BACHELOR OF SCIENCE IN NURSING:

NURSING INFORMATICS
COURSE MODULE COURSE UNIT WEEK
2 8 9

Incorporate Evidence and Policies in Nursing Informatics

Read course and unit objectives

Read study guide prior to class attendance
Read required learning resources; refer to unit
terminologies for jargons
Proactively participate in classroom discussions
Participate in weekly discussion board (Canvas)
Answer and submit course unit tasks

At the end of this unit, the students are expected to:

Cognitive:
1. Discuss the clinical decision support systems
2. Enumerate components of clinical decision support systems
3. Cite key functions of clinical decision support systems
4. Give examples of early clinical decision support systems
5. Identify policies and issues related to the practice of nursing informatics.

Affective:
1. Listen attentively during class discussions
 2. Demonstrate tact and respect when challenging other people’s opinions and ideas
3. Accept comments and reactions of classmates on one’s opinions openly and graciously.

Psychomotor:
1. Participate actively during class discussions and group activities
2. Express opinion and thoughts in front of the class

Saba, V., and McCormick, K. (2006) Essentials of Nursing Informatics 4th Edition, Overview of
Computers and Nursing, Historical Perspectives of Nursing and Computer (pp 70-84). New York:
McGraw-Hill Companies

Introduction

Decision Support Systems (DSS) are automated tools designed to support decision-making activities
and improve the decision-making process and decision outcomes similar to Artificial Intelligence (AI).
Such systems are intended to use on enormous amounts of data that exist in information systems
to facilitate decision process. A clinical decision support system (CDSS) is designed to support
healthcare providers in making decisions about the delivery and management of patient care. A
CDSS program’s goals may include patient safety and improved outcomes for specific patient
populations as well as compliance with clinical guidelines, standards of practice, and regulatory
requirements. Within the complexity of today’s healthcare environment there is an increasing need
for accessible information that supports and improves the effectiveness of decision-making and
promotes clinical accountability and the use of best practices.

The definition of CDSS is well explained by Wyatt and Spiegelhalter. They regard Clinical Decision
Support Systems as active knowledge systems which use two or more items of patient data to
generate case-specific advice. Clinical DSSs are typically designed to integrate a medical knowledge
base, patient data and an inference engine to generate case specific advice.

Components of Clinical Decision Support System (CDSS)

The following five elements are necessary, but not significant for a real-time clinical decision
support system:
 • Integrated real-time patient database – combines patient data from multiple sources (e.g.
lab, radiology, pharmacy data etc.). This is needed to provide context for results
interpretation.

• Data-driven mechanism – allows event triggers to go into effect and activate alerts and
reminders automatically.

• Knowledge engineer – translate the knowledge representation scheme used in the system
so clinical knowledge in the system can be extracted and translated into machine
executable logic.

• Time-driven mechanism – permit automatic execution of programs at a specific time to

alert healthcare provider to carry out a specific function or ensure that action has been
completed (e.g. medication administration, time alerts)

• Long-term clinical data repository – data collected over time from a variety of sources
allowing a longitudinal patient record.

Key Functions of CDSS

Perreault and Metzger identified four (4) key functions of CDSS in the healthcare field:

• Administrative - Supporting clinical coding and documentation, authorization of

procedures, and referrals.
• Managing Clinical Complexity and Details - Keeping patients on research and
chemotherapy protocols; tracking orders, referrals follow-up and preventive care.
• Cost Control - Monitoring medication orders; avoiding duplicate or unnecessary tests.
• Decision Support - Supporting clinical diagnosis and treatment plan processes; and
promoting use of best practices, condition-specific guidelines, and population-based
management

Early Clinical Decision Support Systems

• Internist I - was a rule-based expert system designed at the University of Pittsburgh in 1974 for
the diagnosis of complex diagnosis of complex problems in general internal medicine. It uses
patient observations to deduce a list of compatible disease states (based on a tree-structured
database that links diseases with symptoms).

• MYCIN - was a rule-based expert system designed to diagnose and recommend treatment for
certain blood infections (antimicrobial selection for patients with bacteremia or meningitis). It was
later extended to handle other infectious diseases. Clinical knowledge in MYCIN is represented
as a set of IF-THEN rules with certainty factors attached to diagnoses. It was a goal-directed
 system, using a basic backward chaining reasoning strategy (resulting in exhaustive depth-first
search of the rules base for relevant rules though with additional heuristic support to control the
search for a proposed solution).

• CASNET - (Causal Associational Networks), developed in the 1960s, was a general tool for
building expert system for the diagnosis and treatment of diseases. The most significant Expert
System application based on CASNET was CASNET/Glaucoma for the diagnosis and treatment
of glaucoma.

• DxPlain - is a decision support system which uses a set of clinical findings (signs, symptoms,
laboratory data) to produce a ranked list of diagnoses which might explain (or be associated with)
the clinical manifestations. DXplain provides justification for why each of these diseases might
be considered, suggests what further clinical information would be useful to collect for each
disease, and lists what clinical manifestations, if any, would be unusual or atypical for each of
the specific diseases

Myths Affecting Development of CDSS

• The healthcare industry challenged three basic assumptions which strongly influenced the
development of decision support systems:

o “Diagnosis is the dominant decision-making issue in medicine”

o "Clinicians will use knowledge-based systems if the programs can be shown to function at
the level of experts"
o "Clinicians will use stand-alone decision-support tools."

• By implication, these myths, which are gradually being overcome, partly contributed to the
relative lack of success of DSS in clinical care.

Policy Issue #1: Nursing Informatics as a Specialty

In 1992, the American Nurses Association (ANA) recognized nursing informatics (NI) as a specialty.
Attempts in 1989 to be recognized as a specialty failed, but political forces within ANA supported the
request when it was repeated in 1992.

The term NI first appeared in the literature in 1980s. It has constantly evolved molded by the
maturation of the field and influenced by health policy. NI practice differentiates itself from other
areas of nursing practice but emphasizes its interaction with informatics discipline such as
mathematics, statistics, linguistics, engineering, computer science and health informatics.

NI supports national efforts, such as those outlined by the Pew Health professions and Institute of
Medicine to increase interdisciplinary education.
To become a specialty, it was necessary for NI to show that educational programs are available to
prepare nurses to practice in the field. The field of NI has slowly expanded since 1992. It will be
interesting to see how the current focus on IT impacts the growth of NI as a specialty

Policy Issue #2: Nursing Informatics Practice

Nursing has experienced a number of shortages in recent history. The healthcare industry is headed
for a major crisis in the nursing workforce. At the same time, the aging of baby boomers will cause
increased demand for hospital services.

In 2002, the American Academy of Nursing (AAN) Commission on Workforce launched a multiphase
project to develop IT that will help support nurses in their day-to-day work, thereby reducing demand
on their jobs. Given the average age of nurses are 45.2, technology devices would enable some
nurses to stay in their careers longer.

On the other hand, patient safety is also a concern for nurse informaticist. Proposals to increase
patient safety with the use of IT have been made by a variety of groups. California law 1875, for
example, passed in 2003, applies pressure to hospital to install IT to help healthcare providers
reduce errors.

The Health Insurance Portability and Accountability Act (HIPAA) was passed in 1996 and is intended
to improve the public and private healthcare programs by establishing standards to facilitate the
efficient transmission of electronic health information.

Policy Issue #3: TeleHealth and Nursing Informatics

Telehealth is defined as the use of electronic communication networks to transmit data or information
that focuses on health promotion, disease prevention, diagnosis, consultation, education, and/or
therapy. In one of its many forms telehealth has been practiced ever since the advent of the
telephone. Telehealth in patient care covers many areas, but can be divided into two distinct parts,
the technology and the provider/client relationship. On the technology side are many different
technologies including advanced image and audio capabilities that range from high resolution still
images to sophisticated interactive teleconferencing systems. Technology is now available that
allows a virtual simulation of tissues and blood flow. Use of the Internet to transmit the feel of a
lesion, or even muscles and bones, prior to surgery will happen soon.

As part of its participation in the national dialogue on telemedicine/telehealth, ANA on August 29,
1996, submitted preliminary comments to a Joint Working Group (JWG) convened by the Health
Resources and Services Administration (HRSA) of the U.S. Department of Health and Human
Services. ANA continues to develop a more detailed and comprehensive analysis of the broad range
of issues relevant to the continued growth and development of telehealth. There have been various
proposals made to amend the current state-based system to adapt to the increasing demands of
telehealth. Of these, California State Senate Bill 1665 has advanced the farthest. It addresses some
of the issues related to telehealth -- for instance, by allowing for consultation services from an out-
of-state practitioner -- but leaves open many other issues related to provision of care other than
consultation, including primary health services.

Decision Support Systems (DSS)- automated tools designed to support decision-making

activities and improve the decision-making process and decision outcomes similar to Artificial
Intelligence (AI).

Open Clinical (2008), Clinical Decision Support Systems, Retrieved October 14, 2019 from Open
Clinical Webpage, Website: http://www.openclinical.org/dss.html#functions

• If you were tasked to develop a Philippine Policy on Health Informatics, what would it be and
why? (300-500 words)
• Download a research article on DSS and explain the following: Objectives, Methods, Results
and Implications.

Saba, V., and McCormick, K. (2006) Essentials of Nursing Informatics 4th Edition, Incorporating
Evidence: Use of Computer-Based Clinical Decision Support Systems for Health Professionals,
Nursing Informatics and Healthcare Policy (pp 167-194). New York: McGraw-Hill Companies

ANA (2008), TeleHealth: Issues For Nursing, Retrieved October 16, 2019 from American Nurses
Association Webpage, Website:
http://nursingworld.org/MainMenuCategories/HealthcareandPolicyIssues/Reports/ANAPrinciples/N
urseStaffing/Telehealth.aspx

Topwireless Inc. (2008), Different Types of Wireless Device, Retrieved October 14, 2019 from
TopWireless Webpage, Website:
http://www.topwirelessmall.com/wireless-device.html