ePoster #100 - Using Interdisciplinary Clinical Decision Support to Optimize Utilization of Established Guidelines to Prevent Chemotherapy-Induced Nausea and Vomiting (CINV)
Denise McMahon, MSN, RN, OCN®, University of Miami Miami, FL, email@example.com
Marijean Marma, BSN, RN University of Miami Miami, FL, firstname.lastname@example.org
Prevention of CINV is critical to optimizing outcomes of cancer therapy. While clinical guidelines for management of CINV are widely available, widespead implementation has not occurred. In addition to the emetogenicity of the chemotherapeutic agents, patient’s individual risk-factors must be considered. Characteristics including sex, age, alcohol use, and history of motion or morning sickness accompanied by nausea and vomiting; can increase the risk of CINV. Patients rely on the oncology team to provide an emetogenic care plan that meets their individual needs. Utilizing a computer-based algorithm that provides decision support may help to optimize CINV outcomes.
To describe a computerized clinical decision support model that includes embedded tools for CINV risk-assessment analysis, including chemotherapy regimen and patient characteristics. Advances in technology can assist the oncology provider with appropriate antiemetic choices. As a result, oncology patients receive symptom-oriented antiemetic therapy, which allows for improved outcomes.
Oncologists and nurse practitioners are provided with evidence-based guidelines to assist with developing an initial comprehensive antiemetic care plan, incorporating individual and regimen factors. Regimes will include default antiemetic choices as determined by the National Comprehensive Cancer Network (NCCN) and the American Society of Clinical Oncology (ASCO) guidelines. Using an emetogenic scale, subsequent cycles incorporate oncology infusion nurse assessment of patients' experience of acute and delayed CINV. Nursing responses generate a score that is linked to the patient’s pharmacy profile. The oncology pharmacist reviews the total score derived and, if order modification is required, informs the ordering clinician, and assigns individualized antiemetic regimen.
The oncology infusion nurse and pharmacist must agree on antiemesis. Metrics including number of times the antiemesis regimen is modified and cost analysis of antiemtic use will be obtained.
The oncology infusion nurses' assessment at the point of care can lead to patient adherence to the prescribed chemotherapy regimen. Consensus-based guidelines to assist with developing a comprehensive antiemetic care plan are readily available to oncology clinicians yet are not consistently incorporated into practice. Standard antiemetic decision support can be created to incorporate second and third line antiemetic protocols in the event of anticipatory or delayed CINV experienced with the initial cycle of chemotherapy.
ePoster #200 - Applying Technology to Clinical Practice: Electronic Medication Administration Record Documentation
Lisa Caltieri, MSN, RN, OCN®, Memorial Sloan-Kettering Cancer Center New York, New York, email@example.com
Nilda deJesus, MSN, RN, Memorial Sloan-Kettering Cancer Center, New York, New York, firstname.lastname@example.org
Lana Luo, BS, Memorial Sloan-Kettering Cancer Center, New York, New York, email@example.com
After successfully completing the implementation of an electronic medication administration record (eMAR) at the largest NCI-designated comprehensive cancer center, the Department of Nursing Informatics (NI) has embarked upon the maintenance period of the project’s life cycle. The nurse informaticist’s role is critical in re-evaluating the application’s stability and striving to improve the product for their users. Open communication with end-users is very important. Assessing how electronic documentation of medications can enhance or hinder clinical practice is vital. Utilizing the technology to improve patient safety/care, meet regulatory requirements, and provide accurate coding information is crucial.
This poster presentation will demonstrate how, in the pursuit of applying technology to clinical practice, the Department of Nursing Informatics embarked upon designing the Institution’s electronic medication administration record (eMAR) with “follow-up task” functionality in collaboration with the Inpatient and Ambulatory eMAR SuperUser Committees.
The follow-up task technology has facilitated the aforementioned goals. Currently there are three follow-up tasks functions: (1) Pain Reassessment (JCAHO requirement), (2) Patch Removal (patient safety/care), and (3) Stop Time (ambulatory coding requirement). These secondary tasks plot on eMAR immediately after the primary task is marked--visually reminding the nurse of pending tasks.
Monthly pain assessment audits measure compliance with regulatory requirements. Review of RISQ (Reporting to Improve Safety and Quality) Reports involving medicated patches measure patient safety goals. The reduction in number of days to final bill and improved revenue capture helps evaluate ambulatory coding requirements.
ePoster #300 - The Analysis Phase of the Hematology and Oncology Protocol Eligibility Project
Christy C. Arrowood, RN, BSN, Duke Oncology Network, Durham, NC, firstname.lastname@example.org
An important component to clinical trial accrual is efficient evaluation of patient eligibility for clinical trial participation. Screening often involves the review of multiple protocols, inspection of medical records, clarification of clinical information from the oncologist, consultation with study investigators, and direct inquiries to the patient. Due to the abundance of clinical trials in academic medical centers, oncologists rely heavily on the clinical trials nurse (CTN) to assist with screening. However, it is not always feasible for the CTN to evaluate a patient for a specific trial during a patient’s clinic visit. In addition, the oncologist may not be fully aware of specific eligibility criteria for protocols. As a result, if clinical trial options are not investigated prior to the patient’s clinic visit, participation may be delayed which may impact the patient's health and quality of life.
The purpose of the Hematology and Oncology Protocol Eligibility (HOPE) project is to develop and implement a prototype of an electronic application to efficiently screen patients for potential clinical trial options available in the community clinic or affiliated academic medical center. The prototype will be utilized by CTNs and oncologists. This project will be approached using a mixed methodology of the traditional analysis phase of the system life cycle and prototyping. The focus of this presentation will be the analysis phase of the HOPE project.
The presentation will describe the strategies and report results of the following analysis phase activities: define the project scope, identify the key stakeholders, assess the current processes for clinical trial screening, gather the application user requirements, and describe the workflow for prototype use.
Once the developed prototype is implemented, the analysis phase objectives will be evaluated from the prototype user feedback, follow-up survey results, and observations from CTNs and oncologists.
The CTN is integral to the conduct of the analysis phase. With thoughtful planning, the HOPE prototype implementation has potential to exhibit research efficiencies. By using an electronic application to streamline efforts to screen patients, clinical trial accrual efficiencies can have a positive impact on patient access to improved cancer treatments.
ePoster #400 - Oncology Adviser - A Quality Initiative for Oncology Staff, Patients, and Caregiver
Kelly Kish, RN, MS, AOCN®, Oncology Conververgence, Inc., Tempe, AZ, email@example.com
The reviewer of this ePoster will be able to verbalize resources provided to medical and radiation oncology staff, patients, and their caregivers via a new innovative software application in order to navigate through the challenging financial aspects of oncology treatment(s).
Nurses, Nurse Navigators, Physicans, Pharmacists and Financial Counselors are required to work closely together to coordinate the best treatment plan for the cancer patient and then assist patients with navigation through the healthcare system to assure appropriate insurance and/or financial coverage for all cancer treatments. OncoAdviser was developed as a single online source to provide the multitude of resources required for cancer center staff and patients undergoing cancer treatment.
The purpose of the project was to bring together tools required by both medical and radiation oncology clinical and financial staff to assist patients through the financial aspects of undergoing cancer treatment. Typically these tools and resources are spread throughout different departments, multiple manuals, software applications and internet resources. A program that could bring these resources to one application and be accessed by all members of the cancer center team would streamline efficiencies and provide valuable information to the cancer patient.
Oncology specific financial counselors were the target job type in a large oncology specific consulting and billing company. A software application was developed to assist staff working with cancer patients to: develop a cost of treatment for a specific plan of care; access pharmaceutical assistance programs; access billing and coding guidelines; access patient education tools; reference drug information such as NDC’s, dosing guidelines; crosswalk ICD9 codes to ICD10; access current available research protocols.
The application improved the efficiency of the financial counselor, and was also widely utilized by coders, accounts receivable, nursing and executive staff. Functionality was added to be able to analyze cost/expense data related to specific chemotherapy regimens and/or radiation treatment plans specific to the institution. The application is now currently is use in academic cancer centers, hospital owned practices, and private practice.
Cancer treatment(s) and their financial implications are a maze for patients. OncoAdviser is a tool to assist with that maze. OncoAdviser is a means by which both financial and clinical staff can work from the same “playbook” to improve the quality of not only the information provided to patients but also the quality of the interactions related to discussions of the finances of cancer treatment.
ePoster #500 - Health Information Technology and the Nurse informaticist: Developing Scope and Standards Merging the Clinician with Technology
Luisa Rounds , RN, BSN, Select Medical , Omaha, NE, firstname.lastname@example.org
The objective is to evaluate the experiences as a clinical nursing informaticist in an intersecting role in health care, computer science, and information science. To provide a discussion how the nursing role is utilized and provide recommendations for the scope and standards to implement and sustain electronic medical records (EMR) and electronic medication administration record (eMAR). To highlight the importance and value of a nursing presence/role in health information technology and to have the appropriate scope and standards to support success.
Nurse informatics plays a role in healthcare reform, Meaningful Use and the Affordable Care Act by managing health information and establishing strategy, planning, and sustainment. This role is part of an Team comprised of clinical and non-clinical staff. The nurse informaticist becomes a naturally interwoven component in improved healthcare delivery. A level of experience is required in the scope and practice to assess the project and manage the change, engage buy in from key stakeholders and end users by utilizing and applying a clinical knowledge base for paperless systems within varied specialties.
The purpose is to discuss nursing informaticist scope and standards in converting healthcare systems from paper to EMR's and eMAR's. The nursing informatics role become health information experts with their ability to disseminate evidence based practice and clinical knowledge into an electronic format and use of hardware/software at the bedside delivering patient-care. These individuals are then able to communicate with project management, physicians, nursing and pharmacy through engagement and education.
The scope and standards gain recommendations with reviewing the practices as a nurse informaticist. The practices include discussions in the varied credentials and education levels, the nurse’s knoweldge in project and change mangement, an educator with train the trainer resources for end users and clinical champions,industry knowledge in hardware and software products, and using the latest evidence based practice in varied healthcare disciplines translated to deliver individualized patient-care with the use of hardware and software products such as scan guns, computers, electronic documentation, and order entry.
Evaluation comes through customer satisfaction namely through patients, physicians, nursing and pharmacy, and quality improvement indicators and the systems effectiveness.
Credentials and educational preparation vary. Mostly LPN, RN’s and MSN’s currently are working in these roles and this creates differing scopes and standards. Certification choices vary by organizations such as CCHIT and HIMSS. Advanced degrees vary in a masters in science of nursing or post graduate informatics specialty and non-nursing masters in science in health informatics. With the nurse informaticist keeping up-to-date with varied healthcare disciplines and varied sites for EMR perhaps there could be future specialized certifications and education as a nurse informaticist in oncology, ambulatory vs. an inpatient facility.
The nurse informaticist role includes to assess information and knowledge needs of health care professionals such as pharmacists, physicians, nursing and patients within the system. Implementation occurs with a project plan to kick off electronic medical records and sustains the system over time with continuous improvement in clinical information. The nurse informacist characterizes, evaluates, refines and adapts software systems and hardware options with the facilities politics and culture. They focus strategically to engage, train, and empower end users,provide patient safety and satisfaction with evidence based practice, protocols, policies, clinical decision support, in order to create and capture improved workflow.
The project and change management includes a knowledge base in leading projects for example with processes through work breakdown structure and project plans. Change management will help users through the road blocks and enable them to experience a positive journey. This process is always easier when people know what they are getting into, feel supported, and are prepared for what lies ahead, both good and bad. Nurses are at the front-line of the team to lead and sustain the transition from paperless to electronic.
Hardware and software scope and standards are part of the nursing informaticist role in understanding equipment such as scan guns, printers, thin clients, tablets, laptops, desktops with delivering patient care and the use of EMR Software vary according to vendor selection, maintenance and upgrades, testing software capabilities designed for the facility and training. Also, interfacing and interoperability knowledge by the nurse to implement information and communication systems such as laboratory and radiology, physician orders, and clinical decision support. The nurse’s scope in practice will greatly benefit by ensuring and customizing software to utilize clinical guidelines, evidenced based practice, and formal medical terminologies.
ePoster #600 - Keeping Safe Practice in a new EMR
Fiona McCaughan, RN, BS, MS, OCN®, Winchester Hospital, Winchester, MA, email@example.com
Nursing has significant responsibility in keeping patients safe when administering chemotherapy/ biotherapy. ONS standards include double checking these and the essential data elements required.
We implemented an EMR which did not clearly display the data elements used in calculations, to the clinicians involved. We had to modify our practice with the physicians/nurse practioners, pharmacists and nursing and work with the IS department to create reports and limits on data fields.
Review one EMR process for ordering chemotherapy and the steps taken to ensure patient safety. Lessons learned from one organization in implementing a new EMR to provide standardization, and to provide the information so the staff are able to correctly calculate the doses. Suggest examples for evaluating an EMR.
We reviewed our ordering process for chemotherapy/biotherapy and determined that we had medication errors, some had reached the patient. In reviewing those errors we determined that some of the errors were due to the system and some were keying errors by staff. The system based errors included volume errors on infusion bags. In addition, the flexibility of the system allowed for the ordering clinician to order the same chemotherapy agent several times in a day, to order it on a prn basis and to alter the route of administration to routes not used in the clinic, i.e. intranasal. The system allowed the ordering clinician to change the dose basis, the final dose, or use a percentage change, these were not transparent in the system to the end user.
We conducted an FMEA on the ordering process .
We developed three approaches to provide for patient and staff safety: changes to the ordering process, for staff checking and recommendations for the EMR vendor.
Staff: Safety huddles in the infusion room, updated the process for high risk medications and included the second check to include the IV pump settings also, staff document their calculations in the EMR, in one central place that all staff can see and document in the same area, reports for staff to review orders. IS limited time frames that values can be used automatically and alarms for staff when values are out of range.
Ordering process: Use standardized careplans only, and to make dose adjustments in one way only and to document in the chart the dose adjustments. (Our providers dictate and notes are not available when the patient is in the infusion room
Vendor: Correct the volume errors for infusion, provide data used in calculations clearly, limit staff to only valid choices
ONS standards for completing an independent review / calculation of chemotherapy/ biotherapy is essential for patient safety and for the team to be able to clearly understand the physician/nurse practioner's orders. We implemented a new EMR that did not clearly do this and needed to modify our practices to ensure patient safety.
ePoster #700 - The Nurse Informaticist: A Clinical Leader for Customizing the Electronic Medical Record
Joanne Rimac, MS,RN-BC, OCN®, Department of Veterans Affairs, Cleveland, OH, firstname.lastname@example.orgemail@example.com
Amy Ciszak, BSN, RN, Department of Veterans Affairs, Cleveland, OH, firstname.lastname@example.org
The Department of Veterans Affairs Electronic Medical Record (EMR) which is known as the Computerized Patient Record System (CPRS) permits local medical record customization. A feature known as health factors is available to the informatics nurse when developing documentation templates for end-users. The informatics nurse is instrumental in development of the EMR health factors and is responsible for educating end-users regarding this custom feature.
The CPRS health factor is analogous to point of care documentation data retrieval. A health factor placed within a CPRS element is used for developing what is referred to as objects. The object allows the end-user to view the most recent documentation in the system pertaining to the current clinical situation. A second use for health factors is branching logic which enhances the clinical decision making process.
The specialties of Radiation Oncology and Surgical Oncology benefit from the placement of health factors within the clinical documentation pertaining to outpatient visits.
The Surgical Oncology Multidisciplinary Survivorship nurse documents the distress screening tool data in the CPRS progress note at all clinic visits. It is imperative the Behavioral Psychologist caring for the patient is cognizant of previous distress screening tool scores entered by nursing. The Radiation Oncology Nurses choose specific nursing diagnosis, goals, and interventions when documenting in the CPRS progress note at the initial patient visit.
The object related to the documented distress screening tool score is readily available within the Behavioral Psychologist’s progress note which aids the clinician to determine the necessary follow-up care. The selected data elements tagged in the Radiation nursing note with health factors then populate or upload into subsequent weekly CPRS progress notes via branching logic. This automated system allows the nurse to document goal progress of the specific nursing diagnosis identified at the initial visit in a timely fashion.