Informatics is the merging of technology and information in the creation of a product or service which is useful to society or the individual (Laureate Education, 2018). Nursing informatics, in particular, is helpful in managing the myriad data produced in the healthcare process. As we start our study of nursing informatics, the connection between nursing science and information science needs to be emphasized. Nurses interact with information as a basic element of their role. Assessment, in all its forms, produces data which is processed and recorded as information for reference and analysis in decision-making (Mastrian & McGonigle, 2018). Access to accurate data is necessary for nurses to use clinical reasoning and judgment in the formation of knowledge. This post will describe a situation in which proper data collection and management would benefit patient care.
The Scenario: Lack of Uniformly Electronic Patient Health Record
The scenario which I will describe is not a hypothetical one; this is a real problem within the organization which employs me. I work at a level one inpatient psychiatric hospital. When I began my employment there five years ago, the entirety of the patient health record was documented manually on paper. The pitfalls of paper charting are well documented; two of the main issues being accessibility and portability. Two years ago, an electronic medication administration record (EMAR) was introduced. One year ago, some of the ancillary orders were built into the EMAR, quite poorly. The features of the EMAR we currently use are as follows: all medication order input and discontinuation, limited ancillary order input and discontinuation, vital signs input, limited assessment input, and all medication administration documentation. The assessment input is limited to certain assessments which are necessary to administer medications such as the Posero opioid-induced sedation scale (POSS). Note that other similar assessments required to administer medications, such as modified severity assessment scale (MSAS) and clinical opiate withdrawal scale (COWS), are arbitrarily not built into the EMAR. The rest of the patient health record is still recorded manually. It is easy to see how this is confusing. The organization refuses to purchase the entire electronic health records (EHR) platform and instead had the EMAR retrofitted to include some, but not all, of the ancillary orders and assessments. Because the EMAR was not meant for ancillary orders or assessments, the system is ineffective and confusing.
What we are left with is best described in terms of its deficiencies and failures. The issue is as much with the fact that the health record system is not uniform as it is that the majority of the patient health record is still documented manually on paper. Having a mixed health records system causes unnecessary confusion and errors. Workflow, accuracy, and communication suffer. Most of the physicians refuse to use the EMAR to input orders; this means that they hand write orders in the paper chart and nurses must transcribe these into the computer. All of the physicians refuse to review patient vital signs in the EMAR, so nurses must chart vital signs in the paper chart for the physicians and transcribe them to the EMAR in order to administer medications. Some, but not all, of the assessments must be performed on paper and then transcribed to the EMAR in order to administer medications. Because each physician can choose between the paper chart and the EMAR as the place where they enter their orders, nurses also have to review two separate places for new patient orders. Each of these instances of double charting and double reviewing add an extra step, making room for transcription errors and wasting time. Errors and wasted time are costly to stakeholders across the entire care continuum. Most important is the cost to patients in the form of poor patient care.
Description of Data
The data which I would collect are patient health record data. I would, specifically, collect the data uniformly in an EHR platform. The EHR platform includes many benefits. The data would be collected at the point of care and immediately entered directly into the EHR when possible. Healthcare workers collect data through patient assessment, documentation of interventions, and documentation of responses. These data are recorded at the point of care directly into the EHR. Clinicians would access the data electronically. Patients could access the data electronically, with the option to have the data printed from the EHR to be accessed manually for patients without computer access.
Knowledge Derived from Data
The knowledge which would be derived from this data set is knowledge of the patient health record. Assessment is the first step in the nursing process (Orlando, as cited in Toney-Butler & Thayer, 2019). Without access to proper assessment data, information cannot be used to plan, intervene, or evaluate properly. Assessments and interventions may be unnecessarily duplicated if the data is not readily available to successive clinicians caring for the patients. This duplication would represent a violation of patient rights and the nursing code of ethics (American Nurses Association, 2014).
Conclusion
Nurses use data to form information and knowledge, achieve better efficiency, enhance communication, and improve patient care (Laureate Education, 2018). In order for nurses to be effective in their role they must have access to efficient system of data management. The field of informatics, and specifically nursing informatics, is a growing specialty aimed at addressing the monumental task of managing the innumerable data produced by the healthcare process.
References
American Nurses Association. (2014). The code of ethics for nurses with interpretive statements. Retrieved from https://homecaremissouri.org/mahc/documents/CodeofEthicswInterpretiveStatements20141.pdf
Laureate Education (Producer). (2018). What is Informatics? [Video file]. Baltimore, MD: Author.
Mastrian, K. G., & McGonigle, D. (2018). Introduction to information, information science, and information systems. In D. McGonigle & K. G. Mastrian (Eds.), Nursing informatics and the foundation of knowledge (4th ed.) (pp. 21-34). Burlington, MA: Jones & Bartlett Learning.
Toney-Butler, T. J., & Thayer, J. M. (2019). Nursing process. StatPearls [Internet]. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK499937/