Supporting Evidence Based Practice Through Information Technologies

1. Supporting Evidence Based Practice Through Information Technologies Diane Doran, RN, PhD, FCAHS Lawrence S. Bloomberg Faculty of Nursing, University of Toronto

2. 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

3. 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

4. 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.

5. Competencies for Quality Health Care • Evidence-based practice • Quality Improvement • Informatics Crossing the Quality Chasm (Institute of Medicine, 2001)

6. Knowledge to Action Graham et al. 2006

7. MEASUREMENT outcome outcome process PDCA PROCESS Clinical Improvement Worksheet Aim: Accelerate clinical improvement by linking outcomes measurements and process knowledge with the design and conduct of pilot tests of change. • OUTCOMESSelect 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? • PROCESS Analyze the process • What’s the process for giving care to this type of patient? Functional Health Status Access System Assessment Dx Rx Satisfaction Against Need Clinical Outcomes Evidence Based Practice Patient with need for “x” Follow-up TotalCosts • CHANGES Generate change ideas • What ideas do we have for changing what’s done (process) • to get better results? • Eugene C. Nelson, DSc, MPH, and Paul B. Batalden, MD • July 1995, Lahey Hitchcock Clinic • PILOT Select first/next • change for pilot testing • How can we pilot test an improvement idea using the • Plan-Do-Check-Act method? Side A Based on the Serial Vee approach to improving clinical care: See article in April issue of The Joint Commission Journal on Quality Improvement.

8. Outcomes Focused Knowledge Translation

9. 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

10. 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.

11. Feedback about Patient Outcomes • Feedback encourages practice reflection • Improves clinician provider communication (Pyne and Labbate, 2008) • Encourages practice improvement (Lambert et al., 2005)

12. Where do we need to go & how do we get there? Informed by research: 3 studies • Outcomes in the Palm of Your Hand • Evidence at the Point of Care Through an e-Health Intervention • Evaluation of Mobile Information Technology to Improve Nurses’ Access to and Use of Research Evidence

13. The Emerging Role of Portable Technologies in Hospital and Community Nursing

14. 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).

15. 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-.

16. e-Volution in Outcomes-Focused Knowledge TranslationTM

17. 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

18. 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

19. Health Outcomes for Better Information and Care • Functional status • Symptoms • Pain • Nausea • Dyspnea • Fatigue • Therapeutic Self-Care • Pressure Ulcers • Falls

20. 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)

21. Outcome Assessment Outcome assessments are recorded through the wireless network.

22. Feedback Module Displays line graphs based on up to 6 prior assessments.

23. Best Practice Guidelines Key messages from the RNAO NBPG and College of Nurses of Ontario Practice Recommendations

24. BPG Module Braden Scale is initiated on the Outcomes Assessment Tool

25. Score is calculated by system and presented to the nurse

26. Recommendations are displayed

27. Research Development 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. Phase 1: Hospital-and community nurses contributed to the development of the system Phase 2: Usability evaluation in Lab study 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 Outcomes- Focused Knowledge Translation Intervention. Worldviews on Evidence-Based Nursing, 4(2), 69-77. Phase 3: Evaluation in field study

28. Field Evaluation Design: Quasi-Experimental Setting • Three Hospitals: 6 control units and 6 experimental units • Three home care agencies

29. 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

30. Sample Characteristics

31. Communication Among Health Care Providers

32. ANCOVA ResultsDifference Between Experimental and Control Units

33. Communication: Home Care

34. 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.

35. Limitations • Not integrated into the nurses’ documentation • Limited exposure of nurses to the intervention • Usual documentation paper based

36. Enhancing Service at the Point of Carefor Patients with Mental Health Problems and Addictions Through an e-Health Intervention

37. RESEARCH TEAM

38. Purpose To evaluate the usability and effectiveness of a knowledge translation system (e-Volution/ TREAT) aimed at enhancing communication and improving client-centered evidence-based care for clients who are living with schizophrenia or concurrent disorder

39. 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

40. 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

41. Schizophrenia Practice Guidelines Review Gaebel et al. 2005 (British Journal of Psychiatry)

42. Guidelines Selected • Social function • Support systems, including family and ‘significant other’ networks • Addictive behaviours

43. 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.

44. 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

45. 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.

46. Viewing background information If a BPG is chosen, the background can be viewed (rationale, evidence level, source)

47. Customizing the BPG • Clinicians can customize the intervention and make it client-specific in the “Comments” section.

48. Pilot Evaluation Study Design • Quasi experimental • Pre-Post test design; 4 month follow-up • Two experimental units and two control units

49. 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

50. Sample Characteristics, Staff 55 staff attended workshops about e-Volution/TREAT