Documentation
- 2 key elements of collaborative work - communication & documentation.
- Process of obtaining, organizing, and conveying health information.
- In print or electronic format.
- Component of larger health information technology (HIT).
- Used to support information synthesis.
Nursing Expectations
Technology can not replace our knowledge and expertise in making a
decision, technology is there as a support not to replace our training
and critical thinking.
* Competency in health information technology is an expected
requirement as an entry to practice competency from CNO and CASN.
* We need to have the ability to use information and communication
technologies to support information synthesis in the delivery of care
of people, families and communities.
* Obligated by CNO regulations to protect and secure the data that we
have access to, as well as ensuring that the information that we are
sharing protects the patient’s privacy.
Health Informatics
the application of
information technology to healthcare,
which involves the management and use
of health information to improve patient
care, outcomes, and research.
Computerized Health Information Technology (HIT)
Systems
- Computers allow accessible information
- HIT are the hardware, software and
infrastructure required to collect, store,
access and exchange electronic health care. - Making care safer by engaging people as
partners, promoting communication &
increasing preventative practices with
evidence informed care. - We as nurses need to know how to
incorporate technology into practice - Designed to support multiple information
needs.
E-Health Records
Electronic Health Records (EHR) are a lifetime record
of all health care occurrences.
EHRs are a component of the larger health
information technology (HIT) system.
The use of HIT can improve people’s safety and
health outcomes and assist providers in being more
efficient and effective.
* EHR – Electronic Health Record
* EMR – Electronic Medical Record
* EPR – Electronic Patient Record
* PHR – Personal Health record
3 Keys to Electronic Records
INTEROPERABILITY
Allowing different health agencies to “talk to each other” to exchange health information.
This helps reduce redundancy as unnecessary repetition of tests is avoided.
PORTABILITY
Electronic records are more durable and portable than paper charts, and they are easily
transferable. Presently there is no single national EHR in Canada, so access to health
information by others is limited.
EASE OF ACCESS
Access can be had at the point of care or remotely using digital devices. People can give
permission for access by multiple caregivers for anytime.
Essentials of Nursing Documentation
-clarity
-efficiency
-safety ( made care safer by forcing
standardization of nursing terminology, eliminate use of
inappropriate abbreviations, and avoid problems of
illegibility.)
Standards of Documentation: Ethical, Regulatory &
Professional
- Confidentiality and Privacy- act of limiting disclosure of private matters appropriately,
maintaining the trust of the individual. - Legal Aspects of Charting- ‘Not documented, not done’
- Accountability- develop data for multiple levels of accountability, including for individual
health care providers, government agencies and policymakers.
Big Data
Big Data analytics is the process of examining and uncovering valuable insights from
large and complex datasets.
Importance of Big Data Analytics in
Population Health Management
- Identifying health trends and patterns within a
population. - Predicting and preventing diseases and health
risks. - Assessing the effectiveness of interventions and
healthcare programs. - Supporting evidence-based decision-making for
population health strategies.
Role of Nurses in Big
Data Analytics
Utilizing data analytics tools to
identify health trends and risks.
Big Data analytics plays a vital role
in population health management,
enabling nurses and healthcare
professionals to make informed
decisions, improve patient
outcomes, and optimize healthcare
delivery.
Participating in data collection and
documentation processes.
Collaborating with interdisciplinary
teams for data-driven decision-making
What is Digital Health?
- The act of using
technology to support
our practice. - Many different ideas of
what technology
represents. - For the purposes of this presentation
technology is “systems and devices that
are non-human and have a
computerized function.” - For example: computers, eHealth,
information and communication
technology, informatics, smart devices.
Why Digital Health?
-Communication
Facilitation
-Enhanced
Workflow
-Artificial
Intelligence
Types of Digital Health Technology Robots
- Robots are being developed to perform roles such
as personal service, medication administration,
assisting with ambulation, engaging in supportive
communication. - Nurses will be freed up from doing ADL tasks, to
be able to focus on critical thinking, collaboration,
negotiating, navigating, assessments and
compassionate care. - Being developed at a rapid pace, will continue to
grow and change in the next 10 years.
Types of Digital Health Technology: Biomedical
Monitoring
- Examples are noninvasive automatic recordings of vital
signs, wireless telemetry, smart beds with sensors,
wearable devices to be alerted if someone fell. - Wearable devices in the community that can measure,
heart rate, respiratory rate, blood pressure that is then
uploaded to an app which a healthcare provider can
review. - We already see this very prevalent in the community
with things like continuous glucose monitors, apple
watches and fit bits.
Types of Digital Health Technology: E-Visits and
Telehealth
E-Visits
* A person may use the
biomedical monitoring
devices to transmit
health data to home
care nurses.
* Major reductions in
hospital admissions and
number of actual home
visits required.
Telehealth
* Early adoption of telehealth
in 1970 via the use of
telephone technology.
* Now includes internet access
and high- definition visual
and audio two-way
communication.
* The telehealth nurse can
see, monitor and remotely
interact with people using
their own devices.
Types of Digital Health Technology: Computerized
Clinical Decision Support Systems
- Information programs that are designed to assist in decision making.
- The patient’s information is inputted, and the database provides you with person
specific care guidelines, such as alerts, diagnostics, and disease management. - For example, the clinical decision support system (CDSS) for sepsis management. As you
input your patient’s vitals and lab results, the system will alert you to how likely your
patient is septic, what tests should be ordered and what medications should be started. - Some CDSS use machine learning as a way to recognize patterns and make predictions,
they are able to learn from past experiences and look at trends in data to make their
decisions.
Benefits of Health Technology
- Digital health apps are easy for anytime,
anywhere learning. - Improved health learning with interactive
computer teaching programs. - Assist people to self-manage and communicate
with health care providers. - People can control their own personal health
records. - Can improve workflow and provide safer care.
cons of health tech
-Interoperability
* The fast changes in technology
create a steep learning curve
for nurses.
* Nurses should be involved and
have input in the development
of programs.
* If nurses find that their
workflow is disrupted by
technology issues, they will
find “work arounds” that can
negatively impact patient
safety.
-Alarm Fatigue
* A CDSS might send
many alerts in a day, so
nurses learn to ignore
them.
* As many as 90% of
alarm alerts are
overridden
-Data Privacy
* As we put more personal
data online, it is important to
we are protecting and
securing this data
* Need for sophisticated and
secure data management
programs
* Ensuring proper data
governance and ethical use of
health information.
summary
- Digital health is transforming the ways nurses communicate with other health
professionals. - Technology provides nurses with new tools to assist with person centered care.
- Communication with health care professionals is improved with access to digital health
and use of E-records - Quality of care provided improved.
