Improving Healthcare Quality and Patient Outcomes Through the Integration of

Evidence-Based Practice and Informatics

1. Define evidence-based practice.
2. Discuss how evidence-based practice impacts healthcare quality, safety, and cost reduction.
3. Discuss barriers and facilitators for successful implementation of evidence-based practice in
the clinical setting.
4. Discuss the evidence-based practice paradigm and process.
5. Identify technology tools in clinical practice which support evidence-based practice.
6. Discuss the role of clinical decision support systems in evidence-based practice.
7. Identify considerations for a successful clinical decision support system.
8. Discuss the integration of evidence-based practice in clinical areas.
9. Discuss a professional practice model which supports evidence-based practice.
10. Identify data types of standardized terminology.
11. Explain the differences between data, information, knowledge, and wisdom.
12. Discuss options available with vendors in support of evidence-based practice.
13. Identify regulatory and agency impacts on decision support.
• KEY WORDS
 Evidence-based practice
 Decision support
 Clinical decision support
 Evidence-based adaptive clinical decision support
 PICOT
 Data
 Nursing informatics
 Clinical terminology
 Technology tools
 Professional practice model
 Quality measures
Chapter Outline
Improving Healthcare Quality and Patient Outcomes Through the Integration of
Evidence-Based Practice and Informatics
1. Introduction
a. There is mounting evidence that implementation of evidence-based practice (EBP) by
nurses and other health professionals results in higher quality healthcare, improved
patient outcomes, less variation in care, and reduced costs compared with care that is
steeped in tradition or based on outdated policies and practices
(1) In addition, findings from studies have supported that when nurses believe in the value of
EBP and are able to implement evidence-based care, they have higher job satisfaction and
better group cohesion, which are key determinants of job turnover guide best practices
(2) In contrast to research that generates new knowledge and evidence for practice, EBP
translates evidence from research into clinical practice to improve healthcare quality and
patient outcomes
(3) Because of the known positive outcomes associated with EBP, the Institute of Medicine
set a goal that 90% of healthcare decisions will be evidence-based by 2020
(4) Despite its positive outcomes and recent mandates by leaders, professional organizations,
and policy makers to base and reimburse care on the best and latest evidence, EBP is not
consistently implemented by numerous healthcare systems and clinicians across the United
States
b. There is no doubt that the use of technology with clinical decision support systems can
enhance the delivery of evidence-based care
(1) However, technology must be used by clinicians who implement the steps of EBP and
healthcare organizations that cultivate system-wide cultures of EBP if highquality evidence-
based care is to be sustained
c. In 2000, Sackett and colleagues defined EBP as the conscientious use of current best
evidence in making decisions about patient care
(1) Since then, EBP has been broadened and described as a problem-solving approach to the
delivery of care that integrates the best evidence from well-designed studies
with a clinician’s expertise and patient preferences and values in making clinical
decisions(Melnyk & FineoutOverholt, 2011)
(2) Both external evidence (i.e., findings from research) and internal evidence (i.e., evidence
that is generated from outcomes management or quality improvement projects) should be
used in evidence-based decision making
(3) When clinicians deliver EBP in a context of caring as well as an organizational culture
and environment that support EBP, the highest quality of care and best patient outcomes are
achieved
(4) If healthcare systems are to be redesigned to improve the quality of care and patient
outcomes as well as reduce costs, clinicians must translate internal and external evidence that
is collected, analyzed, and critically appraised into useful information to guide best practices
2. The seven steps of EBP
a. There are seven steps in the EBP process

(1) In the first step, which is Step 0, a spirit of inquiry in clinicians and a culture of EBP must
be cultivated in order to stimulate the asking of burning clinical questions to improve patient
care
(2) Once a clinical question is generated, Step 1 in the EBP process involves formatting
clinical questions into PICOT format (P = patient population, I = intervention or interest area,
C = comparison intervention or group, O = outcome, and T = time)
(3) Formatting clinical questions in PICOT format is necessary to streamline the search for
evidence to answer the question

b. In Step 2 of the EBP process, a search for the evidence is conducted by entering each
key word from the PICOT question into the database that is being searched (e.g.,
Medline, CINHAL) and then combining the search words together to reveal the studies
that may answer the question
(1) Reliable resources that should be used to find an answer to the PICOT question include
systematic reviews, clinical practice guidelines, pre-appraised literature, and studies from
peer-reviewed journals
c. In Step 3 of EBP, a rapid critical appraisal of the studies from the search is
conducted, followed by an evaluation and synthesis of the research evidence
d. In Step 4, evidence is integrated with the clinician’s expertise and patient preferences
and values to make a decision regarding whether a practice change should be made
(1) Once a practice change is made based on the best evidence, outcomes should be measured
to determine positive outcomes of the change (i.e., Step 5)
(2) Evaluation of outcomes is an essential step in EBP as it helps to determine if the EBP
practice change was successful, effective, equitable, timely, and needs to be modified or
discarded
(3) The last step in the EBP process, Step 6, is disseminating the outcome of the practice
change through presentation or publication so that others can benefit from the process

3. Barriers and facilitators of EBP

a. There are multiple barriers to advancing EBP in healthcare
systems, including
(1) Misperceptions by clinicians that it takes too much time
(2) Lack of EBP knowledge and skills
(3) Organizational cultures that do not support EBP
(4) Lack of resources, including clinical decision support tools
(5) Executive leaders and managers who do not model and/or support EBP
(6) Lack of EBP mentors to work with point-of-care staff on implementing evidence-based
care
(7) Inadequate access to databases by clinicians in order to track patient and system outcomes
(8) Negative attitudes toward research
b. Findings from studies also have established key facilitators
of EBP that include
(1) Strong beliefs about the value of EBP and the ability to implement it
(2) EBP knowledge and skills
(3) Organizational cultures that support EBP
(4) EBP mentors who have in-depth knowledge and skills in evidence-based care as well as
individual and organizational change
(5) Administrative support
(6) Clinical promotion systems that incorporate EBP competencies
(7) EBP tools at the point-of-care, such as clinical decision support system

4. Cultivating a culture that supports and sustains EBP

a. In order to cultivate a culture and environment that supports and sustains EBP, an
organization must provide systemwide support for evidence-based care
(1) This support begins with a vision, philosophy, and mission that incorporate EBP as a key
component, which are made visible to all throughout the organization
(2) High-level administration and nurse managers must not only “buy-in” to this vision, but
also model EBP themselves as much of how clinicians perform is learned through observation
of their key leaders and managers
(3) Integrating EBP and the newly created EBP competencies for registered nurses and
advanced practice nurses throughout the clinical ladder system if one exists also
establishes the importance of evidence-based care for staff advancement
(4) Furthermore, ample resources and supports must be provided to clinicians that enhance
their ability to provide evidence-based care. Examples of resources and supports are identified

The Role of Technology in Supporting

Evidence-Based Practice
1. Technology tools in clinical practice
a. Nurses, nurse practitioners, and healthcare providers today are very cognizant of the
push for cost containment, improved patient safety, improved quality of care, and
reduced variation in care throughout not only the United States but the world
(1) It is readily observed, there is a shift in healthcare choices being made based on quality
and outcomes, not solely cost as reimbursement moves toward payments for quality
b. Information technology (IT) has brought to healthcare a compendium of new tools
which support EBP
(1) As a consequence, IT has not only improved, but also complicated many currently
existing processes
(2) A goal of informatics is to use technology to bring
critical and essential information to the point-of-care to increase efficiency, make healthcare
safer and more effective, and improve quality and outcomes
(3) Despite the advancement in IT, the most effective, evidence-based care remains evasive
for nurses
2. Competencies
a. Nursing professionals range in age from their early 20s to
their 60s with the average age of a registered nurse today in
their early 50s
(1) This range presents a significant range of learning skills and comfort with technology and
EBP
(2) Nursing students today are very adept with using iPads, iPhones, laptops, and other
technology devices
(3) They have been using them since childhood
(4) In 2006, a National League of Nursing (NLN) study revealed 60% of nursing programs
had a computer literacy requirement and 40% had an information literacy
requirement
(5) Less than 50% of the respondents stated informatics was integrated into the curriculum
and experience with information systems provided during the clinical experiences
(6) As an outcome of the study the NLN published a position statement recommending
nursing schools require all nursing students graduate with knowledge and skills
in each of three critical areas: computer literacy, information literacy, and informatics
b. Pravikoff, Tanner, and Pierce found that nurses use experientially acquired
information from interactions with peers, patients, colleagues, and physicians greater
than scientific evidence from medical and research journals
(1) This finding still exists today
(2) It is imperative for nurses today to have the skills required to engage in EBP
(3) Preparing undergraduate nursing students in EBP and the use of the proper technology has
significance for advancing EBP in nursing
(4) Rush states, “the preparation of undergraduate nursing students for using evidence to
guide practice is no longer optional. Evidence-based practice is imperative for ensuring
quality, cost-effective safe care and more predictable outcomes for healthcare consumers”
.
Decision Support and Evidence-Based Practice
1. Decision support systems
a. Decision support systems (DSS) “are automated tools designed to support decision
making activities and improve the decision-making process and decision outcomes
(1) Such systems are intended to use the enormous amounts of data that exist in information
systems to facilitate decision processes”
b. Clinical decision support systems (CDSS) are systems designed “to support healthcare
providers in making decisions about the delivery and management of patient care”
(1) They have “the potential to improve the patient safety and outcomes for specific patient
populations, as well as compliance with clinical guidelines and standards of practice and
regulatory requirements”
c. Evidence-based adaptive clinical decision support systems are systems designed with
multiple rules and access to multiple databases for information
(1) They are complex systems and contain mechanisms to incorporate new findings and
evidence

2. Standardization of terminology and data

a. Clinical Terminologies are a factor which plays a significant role in increasing the
availability of evidence at the point-of-care
(1) They have not matured to a level to be used in clinical information systems (CIS)
(2) Standardized clinical terminology is necessary for the evidence to be both computable and
interoperable with multiple systems
(3) The next step is to facilitate EBP by increasing the transparency to the healthcare provider
b. To be efficient, the evidence for EBP must be incorporated into the everyday
workflows and care processes used by nurses and other healthcare providers
(1) The data must be integrated with the clinical systems used by the providers and provide
readily accessible evidence-based knowledge for the end user at the point-of-care when
needed
(2) To be successful it is essential to link evidence to assessments, results, documentation,
orders, and plans of care
(3) Gugerty states, “It’s in these forms—plans of care, order sets, standardized rules and
alerts, and the like—that evidence will finally be widely, consistently, and reliably
used at the point of care”
c. Standardized nursing terminology is required for quantifiable and retrievable data. It
allows for documentation and coding of Nursing practice in the EHR
(1) IT systems document and code nursing practice, aggregate and compare coded data across
client settings, populations, and time, and develop core databases for data mining and meta
analysis
(2) Terminology is also required for compliance with regulatory and payer requirements

d. What are the criteria for standardized nursing terminology?

(1) Cimino’s desiderata for the design of a controlled healthcare vocabulary included free,
usable in all clinical settings, interoperable, atomic level concepts with unique
codes and definitions, nonredundant and nonambiguous, domain completeness, uses open
architecture, can be quantified, designed for computer-based systems, developed empirically
from research, and link nursing diagnosis to interventions and outcomes
e. Identification of common data definitions
(1) It is not uncommon for different departments, hospitals, and systems to have different
definitions of the same data elements
(2) Unless everyone is using the same set of data definitions there will be errors in data
collection, analysis, and conclusions
(3) This is one reason the Meaningful Use Core Measures and Quality Measures are explicitly
defined for data collection and reporting
(4) Travers and Mandelkerhr identified seven aspects which should be considered for
identification of common data definitions
(5) Each of these is also essential for Meaningful Use Core Measures and Quality Measures

f. Tools for managing clinical data

(1) Tools can vary from Excel spreadsheets and Access databases to database programs

g. Data quality
(1) Inaccurate and incomplete data will impact the quality of the data upon which decisions
will be made and impact quality
(2) Data end users should understand how the data they are using is defined
(3) Many computer programs contain features to prevent data entry errors by restricting the
type of data which can be entered such as a date in numeric form or limiting the range

h. System selection issues

(1) Clinicians should participate in the selection process for CIS and consider data
requirements during the selection process
(2) They should consider the quality and availability of the data for use on the back end to
facilitate other uses of routinely collected health data such as benchmarking, quality
improvement, research, and surveillance
(3) Vendors should be questioned as to the types of reports available, ability to customize
reports and create ad hoc reports, and the ability to export data for use with other applications
(4) “Data consistency and completeness are critical to the scientific rigor or retrospective
studies”
(5) “Underestimating the importance of data management can hinder data quality, impair
research results, misinform clinical practice, or generate invalid hypotheses for new clinical
trials”

3. Considerations for successful CDSS

a. Lee completed an extensive literature search to identify and organize the system
features of decision support technologies targeted at nursing practice into assessment,
problem identification, care plans, implementation, and outcomes
(1) Bryne and Lang examined nursing data elements from evidence-based recommendations
for clinical decision support
(2) The analysis provided a description of the representation of data elements and issues
related to the availability of data for use in the future development of clinical decision support
systems to prevent ICU delirium
(3) They found the matched data elements were primarily text based, entered by RNs on flow
sheets and care plan
(4) “Even though there was a high number of potential data element matches, there was
considerable variable data availability related to clinical, conceptual, and technical factors.
The further development of valid and reliable data that accurately capture the interaction
between nurse, patient, and family is necessary before embarking on electronic clinical
decision support”
(5) Bryne and Lang found the build of the CDSS could allow for multiple data sources to be
analyzed, but that did not address the practical implications of redundancy, ambiguity, and
lack of conceptual clarity identified in the data sources
(6) For their study, they provide three recommendations for the capture of nursing care in a
standardized format to be used in CDSS support
(7) They were
i. Improve the electronic capture of nursing phenomena and care processes
ii. Promote the use and integration of standardized nursing terminologies such as ICNP and
SNOMED-CT
iii. Capitalize on data elements with high data availability
b. Sittig identified five elements as prerequisites for a clinical real-time point-of-care
clinical decision support system
(1) They include
i. Integrated, real-time patient database. The database must be able to integrate data under a
common patient identified. It stores and updates all data as soon as results are available,
forming the basis of any real-time CDSS effort and ability to implement logic that involves
patient-specific data from multiple data source
ii. Data-drive mechanism. A data-drive mechanism enables a flag or trigger to be set so that a
program can be activated when a particular type of data or data item (e.g., clinical laboratory
results or a chest radiograph report) is stored in the database. These triggered events allow for
the system to be automatic, real time, and asynchronous. Such systems are real time in that
they run as soon as the data is stored, instead of at a specified time of day
iii. Knowledge engineer. An informatics expert who is responsible for extracting and
translating the clinical knowledge into machine executable logic
iv. Time-drive mechanism. This allows for programs to be executed automatically at a
specific time in the future (e.g., 2 a.m.) or after a specific time interval has passed (24 hours
after transfer). Logic can be used to remind clinicians to perform specific activities or to
check that the appropriate action has been performed
v. Long-term clinical data repository. A long-term clinical data repository contains the
patient-specific data from a variety of clinical sources collected over a period of several
years.It allows for the development of reliable statistical predictors of specific events. For
example, one could develop a logistic regression equation that identifies the
pathogen most likely to be found in a particular specimen and recommends the least
expensive antibiotic. The database could also be used to identify potential problem areas, such
as the percentage of patients with diabetes who have not had an HBA1C test performed
within the last six months
c. The functions of clinical decision support systems include alerting, reminding, critiquing,
interpreting, predicting, diagnosing, interpreting, image recognition, assisting, and suggesting
(1) One of the benefits of clinical decision support systems is the evidence can be driven into
practice in a timely manner
(2) Garg et al. reported that 76% of reviewed studies indicated that clinician performance was
improved through the use of reminders
(3) Diagnostic aiding systems were found to be beneficial in 40%
(4) Automatic prompts to the end user were more effective than the end user needing to
activate a system with changes in physician performance 73% with auto prompts, and 47%
when required to activate the system
(5) The highest success function identified was the use of reminders and alerts

d. DSS are passive or active

(1) A passive system would notify an individual of an event, such as an abnormal finding
where an active system will offer suggestions or take actions such as place a specific order
when specific criteria are met
(2) DSS always allow for the provider to have the option to ignore the alert, override the alert,
or inactivate the alert after their synthesis of the information and suggested actions
(3) It must always be remembered the clinician is the final decision maker
e. Clinical decision support systems allow for optimization of both the efficiency and
effectiveness with which clinical decisions are made and care is delivered
(1) The costs of clinical decision support systems can be high, however, the savings occur in
the improved decision making at the bedside, improved quality and outcomes, and reduction
of errors
(2) Mullett, Evans, Christenson, and Dean concluded at InterMountain Healthcare Primary
Children’s Medical Center in Utah the use of a pediatric anti-infective decision support tool in
the Pediatric Intensive Care Unit (PICU) was beneficial to the patient and reduced the rates of
erroneous drug orders, improved therapeutic dosage targets, and decreased anti-infective costs
per patient
f. Disparities have been documented by Medicare and other agencies in the treatment of
diseases such as heart disease and congestive heart failure
(1) This was one of the incentives behind the CORE measures to reduce variation in practices
when evidence has proven the impact of procedures and medications
(2) The goal is to reduce variations, cost and improve quality and this is being expanded in
2014 to include CORE measures and quality measures
(3) CORE measures can be found on the CMS Web site at www.cms.gov/EHR Incentive
program

What can Outside Reference Sources (Vendors)

Bring to the Table?
1. Overview
a. The tools for EBP have evolved from paper and pencil to EBP embedded in the CIS
via links and DSS at the point-of-care
(1) The utilization of technology has also moved the amount of evidence available at the
point-of-care from low to high
b. Not only have the methods for using evidence changed, but also the producers or
originators of EBP have changed in the past 20 years
(1) In the 1980s Clinical Practice Guidelines were developed by individual hospitals and the
responsibility was on the hospitals
(2) That trend changed in the 2000s to eliminate healthcare delivery organizations from
building their own to their use of commercial vendors for information and incorporation into
practice
(3) Healthcare organizations are no longer building their own evidence-based packages, but
instead partnering with governmental agencies (Medicare), professional societies, and
companies such as Zynx, Wolters-Kluwer, Thomson, Clineguide, and Micromedex who are in
the business of providing evidence-based packages
(4) The vendors provide the evidence, however, they do not decide what evidence is chosen to
incorporate into practice
(5) With vendors maintaining the responsibility for reviewing the research and presenting the
best practices to the facilities the information can be incorporated into the bedside care in a
more expeditious manner
c. Electronic health record (EHR) system vendors also provide various services
(1) Their services can be categorized into three areas
i. In-house CDS content. Vendors provide a variety of in-house CDS content such as alerts
and reminders, order sets, documentation templates, drug–drug and allergy checking and flow
sheets. This requires regular updates and client maintenance
ii. Third-party CDS content. Vendors use third-party CDS content
iii. Content knowledge sharing. The vendor provides a knowledge sharing environment
Options may include a vendor hosted portal where clients can access information provided by
the vendor or by its clients on how to implement a specific CDS capability, or a vendor
hosted environment where clients share resources such as rules and workflows, and shared
bench marking database with associated analytics

Integration of EBP Technology in the Clinical Areas

1. Overview
a. Barriers to research implementation were identified three decades ago
(1) Melnyk states “although progress has been made over the years, the same barriers to EBP
identified decades ago (e.g., time, lack of knowledge and skills, peer resistance, lack of
accessto resources, and EBP mentors) continue to exist in healthcare systems
(2) Most recently…new findings indicate that resistance from leaders and managers along
with environments steeped in tradition were top barriers to provision of evidence based care”
2. Information access
a. There are over 150,000 medical articles published each
month

3. Data, information, knowledge, wisdom, healthcare business intelligence

a. Worthley defines data as the raw materials from which information is generated and
information is the relevant, usable commodity needed by the end user
(1) “Information is born when data are interpreted”
(2) In order for information to be useful it needs to be accurate, timely, complete, concise, and
relevant
b. Englebardt and Nelson explain the Nelson Data to Wisdom
Continuum:
(1) Data is provided; data generates information; information generates knowledge and the
interpretation, integration, and understanding of knowledge leads to wisdom
(2) Healthcare business intelligence requires a foundation that encompasses comprehensive
data management of reporting, analytics, data warehousing, and dashboards
(3) Successful business intelligence provides information knowledge at the clinician’s
fingertips
c. Five tenets of successful healthcare business intelligence are
(1) Data quality
(2) Sponsorship and leadership
(3) Technology and architecture
(4) Value
(5) Culture change
d. Weiskopf and Weng found there is little consistency in the methods used to assess
EHR quality data
(1) Overhage, Ryan, Reich, Hartzema and Stang, and Weiskoph and Weng believe if the
reuse of EHR data for clinical research is to become accepted, researchers and clinicians
should adopt validated, systemic methods of EHR data quality assessment
(2) They empirically derived five dimensions of data:
i. Completeness: accessibility, accuracy, availability, omission, presence, quality, validity,
rate of recording
ii. Correctness: Is an element present in the EHR true? This dimension includes accuracy,
corrections made, errors reported, validity tested
iii. Concordance: Is there agreement between the elements in the EHR, or between the EHR
and other data sources? Other considerations are agreement, consistency, reliability, variation
iv. Plausibility: Does an element in the EHR make sense in light of other knowledge about
what that element is measuring? Are the data accurate, believable, trustworthy, and valid
v. Currency: Is an element in the EHR a relevant representation of the patient state at a given
point in time? This is a dimension of timeliness
(3) “Although the five dimensions of data quality derived during our review were treated as
mutually exclusive within the literature, we feel that only three can be considered
fundamental
i. Correctness
ii. Completeness
iii. Currency
(4) By this we mean that these dimensions are nonreducible and describe the core concepts of
data quality as it relates to EHR data reuse”
e. Bowles et al. found doing research across multiple institutions using the EHR, they present
multiple issues, even when working with sites with the same vendor
(1) Contributing factors identified included differing versions of the EHR, customizations,
variations in documentation policies and procedures and quality, and user interfaces

Technology is Only a Tool for EBP

1. Integration of evidence into healthcare decisions
a. The transition to EBP is a cultural change process
(1) In 2008, Anderson and Wilson completed a study on the use of CDSS in nursing
(2) They found only six studies that involved CDSS to promote EBP in nursing
(3) They concluded that nursing is lagging behind the progress made in other disciplines,
however, given the mandate for CDSS to qualify for federal incentives they propose an
increase in CDSS use within nursing will occur
b. Castillo and Kelemen identified 12 characteristics of
successful clinical decision support systems
(1) They are
iv. Incorporate into existing systems
v. Integrate into the current workflow
vi. Provide specificity
vii. Incorporate user involvement
viii. Provide education and training
ix. Provide sufficient system support
x. Provide automated system prompts
xi. Provide straightforward alerts
xii. Have simple clinical decision support system displays
xiii. Prompt acknowledgment
xiv. Require minimal clinical decision support system data entry
xv. Have continuous clinical decision support system evaluation and monitoring
c. Brokel, Shaw, and Nicholson found in implementing clinical rules to automate steps in
delivering evidence-based care that to be successful there must be
(1) The use of uniform coded terminologies
(2) A culture to transform care with the use of evidencebased practices
(3) Processes in place to guide the organization and staff
(4) Interdisciplinary involvement which is required to be successful
(5) The transformation from paper checklist, requires an organizational culture to redesign
workflow processes to improve the use of EBP guidelines rules in an EHR
(6) The health system required an organizational culture to redesign workflow processes to
improve the use of evidence-based guidelines
d. Dougherty, Harrison, Graham, Vandyk, and Keeping-Burke identified factors
associated with the success and failure of participants’ efforts to facilitate EBP
(1) Note their factors were not technology issues but process and culture, such as engagement,
resource deficits, lack of focus on an issue, development of strategic
partnerships
2. Regulatory and accreditation agency impacts
a. There are concerns that many documentation processes and requirements are heavily
focused on payment and regulatory requirements rather than care delivery
(1) Much of what is currently documented and contained in the health record is in response to
medico legal, reimbursement, and accreditation and regulatory requirements
(2) Data capture is influenced by federal and state regulations
(3) American Recovery and Reconciliation Act (ARRA) and Centers for Medicare and
Medicaid (CMS) meaningful use regulations published July 13, 2010 have
significantly altered the applications and functionality emphasized
(4) These acts and regulations have deadlines and monetary incentives and penalties in place
for healthcare providers and institutions
(5) The CMS established 24 objectives for eligible hospitals seeking incentive benefits
(6) For Stage 1 hospitals are required to meet 14 core objectives and select an additional 5
from the remaining 9 objectives
(7) One mandatory objective of Meaningful Use is the meaningful use of DSS
(8) The CMS objective requires that eligible hospitals identify a high-priority condition and
then implement one clinical decision support rule related to that condition, along with a way
to track compliance
(9) The Health Information Technology for Economic and Clinical Health (HITECH) Act
was enacted in 2009 and seeks to improve patient care outcomes and healthcare delivery
through major investments in health IT
(10) The goals are to improve quality, safety, and efficiency of patient care; engage patients
and families, improve care coordination; and ensure adequate privacy and security for
personal health information
(11) Meaningful Use (MU) establishes a set of standards which govern the use of EHRs
(12) MU stage 1 criteria focused on: electronically capturing health information in a standard
format and initiating the reporting of clinical quality measures and provider health
information
(13) Stage 2 criteria focused on health information exchanges, data interoperability, and
electronic transmission of patient care summaries across multiple settings
(14) Stage 3 to be launched in 2016 focus on decision support for national high-priority
conditions, improving quality, safety and efficiency, leading to improved health outcomes and
access to comprehensive patient data through patient-centered health information exchanges
(15) An additional documentation and data burden is the requirements engendered by CMS,
incentive payments for meaningful use such as EHRs ability to report specific data elements,
ability to report on certain quality measures, and data exchange between providers and
systems for meaningful use objectives and clinical quality measures

Opportunities are present to empower nurses with IT tools to leverage the vast clinical
knowledge base to improve care, increase patient safety, and meet regulatory
requirements
3. Optimizing existing systems and applications
a. The success of a CDS depends on many factors, one of which is end-user satisfaction
(1) A system for which the end user builds workarounds does not provide any benefit
(2) Three barriers have been identified
(3) They are
a. Excessive use of alerts and reminders
b. Outdated or inaccurate information in the system
c. Inappropriate levels of the alerts
b. Lyerla explains “a reminder or alert that is too general may produce too many
messages and result in clinician frustration, causing the reminder to be ignored, whereas
a system that is too specific may not produce enough messages resulting in missed
appropriate messages”
(1) The development of intelligent systems will depend on high-quality data derived from
patient and clinical sources
(2) The EHR will continue to be a major source of information along with data for a clinical
data warehouse
(3) One important challenge which remains is the high prevalence of narrative text in the
electronic record
(4) Currently there is work on natural language processing and information retrieval,
however, it has not been perfected to meet the criteria for standardized language
c. It is imperative that technology assists in getting evidence to nurses at the point-of-
care
(1) Again, this can be accomplished via various methods such as embedded hyperlinks, text
messages, and icons
(2) Nurses need access to the information during their care provision, not 3 hours later
(3) The integration of the evidence into daily workflows is essential so clinicians can move
readily from task-based care to managing care and knowledge-based decisions
(4) When this is achieved Matter explains the clinicians will be functioning at an elevated
level of critical thinking and incorporate EBP into their daily work to improve efficiency,
effectiveness, and patient outcomes