by Maxim Topaz, RN, MA Doctoral Student
Kavita Radhakrishnan PhD, MSEE, RN
Ruth Masterson – Creber Doctoral Student, MSc, RN
and Kathryn H. Bowles, PhD, RN, FAAN Associate Professor, Senior Editor
University of Pennsylvania School of Nursing
Topaz, M., Radhakrishnan K., Masterson-Creber R. and Bowles K.H. (June 2012). Putting evidence to work: using Standardized Terminologies to incorporate Clinical Practice Guidelines within homecare Electronic Health Records. Online Journal of Nursing Informatics (OJNI), 16 (2), Available at http://ojni.org/issues/?p= 1694
Each year approximately 12 million individuals receive care from more than 33,000 providers in homecare settings across the United States (The National Association for Home Care & Hospice, 2010). These numbers are expected to increase as there is a growing recognition of the importance of outpatient settings and their impact on healthcare outcomes. Nurses are key healthcare professionals who provide homecare for patients with chronic conditions and therefore, are expected to be experts in managing complex chronic conditions (New England Healthcare Institute, 2009). However, it is challenging for nurses to remain current on the frequently updated evidence based knowledge on managing chronic conditions. Recent studies report that homecare nurses often lack knowledge on best practices for treating complex chronic conditions such as heart failure (HF) or diabetes (Albert, 2006; Delaney, Apostolidis, Lachapelle, & Fortinsky, 2011; el-Deirawi & Zuraikat, 2001; Fowler, 2012).
According to the Institute of Medicine, there is a delay of 17 years from publication of research findings to widespread adoption in practice settings (IOM, 2001). The electronic health record (EHR) offers powerful solutions for knowledge representation and application in health care (IOM, 2003). In order to bridge the gap between research and practice and to improve the quality of care, evidence-based Clinical Practice Guidelines (CPGs) can be incorporated into homecare agencies’ EHRs. This integration is especially pertinent since EHRs are expected to be mandated legislatively for the homecare settings in the near future (Sockolow, Adelsberger, & Bowles, 2011). Meaningful and appropriate incorporation of CPGs into EHRs will help homecare nurses implement the best available practices at the point of care. One of the key capabilities of the EHR are Clinical Decision Support (CDS) systems designed to impact clinician decision making about individual patients at the point in time that these decisions are made. Incorporating CPGs into CDS will prompt homecare nurses with the relevant chronic disease management or prevention strategies, which will improve the quality of care delivered to homecare patients. Use of evidence-based guidelines in CDS within the EHR will also improve and standardize the collection of relevant clinical data and allow evaluation of effectiveness of homecare programs (IOM, 2003; Martin, 2005; Monsen et al., 2006; Sucher, Moore, Todd, Sailors, & McKinley, 2008).
To enable widespread adoption and easy integration within EHRs, CPGs should be first translated into a Standardized Language (SL). SL is an agreed upon vocabulary that creates an unambiguous way to store and use clinical data in EHRs. Currently, the American Nursing Association recognizes thirteen standardized languages that support nursing practice (Rutherford, 2008). One example is the Omaha System (OS), an internationally recognized SL focused on homecare and public health settings that has proven potential to meaningfully represent clinical data in EHRs (Martin, 2005). In this editorial, we will present several examples of an emerging nursing body of evidence on the use of the OS to incorporate CPGs for the homecare clinical practices. We will also identify some challenges and future directions for the successful application of CPGs in the EHRs.
Nursing research is increasingly advancing the methodologies used to translate CPGs into the EHR. For instance, one study focused on the translation of a well-established depression guideline into the OS (Monsen et al., 2012). First, the researchers translated the most recent edition of the Institute for Clinical Systems Improvement (ICSI) Guideline on Major Depression in Adults in Primary Care (Institute for Clinical Systems Improvement, 2011) into the OS. Afterwards, the research team reviewed and revised the guideline several times until consensus on the semantic and logical correctness of the translation was reached by the team members. The OS was found a suitable standardized terminology to enable the successful guideline translation. This study provides an exemplar of how to incorporate current CPGs into EHRs in outpatient settings using the OS (Monsen et al., 2012). Also, the OS translated depression CPGs might serve as a base for the creation of future CDS tools.
Another example is our ongoing study funded by a grant from the Faculty Senate Research Committee, School of Nursing, University of Pennsylvania (Topaz et al., 2012). In light of the alarming results from several studies on homecare nurses’ lack of knowledge on best practices for treating HF patients (Albert et al., 2002; Albert, 2006; Delaney et al., 2011), our project aims to bring the best available evidence based knowledge to the point of care. Unfortunately, there are no CPGs that provide best strategies for all HF related nursing treatments and interventions in the outpatient settings. Therefore, we contacted a group of leading HF academic and practice experts in homecare settings to review and extract guidelines relevant to homecare nursing from two well established HF CPGs, namely the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines and Heart Failure Society of America (HFSA) guidelines (HFSA, 2010; Hunt et al., 2009). These relevant and validated HF homecare CPGs are now being translated into the OS for their possible incorporation into the homecare agencies’ EHRs. In the final step of our project, the translation will be validated through experts’ review and consensus. In agreement with the previous research in the field, our preliminary results show that the OS is an appropriate framework for the translation of HF CPGs.
The results of this emerging body of evidence suggest that nursing informaticians are on the forefront of medical informatics research that focuses on the translation of evidence to clinical practice through the information technology. These tendencies are also well aligned with the suggestions of several recent reports (for example the IOM report on the Future of Nursing) (IOM, 2010) and legislative efforts aimed towards a widespread incorporation of evidence into clinical practices (such as the Meaningful Use) (ONC, 2011). However, successful incorporation of CPGs into practice faces several challenges that are yet to be comprehensively addressed by the health informatics researchers and healthcare stakeholders.
As mentioned earlier, evidence-based CPGs for many chronic diseases, such as HF or diabetes, do not exclusively focus on nursing care. Moreover, most of the existing guidelines are developed for use by prescribing providers such as physicians or nurse practitioners. Therefore, additional time and expertise is required to adapt and extract CPGs to non-prescribing homecare nurses. Also, the boundary between information on CPG interventions for prescribing healthcare providers and what could be background information for homecare nurses is unclear. For example with HF patients, while it is beneficial for nurses to know the rationale for medication prescription, would information on recommendations for initiating coronary revascularization treatment or placement of ICD devices also be relevant to homecare nurses?
One of the solutions to this problem is to have homecare nursing research and practice experts extract and review relevant evidence to build homecare appropriate clinical pathways and guidelines. However, this approach is somewhat challenging because of the lack of the readily available nursing expertise and the required funding to cover reviewers’ efforts. We would also suggest that professional CPG-constructing organizations, such as the Cochrane Collaboration or the National Guideline Clearinghouse in collaboration with home health associations or consortiums related to SL, such as the Omaha System Partnership for Knowledge Discovery and Health Care Quality (Monsen, Martin, & Bowles, 2012), should pay more attention to building CPGs relevant for non-prescribing practitioners in the homecare settings. These CPGs should focus on the behavioral aspects of chronic diseases self-care and assessment strategies for homecare nurses.
Another issue arises when CPGs are translated to a standardized language or terminology. Similarly to the between languages translation, the challenge is to evaluate the accuracy, completeness and appropriateness of the translation. In this case, the expert consensus is often used to validate translation of CPGs to SL. However, obtaining a unanimous consensus on the validity of the translation might be challenging. A partial solution is to apply a formal consensus methodology, such as the Delphi method, which could help establish content validity of the translated guideline (Chang, Gardner, Duffield, & Ramis, 2010; Huang, Lin, & Lin, 2008). The translated guideline could be reviewed and revised until majority consensus is attained on the equivalence of the translated guideline instructions with the SL terms. Another solution is to standardize the translation processes and educate a readily available body of experts qualified to assist and evaluate the translations. One example of such an effort is a workshop conducted in the last April by K. S. Martin and K. A. Monsen, leading experts and members of the OS Board of Directors. This workshop was aimed to certify OS coders and standardize the process of CPG OS translation. More efforts like this are urgently needed to enable a standardized and reliable translation of evidence to clinical practice.
Putting the evidence to work through the use of CDS tools is yet another urgent challenge that needs to be addressed in this context. Currently, most of the EHR systems in the homecare settings are constructed and maintained by the diverse body of vendors, starting from large companies such as McKesson to small local EHR businesses. As suggested by the recent Institute of Medicine report titled “Health IT and Patient Safety: Building Safer Systems for Better Care” (2012), this complexity and proprietary restrictions often lead to the lack of transparency on the structure and functionalities of EHRs. Also, healthcare providers depend on vendors for updates and creation of the new CDS tools. This results in the lack of clear and standardized instructions on how to best incorporate the translated CPGs into the existing or new CDS tools. Also, the complex interplay between the vendors and providers might contribute to the delays in CPGs application in real practice as both of the sides have very limited time and resources to accomplish this complex task.
These complex vendor-provider issues are addressed, to at least some extent, by the upcoming legislative changes. For example, advanced stages of the Meaningful Use will require the application of CDS using updated CPGs (ONC, 2011). Also, the upcoming (and debated) healthcare reform is deemed to change healthcare reimbursement strategies leading to better vendor-provider collaborations and focus on the quality of care through the most updated evidence. These significant efforts aimed towards the improvement of healthcare coordination and quality should improve the application of the CPGs in homecare practices in the near future, but meanwhile more research and practical solutions are needed.
Reflecting on the existing literature and the emerging trends in the evidence translation research, we suggest several future directions for homecare providers, vendors and researchers. First, creating a standardized architecture and structure of the CDS systems should become a priority. According to one of the proposed stage II meaningful use criteria “each CDS intervention must enable the provider to review: the developer of the intervention, bibliographic citation, funding source of the intervention, and release/revision date of the intervention” (CMS, 2012. p. 73.). If this proposed requirement becomes a reality in the near future, providers that don’t have the required CDS information in place might be financially penalized by the CMS. To address this, CDS tools of the near future should be flexible and allow providers to add/change instructions or other related information frequently, for example when the CPGs are updated. To align with the new meaningful use requirements, we incorporated detailed information about the grades of evidence for each intervention and bibliographic citations in our homecare-adapted HF CPGs.
Our additional suggestion stems from the understanding that CPGs implementation in real settings is a team effort of clinicians, homecare agencies, vendors and researchers. To stay up to date with the most recent evidence and avoid potential financial loss, homecare agencies will have to be more proactive in terms of hiring clinicians with informatics skills and achieving better collaboration with their EHR vendors. In turn, healthcare informatics researchers should focus their attention on providing the vendors and clinicians with a best possible standardized architecture for the flexible, easily updated and safe CDS tools. Lastly, preparing for the upcoming changes vendors should create more transparent EHR systems that will enable better control and involvement of the healthcare providers.
Albert, N. M. (2006). Evidence-based nursing care for patients with heart failure. AACN Advanced Critical Care, 17(2), 170-83; 184-5.
Albert, N. M., Collier, S., Sumodi, V., Wilkinson, S., Hammel, J. P., Vopat, L., . . . Bittel, B. (2002). Nurses’ knowledge of heart failure education principles. Heart and Lung: Journal of Acute and Critical Care, 31(2), 102-112.
Chang, A. M., Gardner, G. E., Duffield, C., & Ramis, M. (2010). A Delphi study to validate an advanced practice nursing tool. Journal of Advanced Nursing, 66(10), 2320-2330.
CMS. (2012). CMS proposed rule for stage 2 criteria for qualification of an EHR for the Medicare incentive program. (). Washington, DC: CMS.
Delaney, C., Apostolidis, B., Lachapelle, L., & Fortinsky, R. (2011). Homecare nurses’ knowledge of evidence-based education topics for management of heart failure. Heart & Lung : The Journal of Critical Care, 40(4), 285-292. doi:10.1016/j.hrtlng.2010.12.005
el-Deirawi, K. M., & Zuraikat, N. (2001). Registered nurses’ actual and perceived knowledge of diabetes mellitus. Journal for Nurses in Staff Development : JNSD : Official Journal of the National Nursing Staff Development Organization, 17(1), 5-11.
Fowler, S. (2012). Improving community health nurses’ knowledge of heart failure education principles: A descriptive study. Home Healthcare Nurse, 30(2), 91-9; quiz 100-1. doi:10.1097/NHH.0b013e318242c5c7
HFSA – Heart Failure Society of America. (2010). Executive summary: HFSA 2010 comprehensive heart failure practice guideline. Journal of Cardiac Failure, 16(6), 475-539.
Huang, H., Lin, W., & Lin, J. (2008). Development of a fall-risk checklist using the Delphi technique. Journal of Clinical Nursing, 17(17), 2275-2283.
Hunt, S. A., Abraham, W. T., Chin, M. H., Feldman, A. M., Francis, G. S., Ganiats, T. G., . . . Tarkington, L. G. (2009). 2009 focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults: A report of the American college of cardiology Foundation/American heart association task force on practice guidelines. Developed in collaboration with the international society for heart and lung transplantation. Circulation, 119(14), e391-e479.
Institute for Clinical Systems Improvement. (2011). Health care guideline: Major depression in adults in primary care, 14th ed, P. Pietruszewski, K. Hanson, (eds.). (). Bloomington, MN: Institute for Clinical Systems Improvement.
IOM. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press.
IOM. (2003). Key capabilities of an electronic health record system. Washington, DC: Institute of Medicine & National Academies Press.
IOM. (2010). The future of nursing: Leading change, advancing health. Robert Wood Johnson Foundation Initiative on the Future of Nursing and the Institute of Medicine.
IOM. (2012). Health IT and patient safety: Building safer systems for better care. Washington, DC: Institute of Medicine: The National Academies Press.
Lundberg, C., Warren, J., Brokel, J., Bulechek, G., Butcher, H., McCloskey Dochterman, J., . . . Giarrizzo-Wilson, S. (2008). Selecting a standardized terminology for the electronic health record that reveals the impact of nursing on patient care. Online Journal of Nursing Informatics, 12(2).
Martin, K. S. (2005). The Omaha system: A key to practice, documentation, and information management. St Louis, MO: Elsevier Saunders.
Monsen, K. A., Neely, C., Oftedahl, G., Kerr, M. J., Pietruszewski, P., & Farri, O. (2012). Feasibility of encoding the institute for clinical systems improvement depression guideline using the Omaha system (in review). Unpublished manuscript.
Monsen, K. A., Fitzsimmons, L. L., Lescenski, B. A., Lytton, A. B., Schwichtenberg, L. D., & Martin, K. S. (2006). A public health nursing informatics data-and-practice quality project. Computers, Informatics, Nursing : CIN, 24(3), 152-158.
Monsen, K. A., Martin, K. S., & Bowles, K. H. (2012). Omaha system partnership for knowledge discovery and healthcare quality: Nursing terminology in action. Computers, Informatics, Nursing : CIN, 30(1), 6-7. doi:10.1097/NCN.0b013e318245cf3e
New England Healthcare Institute. (2009). Remaking primary care: From crisis to opportunity. Cambridge: NEHI.
ONC. (2011). Meaningful use. Retrieved 04/01, 2012, from http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__meaningful_use_announcement/2996
Rutherford, M. (2008). Standardized nursing language: What does it mean for nursing practice? OJIN: The Online Journal of Issues in Nursing, 13(1)
Sockolow, P. S., Adelsberger, M. C., & Bowles, K. H. (2011). Identifying certification criteria for home care EHR meaningful use. AMIA …Annual Symposium Proceedings / AMIA Symposium.AMIA Symposium, 2011, 1280-1289.
Sucher, J. F., Moore, F. A., Todd, S. R., Sailors, R. M., & McKinley, B. A. (2008). Computerized clinical decision support: A technology to implement and validate evidence based guidelines. The Journal of Trauma, 64(2), 520-537. doi:10.1097/TA.0b013e3181601812
The National Association for Home Care & Hospice. (2010). Basic statistics about homecare. ( No. 202.547.7424). Washington, DC: NAMHC.
Topaz, M., Radhakrishnan K., Masterson-Creber R., Kang Y., Monsen A. K., Riegel B. and Bowles K.H.(2012), Translation of heart failure clinical practice guidelines for homecare electronic health record using standardized nursing terminology. PA, USA: University of Pennsylvania Faculty Senate Research Committee, School of Nursing Grant.