Transcript Presentation

Supporting
Evidence Based
Practice Through
Information
Technologies
Diane Doran, RN, PhD, FCAHS
Lawrence S. Bloomberg Faculty
of Nursing, University of Toronto
Objectives
• To increase understanding of the potential of
mobile information technologies to support
evidence based practice and decision making at
the point-of-care
• To increase understanding of the advantages
and disadvantages of different approaches for
integrating research evidence into electronic
care planning tools
• To identify the role of information technology in
the context of other established knowledge
translation interventions
Purpose of CE and Life Long Learning
• Validating one’s own practice and competence
• Gaining new knowledge or skills to apply in the
practice setting
• Closing an identified performance gap
• Improving patient care outcomes
• Generating increased professional satisfaction,
professional identity; possibly preventing or
decreasing burnout
Point-of-Care Learning
• A subset of workplace
learning, point-of-care
learning is defined as
learning which occurs
at the time and place
of a health
professional/patient
visit.
Competencies for Quality Health Care
• Evidence-based practice
• Quality Improvement
• Informatics
Crossing the Quality Chasm (Institute of
Medicine, 2001)
Knowledge to Action
Graham et al. 2006
MEASUREMENT
Clinical Improvement Worksheet
outcome
outcome
Aim: Accelerate clinical improvement by
process
linking outcomes measurements and
process knowledge with the design and
conduct of pilot tests of change.
 OUTCOMES
 PROCESS
Patient with
need for “x”
PROCESS
Select a population
What’s the general aim? Given our wish to limit/reduce
the illness burden for “this type” of patient, what are the
desired results?
Analyze the process
What’s the process for giving care to this type of patient?
Access
System
PDCA
Functional
Health Status
Assessment
Dx
Evidence Based
Practice
Rx
Follow-up
Satisfaction
Against
Need
Clinical
Outcomes
Total
Costs
 CHANGES
Generate change ideas
What ideas do we have for changing what’s done (process)
to get better results?
 PILOT
Select first/next
change for pilot testing
Eugene C. Nelson, DSc, MPH, and Paul B. Batalden, MD
© July 1995, Lahey Hitchcock Clinic
How can we pilot test an improvement idea using the
Plan-Do-Check-Act method?
Based on the Serial Vee approach to improving clinical care: See article in April issue of The Joint Commission Journal on Quality Improvement.
Side A
Outcomes
Focused
Knowledge
Translation
Defining Patient Outcomes
“ The changes in the patient’s health status
that can be attributed to antecedent
healthcare.”
(Donabedian, 1980)
Outcomes measurement tell us about how
patient’s respond to healthcare
interventions
Outcomes Focused Knowledge Translation
• Outcomes-focused
knowledge translation
aims at achieving
continuous
improvement of patient
care through the
uptake of research
evidence and
feedback data about
patient outcomes.
Feedback about Patient Outcomes
 Feedback encourages
practice reflection
Improves clinician
provider communication
(Pyne and Labbate, 2008)
Encourages practice
improvement (Lambert et
al., 2005)
Where do we need to go & how do we get
there?
Informed by research: 3 studies
Communication
& collaboration
Info @ point
of care
Health data
into
knowledge
1. Outcomes in the Palm of Your
Hand
2. Evidence at the Point of Care
Through an e-Health Intervention
3. Evaluation of Mobile Information
Technology to Improve Nurses’
Access to and Use of Research
Evidence
The Emerging Role
of
Portable
Technologies in
Hospital and
Community Nursing
Background
• It is a challenge for nurses to regularly access
information that is current and reliable (Estabrooks et
al., 2003).
• Nurses report a lack of interest or time for reading
journals or using the Internet (MacIntosh-Murray, 2005).
• ICU nurses feeling that seeking and analyzing
information from the Internet or other traditional
information resources could be ethically wrong—taking
time and focus away from patient care (McKnight,
2006).
• Information technology can help promote safe, high
quality care and enhance the continuity of care through
improved communication and decision support (Bates
and Gawande, 2003).
Uptake of Evidence
Systematic review of RCTs
• Computerized systems significantly more
effective than manual systems
• 75% of intervention succeeded when clinical
support was provided automatically (push rather
than pull)
• Information/advice provided at the point of care
more likely to lead to success than when not
provided in this context
Kawamoto, K., et al. (2005). Improving clinical decision support systems: a systematic
review of trials to identify features critical to success. BMJ, 330, 765-.
e-Volution in Outcomes-Focused
Knowledge TranslationTM
Investigator Team
D.M. Doran, University of Toronto
J. Mylopoulos, University of Toronto
A. Kushniruk, Victoria University
L. Nagle, University of Toronto
B. Laurie-Shaw, UHN
S. Sidani, Ryerson University
A. Tourangeau, University of Toronto
N. Levebre, Saint Elizabeth Health Care
C. Haughian-Reid, ParaMed Home Health Care
G. McCarthur, University of Toronto
J. Carryer, University of Toronto
L. Cranley, University of Toronto
Health Policy Change in Canada
•
•
•
•
•
Health Outcomes for Better Information and
Care (HOBIC)
Patient outcomes collected as part of
routine care and documented in health
record
Seamless across the continuum of health
care
Outcomes information available to nurses in
real-time
C-HOBIC – two other jurisdictions in Canada
Health Outcomes for Better Information
and Care
•Functional status
•Symptoms
–Pain
–Nausea
–Dyspnea
–Fatigue
Therapeutic Self-Care
Pressure Ulcers
Falls
e-Volution in Outcomes Focused
Knowledge Translation
Six Functions:
• Patient Outcomes Data
• Real-time feedback
• Best practice guidelines
• Case-based reasoning
• Drug dictionary
• Telephone
• Map (community)
• Order Codes (community)
Outcome Assessment
Outcome
assessments are
recorded through
the wireless
network.
Feedback Module
Displays line
graphs based
on up to 6 prior
assessments.
Best Practice Guidelines
Key messages from
the RNAO NBPG
and College of
Nurses of Ontario
Practice
Recommendations
BPG Module
Braden Scale
is initiated on
the Outcomes
Assessment
Tool
Score is
calculated
by system
and presented
to the nurse
Recommendations
are displayed
Research Development
Phase 1: Hospital-and community
nurses contributed to the
development of the system
Phase 2: Usability evaluation in
Lab study
Phase 3: Evaluation in field study
Doran et al. (2007). Evidence in
the Palm of Your Hand: Development
of an Outcomes-Focused Knowledge
Translation Intervention.
Worldviews on Evidence-Based
Nursing 4(2), 69-76.
Doran & DiPietro (2008). Human
And Social Issues in Information
Systems (Ed. Kushniruk)
Doran, D.M., et al. (2007).
Evidence in the Palm of Your Hand:
Development of an OutcomesFocused Knowledge Translation
Intervention. Worldviews on
Evidence-Based Nursing, 4(2), 69-77.
Field Evaluation
Design: Quasi-Experimental
Setting
• Three Hospitals: 6 control units and 6
experimental units
• Three home care agencies
Field Evaluation
Procedure
• Nurses on the experimental units attended a
training workshop and then used PDAs to
document outcomes of up to ten patients
each.
• Control and experimental unit nurses
responded to questionnaires about the quality
and timeliness of communication on their
units at two points in time
• Chart audits
Sample Characteristics
Sample
Mean age
Experience
Gender
Acute Care
170 nurses
42 years
10 years in
organization
90% Female
Home Care
22
47 years
6.5 years in
organization
91% Female
Hours worked
Education
83% Full-time
53% Diploma
100% Full time
68% Diploma
RNAP BPGs
63% BPGs
available
86% BPGs
available
PBG Utilization
63% not use BPGs 89% had not used
in last month
BPGs in last month
Communication Among Health Care Providers
ANCOVA Results
Difference Between Experimental and Control Units
Dependent
variable
F Value
Partial Eta
Square
R Square
Timeliness of
information
transfer
5.08
p<0.05
6%
11%
General
communication
5.28
p=0.05
6%
20%
Teamwork
3.69
p=0.06
5%
26%
Communication: Home Care
T1 Baseline
T2 follow-Up
Nurse/Nurse
3.81
3.35
Nurse/HCP
3.16
3.50
General
3.02
3.08
Best Practice Guidelines
• Significantly higher likelihood of
appropriate nursing interventions for
patients who met ‘trigger’ criteria for
pressure ulcers (Braden score) and
pain (intensity >1).
• However no difference in the
documentation of nursing
interventions consistent with the
Guidelines between experimental
and control patients.
Limitations
• Not integrated into
the nurses’
documentation
• Limited exposure of
nurses to the
intervention
• Usual
documentation
paper based
Enhancing Service at the Point of Care
for Patients with
Mental Health Problems and Addictions
Through an e-Health Intervention
RESEARCH TEAM
Diane Doran, RN, PhD,
FCAHS
Lawrence S. Bloomberg Faculty of Nursing,
Univ of Toronto
Jane Paterson, MSW
CAMH
Paula Goering, RN, PhD
CAMH
Lynn Nagle, RN, PhD
Lawrence S. Bloomberg Faculty of Nursing,
Univ of Toronto
André Kushniruk, PhD
Health Information Science, Univ of Victoria
Irmajean Bajnok, RN, PhD
Registered Nurses’ Assoc of Ontario
Carrie Clark, MA, OT Reg
CAMH
Rani Srivastiva, RN, MN
CAMH
Funding HTX/CIHR/HInext
Purpose
To evaluate the usability and effectiveness
of a knowledge translation system (eVolution/ TREAT) aimed at enhancing
communication and improving clientcentered evidence-based care for clients
who are living with schizophrenia or
concurrent disorder
Expert Panelists (15)
•
•
•
•
•
•
Schizophrenia unit managers
Psychiatrists
Advanced practice clinicians
Information technology team reps
Educator
Deputy Chiefs Professional Services and
Nursing Practice
• Decision support
• Support from Chief Nursing Officer
Guideline Review Criteria
 Quality of evidence
 Based on a systematic review, using the
AGREE Instrument






Feasibility using existing resources
Relevance/ prevalence
Interdisciplinary acceptability
Potential for change
Consistent with CAMH corporate values
Client-centered
Schizophrenia Practice Guidelines Review
Guidelines
Total AGREE Score
National Institute for Clinical Excellence
(UK)
90
American Psychiatric Association
71
Royal Australia & New Zealand College of
Psychiatrists
62
Scottish Intercollegiate Guidelines
58
Patient Outcome Research Team
55
Finnish Medical Society
52
….
Canadian Psychiatric Association (1998)
36
Gaebel et al. 2005 (British Journal of Psychiatry)
Guidelines Selected
• Social function
• Support systems, including family and
‘significant other’ networks
• Addictive behaviours
TREAT’s care plan
 TREAT’s electronic
Interdisciplinary Plan
of Client Care
(eIPCC)
 Integrates with the
clinical
documentation
process, with feeds
from RAI-MH,
Metabolic and
Restraint
assessments.
BPG + eIPCC =
Evidence-based information
at point of care planning
• Multiple discussions and iterations with the
clinical expert panel
• Created mock-ups and decided on the location
and functionality
• Natural and logical place to show accepted best
practices – at the time of creating an intervention
• Guidelines are displayed based on RAI-MH
triggers
How it works
•
Start typing an intervention in the Plan Section. BPGs associated
with the details for this issue will appear in a drop-down menu.
▸
Scroll over a BPG in the list and click on it to select it. It will
then appear as an intervention (plan) for that issue.
Users can also enter their own free text interventions.
▸
Viewing background information
• If a BPG is chosen, the background can be
viewed (rationale, evidence level, source)
Customizing the BPG
• Clinicians can customize the intervention
and make it client-specific in the
“Comments” section.
Pilot Evaluation Study Design
• Quasi experimental
• Pre-Post test design; 4 month follow-up
• Two experimental units and two control
units
Data Collection
Questionnaires
◦ Inter-disciplinary Collaboration pre and post
implementation (Adams et al. 1995)
◦ Norman Usability questionnaire (adapted)
Qualitative
◦ Observe 3 team meetings on each unit during
field test to learn how eIPCC was being used
◦ Semi-structured interviews to document staff
experiences

Electronic data of care planning tool
Sample Characteristics, Staff
Baseline Survey
68
78%
Sample size
Nurses
Follow-up Survey
61
79%
Other health
professionals
19%
16%
Physicians
Average age
Average unit
experience
3%
47 years
6 years
5%
55 staff attended workshops about e-Volution/TREAT
How is eIPCC used?
• Individually by Health Care Professionals
to communicate plans
• At interdisciplinary team meetings
- as a vehicle to record decisions about
priority issues
- as a framework to guide care plan
review and update
How Often Were the Guidelines added to eIPCC
during 4 months on study units?
Guidelines
Triggered
but not
visible to
user*
Care
planning
initiated
Selected,
added to
plan
Social Skills
Family
Support
223
327
34
47
27 (79%)
14 (30%)
Addiction
66
17
5 (29%)
* For the drop-down list of guidelines to be visible, a user must start
to enter information in the “plan” section of the eIPCC, at which time
the guidelines are presented as part of the decision support process.
Interdisciplinary Care Planning
6 team meetings observed; 58 clients discussed
eIPCC projected on large screen and visible in room
Focus
Issue
Discussed
Care planning
initiated
Guideline
included in care
plan
Social skills
38/58 (66%)
4/38 (11%)
4/4 (100%)
Family
29/58 (50%)
4/29 (14%)
4/4 (100%)
Substance
Abuse
10/58 (17%)
0
0
Barriers to Electronic Evidence-Based
Care Planning
 Team meeting focus on review of medications
and housing/discharge
 Lack of time to update care plan outside of team
meeting
 Work load
 Staffing shortage
 Use of agency and part-time staff
 Computer access …
being timed out, difficulty logging back in, low
comfort ability with using computers, easier access
to the patient chart therefore used more often.
Next Steps
• Collaboration to refine MHAPs
• Research to learn what influences interdisciplinary care planning
• Consider options or flags for alerting users
that guidelines exist
Ontario
MOHLTC
PDA
Initiative
The Personal Digital Assistant (PDA)
Initiative
• This initiative was part of MOHLTC commitment
to create positive and rewarding work
environments that will lead to an increased
retention of nurses.
• The PDA initiative provides nurses (RN, RPN
and NP) with improved access and integration of
evidence directly at the point-of-care.
• Anticipated outcomes of this project include:
– increased support for evidence-based
practice;
– improved patient/client outcomes; and
– enhanced quality of work-life for nurses.
Information Resources
RNAO BPGs
• RNAO BPGs
• McMaster
University
Nursing PLUS
• Lexi or Pepid
Nursing PLUS
Nurses have access to information
resources via PDAs or Tablet computers
Evolution from Phase I to Phase II
• Phase I
– Organizations were not permitted to use
the devices to store, receive or transmit
personal health information during the 12
months of the pilot project.
• Phase II
– Changes to the initiative allow the
organizations to store, receive or transmit
personal health information on the devices,
further supporting integration into practice.
Brand Models as Reported by participants
 BlackBerry
 Palm Treo
 HP-iPAQ
 Fujitsu Lifebook
 Saharas PC Tablet
 Symbol
 Motion C5
 iPhone
 +++
Evaluation Study
Investigator Team
Diane Doran, University of Toronto
Sharon Straus, University of Calgary
Jeremy Grimshaw,
Ottawa Health Research Institute
R. Brian Haynes,
McMaster University Faculty of Health Sciences
André Kushniruk, School of Health Information
Science, University of Victoria, BC
Linda McGillis Hall, University of Toronto
Adam Dubrowski, University of Toronto
Students
Kristine Newman
Tammie Di Pietro
Joan Almost
Ha Nguyen
Andrew Shantz
What were the Research Questions?
• Feasibility and usability?
• Frequencies of information
use?
• Search and retrieval in
Nursing PLUS library?
• Determinants of research
use?
• Influence on nurses’
information needs, job
satisfaction, quality of patient
care?
• What explains variation in use
patterns (Phase 2)?
Study Methods
Phase 1
• Acute care (9 sites)
• Home Care (5
sites)
• LTC (12 sites)
• Primary Health
Care
• Corrections (3
sites)
Sample
• 490 RNs and RPNs
Phase 2
•Acute care (14 sites)
•Community (4 sites)
•LTC (6 sites)
Sample
•742 RNs and RPNs at
Time 1
•504 RNs and RPNs at
Time 2
Questionnaires
Study variables
Phase 1
Phase 2
Barriers to research utilization (Funk
et al. 1991)
√
Perceived quality of care (Rubin et
al., 1990)
√
√
Job satisfaction (Laschinger &
Havens, 1996)
√
√
Context (Alberta Context Tool)
(Estabrooks et al.)
Utilization patterns
√
√
√
Frequency of Using Information Resources
≥ Every Few Days
Phase 1 (%)
≥ Every Few Days
Phase 2 (%)
Drug dictionary
52
39
Medical reference
information
49
41
Google
38.7
42
Nursing+ email
alerts
36.1
31
Search Nursing+
database
29.8
22
RNAO BPGs
24.7
31
Laboratory values
23.6
29
In-house resources
22.9
32
Calculator
20.9
23
Resource
Satisfaction with the Information Resources
Resource
Satisfaction
Satisfaction
Mean(sd)
Mean (sd)
(9-point scale)
(9-point scale)
Phase 1
Phase 2
RNAO BPGs
5.2 (2.2)
5.5 (2.4)
PEPID/Lexi resources
5.0 (2.5)
5.4 (2.5)
Nursing PLUS
4.9 (2.2)
5.2 (2.4)
Chance
Transforming
workplace learning
Opportunity
Necessity
Safer Patient Care for Community
“There are so many new
drugs out there, like BP meds,
etc, and quite an
increasing acuity in the
community.
This is just right there for you”.
Point-of-Care and
Decision Support
Home Care
• “Beautiful for
accessing information
right away”
• “Comfortable to use
in front of patient”.
“He didn’t have a
problem with that at
all. He was quite
happy that somebody
was able to take an
interest in what was
going on and how he
was feeling at the
time”.
Point-of-care
resources
Evidenced-Based Collaborative
Practice
Wound Care Protocol
“The resident thought her asthma attack and
hoarseness was caused by the antibiotics and
wanted to discuss stopping them. It was very
important that she stay on the medications if at all
possible. ….She needed to have the reassurance
based on evidence that the meds were not causing a
respiratory- based adverse effect.”
Peer Support
“I was teaching a fellow
nurse on how to access the
infection control modules and
test. I walked the RPN
through on how to use
PEPID and we looked up
medications (i.e. Lasix,
Coumadin).”
I was orientating a new RPN
in our long-term care facility
and she has a question
regarding an injection she
was about to give. I was
able to able to look up the
requested information at the
resident’s bedside…”
“We reviewed the
picture on how to
complete a task-catheterization,
labour and
delivery…”
Change Over Time By Device
Variable
PDA Users
T (n~73)
Nurse barriers
Organizational barriers
Characteristics of the
innovation
Communication barriers
Improvement in quality of
care
Improvement in job
satisfaction
2.3**
2.0*
2.2*
Tablet
Users
T (n~58)
0.70
0.76
0.59
1.4
-2.9***
2.2*
0.92
-3.5***
1.38
*P<.05, **p< .01, ***p< .001
Device by Sector Interaction
Change in Quality of Care (Phase 1)
Device by Sector Interaction
Change in Job Satisfaction (Phase 1)
• What accounts
for variation in
findings
between device
types and
between health
care sectors
PARiHS Framework
Context
Evidence
Facilitation
Rycroft-Malone et al. (2002)
PARiHS Framework
RNAO BPG
Context
McMaster
Nursing+
Evidence
Facilitation
Medical /
Drug
Reference
Rycroft-Malone et al. (2002)
PARiHS Framework
Leadership
Context
Culture
Evidence
Facilitation
Evaluation
Rycroft-Malone et al. (2002)
Frequency of Use by Sector – Phase 2
Variables Associated with Increase Use of
PDA/Tablet
• PDA versus Tablet (+)
• Technology penetration (+)
• Home Care sector (+)
• Adjusted R2 = .28
Variables Associated with Increased Use of
RNAO BPGs
• Advanced practice, clinical educator role (+)
• Technology penetration (+)
• Home care setting (+)
• Access to structural and electronic resources
(+)
• Organization culture (+)
• Organizational slack staff (-)
• Adjusted R2 = .21
Variables Associated with Increased Use of
McMaster University Nursing+
• Technology penetration (+)
• LTC sector (-)
• ACT Formal interaction (-)
• Organizational slack staff (-)
• ACT culture (+)
• Adjusted R2 = .21
Variables Associated with Increased Use of
Drug Reference Information
• PDA versus Tablet (+)
• Education (-)
• LTC sector (-)
• ACT culture (+)
• ACT informal interactions
• Adjusted R2 = .20
Conclusions
•Mobile
technologies have
the potential to reduce
barriers to research
utilization and support
clinical decision making
•Results were device and
sector specific
•Individual and contextual
variables explain variation in
use
Role of Technology in Knowledge Translation
 Decision support
 Audit and Feedback
 Increase access to information resources at
point-of-decision making
• However information technologies need to be
incorporated into other change strategies
such as:
– Leadership support
– Supportive culture
– Change agents/ facilitation
References
•
•
•
•
•
•
•
•
•
DONABEDIAN, A. (1980) The definition of quality and approaches to its assessment, Ann Arbor, MI, Health
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Thank you & Questions!