocates for, and

protects the rights, health, and safety of the patient which includes protection of the rights of privacy

and confidentiality, protection of human participants in research (American Nurses Association, 2016).

This provision directly relates to the using of patient’s blood for research and protecting their rights

along with protecting the patient’s privacy and confidentiality.

As nurses, we can make sure we always have consent of the patient for research. We also

have to make sure they are under no form of medication that would alter their mind frame so they are

able to make an informed decision and consent. We can make sure we educate the patient on

specifically what their blood is going to be used for.

PRIVACY

Security of the medical records is very important. The security of EMR’s requires extensive

funding, high level technology security, and continuous reassessment which can become quite
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complicated (Amer, K., 2015). An example of a risk benefit analysis of EMR’s is that of electronic

communication between providers and pharmacies for the purpose of medication reconciliation and can

prevent severe drug interactions or unintentional overdosing. These outweigh the risks of possibly

security breaches (Amer, K., 2015). It is also important to remember that patients have rights regarding

who has access to their health information as provided by the Health Insurance Portability and

Accountability Act (HIPPA) (Amer, K., 2015).

Under HIPPA, the information your doctors, nurses, and other health care providers put in

your medical record is protected along with conversations your doctor has about you care or treatment

with nurses and other people, information about you in your health insurer’s computer system, and

billing information about you at your clinic (U.S. Department of Health and Human Services).

As nurses, we can make sure we don’t violate any HIPPA laws or breach any confidentiality.

While having conversations about patients, you have to make sure are in private areas and no one else

is hearing your conversation. When leaving your desk, you must exit out of your screen so that the

patient’s information isn’t available for anyone else to see. We also use our very own sign on

information and password to sign into the secure server which accesses our patient’s information. Our

password must be changed frequently. This helps minimize the chance of information being stolen.

CURRENT DISCHARGE WORKFLOW AT NANTICOKE

I work at Nanticoke Memorial Hospital on the Clinical Decision Unit. Mainly, the patients have

a diagnosis of syncope or chest pain. We usually run the same tests on those patients with the same

diagnosis. A diagnosis of syncope would include a 24 hour holter monitor to monitor the heart's

rhythm, a 2D echo to check any abnormalities with the heart, orthostatic blood pressures to determine

any drop in blood pressure, labs ,and a chest xray. Sometimes, it further includes a neurological

workup to include a CT scan of the head/neck, EEG to monitor brain activity, and MRI of the brain.
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For chest pain, the tests usually include a 2D echo, following serial troponins to see if there was any

damage to the heart, EKG, 24 hour holter, labs, and a possible stress test or cardiac cath.

More times than not, everything comes back negative. The patients are left wondering, “what

actually caused this problem?” They will be told to follow up outpatient with neurology, cardiology, or

pulmonology, and their primary care provider. Most often times, the hospitalist, just puts in an order

for discharge and doesn't come explain any results or further options. They just must have figured their

tests were negative and to follow up outpatient. It is hard for me, as their nurse, to not give them an

explanation for passing out, having extreme chest pain, or feeling dizzy. I am also left wondering if

they will be okay and what the cause could have been.

The hospitals have a certain length of stay per patient that is covered, so they are forced to have

the patient admitted and discharged as quickly as possible. I feel like more time needs to be spent on

the discharge process. I actually had a new doctor discharge his patient and go over all of his home

medication changes with him so that he fully understood and then it was reiterated by the nurse so the

patient fully understood his medication regimen at home. That was the first time I had seen a doctor do

this. He explained that we just print out this list for them on discharge of their medications and follow

up physician list, but the patient may not actually understand that there is a difference from this list and

their list prior to coming into the hospital. They also may not understand who this physician is on the

list or why they may need to be following up with them. I was extremely impressed that he had taken

the time to do that and it completely makes sense. If the patient doesn't understand these reasons and

changes, it is more likely they will be readmitted to the hospital within a shorter amount of time. Our

hospital does not get reimbursed for readmissions within thirty days. If we could spend more time and

money on the discharge process which would in turn lessen the amount of readmissions, it would

decrease the amount of money lost by the hospital. The doctor doing his discharge made it even clearer
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to me that more focus needs to be on the discharge process and other people at my hospital are aware of

that as well. I decided to take a look at our current workflow and ways to improve it.

Currently, the patients are admitted, the tests are performed, the doctor puts in a discharge order,

nurses go over discharge instructions based on diagnosis, list of medications, list of follow up

physicians. If needed, our case manager will find short term rehab for the patient. Sometimes, we do

get homeless patients, and the case manager will arrange for them to stay in a hotel for a few days. The

case manager will also arrange transportation if needed. If the patient is within the Nanticoke

Physician Network, the Care Coordinator will make a call to the patient after discharge to see how their

stay was and if they had any questions. If they are out of network, the Transition Care RN will follow

the patient for 90 days and make phone calls to the patient. United ACO will follow up on all the calls.

MAKING A CHANGE

Nearly twenty percent of patients experience an adverse event within thirty days of discharge

and most could have been prevented. These complications are mainly focused on the discharge process

and include problems such as changes in medications before and after discharge, inadequate

preparation for patient and family related to medications, danger signs, lifestyle changes, disconnect

between clinician information-giving and patient understanding, discontinuity between inpatient and

outpatient providers (Agency for Healthcare Research and Quality). If we could change some of these

things, this would lower the amount of money lost by the hospital due to readmissions, we would

improve patient outcomes which also boots patient satisfaction. It also gives the family relief that their

loved one has been adequately taken care of. This would increase the overall name and trust in the

hospital and other people would want to come to hospital in time of illness which would increase

revenue for the hospital.

I think we need to start by involving as much family and support as possible. Having a support
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system at home and people to lean on is very important in times of sickness. We should make sure the

family or support system is present at time of discharge. I think we should focus on reviewing

medications, educating on warning signs and symptoms, test results should be thoroughly explained,

and we should be making follow up appointments for the patient at time of discharge instead of just

giving them a number to call. We should educate the patient on the steps after the discharge process.

Teach back methods should be utilized so make sure the patient is comprehending and understanding

fully about their diagnosis, test results, and medication regimen. I think we should provide a weekly

medication dispenser so they can separate the pills they need to take each day. We should discuss about

each medication, the generic name for it, what times to take it, how to take it, and the purpose of taking

it. If the test results are still pending at discharge, fully go over with the patient who to call for follow

up results. We should provide a checklist for the patient to make sure the patient is fully understanding

the instructions and a place for them to write down if they can think of any questions they may want to

ask. We should provide an educational video for the patient based on their diagnosis that they watch

the day of discharge. The video would include education on diagnosis, what to expect when they get

home, who will be contacting them at home, and what to expect for the future. The physician should

review the medication list and then it should be reviewed by the pharmacy who should send the list to

the primary care provider. The physician should review the list with the patient first and then the nurse

should also go over the list with the patient. It is so important that the patient understands how and

when to take their medications. It would also include their last dosage time so they wouldn’t double

dose when they got home from the hospital. The new medications are then sent to the patient’s

pharmacy. We should also be going over all the patient’s abnormal labs or scans throughout the

hospital stay so that they can follow up outpatient and recheck them as needed. A follow up phone call

will be necessary to ensure that the patient has all follow up appointments, has all their medication
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needed, all necessary supplies, and all questions are answered. Another follow up call should be within

three days. This should be by a nutritionist. The nutritionist should make sure the patient is following

the appropriate diet and/or maintaining appropriate weight and if an intervention is needed. There

should be a follow up phone call after two weeks and after three weeks. I think the follow up calls

should continue once a month for six months to make sure the patient is comfortable managing their

illness and has all the appropriate support they need.

CONCLUSION AND POLICY FORMATION

From looking at nursing informatics in a social and professional networking way to how we

using our websites and technology, there is a wide range of uses and importance of informatics. This

project gave a small glance at many perspectives. Genomic information paired with patient health

information from their EMR is beneficial in so many ways. This includes improving patient care and a

strong research potential and both patients themselves and society can benefit from this research

(Amer, K., 2015). While it is so beneficial, you must think do the risks outweigh the benefits due to

some ethical, safety, and legal concerns. We, as nurses, can help reduce any breaches of security by

following certain rules and being aware of protocols in place that also help with patient’s rights and

confidentiality.

Workflow maps help standardize how processes and tasks are completed. They eliminate

waste and reduce patient delays. This makes practice more efficient and better productivity for the

hospital. Eliminating waste means reducing spending costs for the hospital. Reducing patient delays in

turn increases patient outcomes.

A policy I have developed involves the discharge process. The policy will be called the

Discharge Process and Follow up Act. The policy will state that the patient is independent and able to

care for oneself at home upon discharge. The policy will enact that every hospital has a transition of
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care team that follows the patient after discharge. The policy will state that there must be a finalized

MAR, reviewed by pharmacy, nurses, physicians, and the patient. This record will then be transferred

through the electronic health network to the primary care physician so that immediate implementation

and follow up care can take place. Along with medications, any lab results, exams, scans, and reports

must be sent to the primary care physician. If the patient does not have a primary care physician, one

will be set up for them. The policy will also state there must be an adequate follow up process for up to

six months of discharge of the patient by the hospital transition of care team. This ensures the patient is

following appropriate care along with medication administration, nutrition, community resources,

lifestyle, and lifestyle management. HIPPA guidelines will be followed throughout the processes of

this policy so the patient's privacy remains intact. All nurses must also be educated on the use of

electronic health records, MARs, best HIPPA practice, and nursing informatics to expand their

knowledge and to decrease errors which will improve patient outcomes and decrease readmissions to

the hospital.
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REFERENCES

Agency for Healthcare Research and Quality. Guide to Patient and Family Engagement. Retrieved

from www.ahrq.gov

Amer, K., (2015, May). Informatics: Ethical Use of Genomic Information and Electronic Medical

Records. Retrieved from:

http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Columns/I

nformatics/Ethical-Use-of-Genomic-Information-and-EMR.html

American Nursing Association. (2016) Retrieved from:

https://anacalif.memberclicks.net/assets/Events/RNDay/2016%20code%20of%20ethics%20for

%20nurses%20-%209%20provisions.pdf

Effect of Bar-Code Technology on the Safety of Medication Administration. NEJM. (2010). Retrieved

from https://www.nejm.org/doi/10.1056/NEJMsa0907115?url_ver=Z39.88-

2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub=www.ncbi.nlm.nih.gov

Huynh N., Snyder R., Vidal J., Sharif O., Cai B., Parsons B., Bennett K. (2016, July). Assessment of

the Nurse Medication Administration Workflow Process. Journal of Healthcare Engineering.

Retrieved from https://www.hindawi.com/journals/jhe/2016/6823185/citations/

U.S. Department of Health and Human Services. Your Rights Under HIPPA. Retrieved from:

https://www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html