Running head: INFORMATICS PAPER 1

INFORMATICS PAPER

Amy Angell

11/17/2018

NUR 410 Nursing Informatics

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Informatics

Informatics in nursing is something that as a nurse it is used every day. Informatics

has many definitions and it is ever changing it is described in early definitions as the use of

computer technology in all nursing endeavors this definition has evolved to include the

nurses, raw information, and technology (Finkelman,2016). Nursing informatics includes all

the areas of care that is analyzed to make the best evidence based practice for all of nursing.

As a nurse, informatics is used in many areas, the computer to chart patient assessment, bar-

coding to insure correct medication administration, and electronic charts . Informatics is used

to share information and promote patient safety. The idea of a formal initiative to share best

practice and competency through the Technology Informatics Guiding Educational Reform

(TIGER) initiative began in 2006 (Sewell, 2016). Patient safety is the driving force behind

informatics the Quality, and Safety. A technology that is used frequently is the telemonitor.

This is a device in the patient’s home that monitors patient vital signs and weight daily. This

information is then transmitted to a nursing station that is reviewed daily. This assists patients

in managing their chronic disease such as CHF or COPD. In this paper it will identify the use

of the telemonitor, why this is best practice to use the technology, importance of maintaining

patients confidentially with its use, how to improve the work flow and process of using this

technology in the home and nursing policy .

Telemonitor

Many times patients are diagnosed with a chronic disease that requires management and

education. With the changes in reimbursement and penalties for patients with a 30-day

readmission to the hospital the telemonitor has become an important tool to assist in the goal of

no readmissions of patients. According to the American Heart Association nearly 6 million

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Americans have been diagnosed with Heart failure with 555,000 persons diagnosed annually.

(Long, Babbitt, & Cohn, 2017). In the United States and Europe Heart failure is the leading

cause of hospitalization with 34% of total Medicare spending directed at heart failure treatment.

This is a chronic disease, that needs to be continually monitored, and the use of the telemonitor

in the home significantly reduces rehospitalization rates (Long, Babbitt, & Cohn, 2017). The

patient must become independent with their care. It is a device that monitors vital signs and

weight on a daily basis. The information is sent to a telemonitor nurse to review. The patient can

begin to see trends and receive education on care. In, the article Theory-Based Telehealth and

Patient Empowerment it is about how the healthcare technology holds great potential to improve

the quality of healthcare delivered (Suter, Suter, & Johnston, 2011). This will help assist patients

with chronic diseases to help them to recognize symptoms of an exacerbation. The American

Telemedicine, defines telemedicine as the use of medical information exchanged from one site to

another via electronic communications to improve patient’s health status (Suter, Suter, &

Johnston, 2011). Closely associated with telemedicine is the term “telehealth” which is a broader

definition of remote health care that may or may not involve clinical services (Suter, Suter, &

Johnston, 2011). Many home health agencies are using telehealth with a nearly 90% of home

health agencies surveyed reported that telehealth improved the overall quality of services

provides for their patients (Suter, Suter, & Johnston, 2011). It also reported 75% of agencies

reported a reduction in unplanned hospitalization and reduction in emergency room visits.

Telemonitors allow vital signs and weights to be sent electronically. It allows for the detection of

early warning signs of disease exacerbation and intervention to be implemented promptly

preventing hospitalization (Suter, Suter, & Johnston, 2011). It allows for a nurse to continually

monitor and educate the patient further on the signs and symptoms that need to be monitored.
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The ultimate goal of the telehealth is to promote self-efficacy to execute the behavior required to

produce positive outcomes successfully. It is hoped that the telemonitor in the home will be

source of empowerment to the patient to make positive change (Suter, Suter, & Johnston, 2011).

This with the home care nurse providing further education and motivation for the patient to make

positive changes. With the assistance of home health agencies, telehealth programs can not only

help cut down costs but empower patient and provide improved quality of life for these patients

(Suter, Suter, & Johnston, 2011). As with all technology we have to make sure to keep patient

data secure.

In any area of informatics, we must remember to keep the patient’s information safe and

secure. One such right is found in the nursing code of ethics, one of the provisions is the

protection of the rights of privacy and confidentiality. This means as the nurse the patient’s

personal and medical information must be protected. As the patient using a telemonitor in the

home, a nurse is calling to check on that patient, and she must be careful whom she is talking to

on the phone the person on the phone may not be someone who she can share medical

information with. Also, the nurse will be faxing information to the physician and it is essential to

make sure this information is faxed to the right office, and the information is protected (ANA,

n.d.). Also, there is a federal law, called the Health Insurance Portability and Accountability Act

of 1996 (HIPAA), that sets rules for health care providers and health plans about who can look at

and receive your health information, including those closest to you – your family members and

friends. The HIPAA Privacy Rule ensures that you have rights over your health information,

including the right to get your information, make sure it’s correct, and know who has seen it

(HHS, 2017) This is something you have to follow even outside the hospital and including

sharing vital signs only with those whom the patient has agreed it can be shared with. As the
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nurse we have to always be mindful of patient privacy and rights. With any use of technology it

involves a process to set-up the telemonitor for the patient’s home in our agency this is a time

consuming work flow process.

Work Flow Process

The current process involves several steps and is rather time consuming for both the patient and

the nurse. The current process to get the telemonitor set-up for the patient is, a referral is

received from either the doctor’s office or the discharging facility. The referral for home care is

gathered by the nurse liaison and has necessary patient’s information and sometimes whether a

patient is for a telemonitor referral. By the time we are referred to this patient they usually have

a chronic disease such as COPD or CHF and have been admitted several times to the hospital

already due to exacerbations. Once the referral has been received then a nurse is scheduled to see

the patient within 48hrs to meet Medicare timely initiation of care guideline. To get the monitor

in the patient’s home, could take a week or two, and in that time the patient could have already

returned to the hospital. Once the nurse arrives and completes her initial admission assessment,

review of medications, and review of discharge instruction. That is when the patient will finally

hear about the telemonitoring program if the patient is then agreeable the nurse would call their

physician to get orders for the telemonitor. Once, this order is received from the admitting

physician. The admitting nurse then calls the telemonitor nurse to give her the referral

information. The nurse will then need to call the office to let the sectary know that a telemonitor

needs to be shipped out to the patient’s home. This will take a few days to reach the patients

home. The monitor will then more than likely stay in the box until the next nursing visit to set-up

the monitor for the patient. The monitor will then finally be set up by the nurse and explained to

the patient. The nurse will do the first test with the patient and make sure that it transmits to the
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nursing station for review by the telemonitor nurse. The patient will be able to do daily vital

signs including weights and the telemonitor nurse will call the patient with any changes or

concerns. The trends can be faxed to the physician to review with appointments or concerns to

hopeful prevent rehospitalization. The telemonitor will also hopefully empower the patients to

manage their chronic disease at home better. The patient will also continue to receive home

visits from the nurse to review results, assessment and continue education on disease

management. This is a process that takes a considerable amount of time and resources with the

patient sometimes getting frustrated about the time it takes to get their monitor. With the use of

informatics we can make this process much less time consuming.

For a new workflow process the patients with chronic disease diagnosis have an

automatic referral for a telemonitor. The primary care provider in the office or hospital setting

will have already explain to the patient that this is a chronic disease that will need to be

managed. That education is key in getting the patient involved and knowledge of the disease

process and purpose of the telemonitor. Many times the patients either are not sure of their

diagnosis or have no idea that it is a chronic disease that doesn’t just go away with medications.

If the patient has already had this education especially from their primary care provider the

patients would be more agreeable to having the telemonitor in their home. Sometimes the

patients are resistant to having something else they need to complete every day, or the patients

want to talk to their physician first, or they are not sure they really need a telemonitor it is after a

couple of admissions they are willing to have the telemonitor set-up. Many patients don’t realize

the severity of their diagnosis and that it is a permanent condition that requires lifestyles changes

on their part to manage the disease. With the diagnosis, the patient will have already been

educated by the physician on the benefits of the telemonitor. The referral is made to the home
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health agency already flagged for a telemonitor. There would be a dedicated nurse with a

telemonitor to admit the patient to complete the necessary paperwork and have the telemonitor

set-up in the patient’s home the same day they are admitted to home care. This would allow

education and monitoring to begin immediately. Then the designated telemonitor nurse would

return the next day to reinforce use and assess for further questions. In, this process several

unnecessary steps are omitted such as waiting for the physician orders, calling the telemonitor

referral, waiting for the telemonitor to be delivered, and then set-up with the next nurse visit.

This makes for a more efficient process the patients can begin immediately monitor their

symptoms and management of their disease. After the monitor is placed and the next day visit is

completed then continued support from the telemonitor nurse occurs. The nurse would be able to

visit in the home once a week and call with any questions or concern throughout the week. The

patients begin trust more if they have a consistent caregiver. The patient and nurse can build a

good relationship, so the patient feels comfortable asking questions and confident in the nurse

abilities. The goal of the telemonitor is to both monitor the patient and prevent complication but

also to empower the patient to manage their disease. This new workflow process would improve

care and hopefully prevent further complications such as rehospitalization. The patient could

begin the learning process their disease management sooner and hopefully makes the patient feel

more confident in their monitoring of the disease.

By creating a simplified workflow process and taking out the unnecessary steps and the

waiting for the monitor to arrive this would save the company money and resources it would

save the admitting nurse time waiting for the physician to return calls to receive the order for the

telemonitor. That nurse also would not have to take an additional step in contacting the

telemonitor nurse then the secretary to ship the monitor to the patient. To monitor the
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effectiveness of this new workflow process, you could monitor if this decreased emergency room

visits, immediate care visits, or hospital stays opposed to telemonitor placement a week or two

following discharge or referral to the agency. Getting the telemonitor to the patient’s home

sooner without delays will increase patient satisfaction and improve outcomes for the patients.

By having a workflow map it is broken into smaller pieces so you are able to more clearly see

what the process is and how to accomplish the stated goal. In this case to get the telemonitor to

the patients home in the quickest most efficient way. The next two pages illustrate both the old

work flow process and the new work flow process map.
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Old work flow process map

Referral Nurse assigned

received Nurse
to see patient
from schedules Nurse must
within 2 days
hospital or visit review call MD to
following
telemonitor request
MD office referral
program and order for
possible telemonitor
telemonitor assess if
patient
agreeable to
program

Once order
received from
MD
telemonitor
referral then
called into
telemonitor
nurse

Once telemonitor set-up Once it arrives to Then secretary

in the home vitals and home. The nurse is called to order
weight recorded daily will make an shipment of
and nurse will review additional visit to telemonitor
and call with concerns set up monitor from agency to
but this could take and instruct on patients home
several weeks to set-up use.
from initial admission
date.
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New Work Flow Process

Education begins
Telemonitor nurse is t Next day visit
with first made to reinforce
diagnosis MD education on
Telemonitor
educates on Yes monitor and
nurse is the
telemonitor order able to admit begin education
and referral is patient and on disease
sent to set-up management
telemonitor nurse telemonitor
same day if
patient is
agreeable to
set-up

Telemonitor
nurse will be
able to make
NO

NO

home visit
weekly and call
patient as
needed to
review and
continue
Continue nursing
education
visits as usually for
monitoring and
education encourage
use of telemonitor in
future if needed
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New policy

With any new process you need to develop a policy using evidence based practice. It begins with

gathering the research that has been proven in studies to give consistent positive results. There

has been increasing evidence that monitoring patient’s in the home lead to better outcomes.

Many of these patients are elderly and have mobility issues that do not allow them to get to

support groups or physician offices (Cowie, 2012). To implement a new policy first information

would be gathered the evidence of why this is important and test your theory using research

using evidence- based practice to implement any change you want to explain the reason and use

an effective change theory one such model would be Kotter’s eight step change model in this

process you create that sense of urgency, further building a guiding coalition, forming strategic

vision and initiatives, enlist volunteer army, enable action by removing barriers, generate

short-term wins, sustain accelerations, and institute change (Finkleman, 2016). By using this

plan it establishes support from the staff the change in process and the new nursing policy can

be fully implemented and followed by the staff. This will create a easier work flow, improve

patient outcomes, and patient satisfaction. The new nursing policy would be as followed:
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Nursing Policy

Objective:

To effectively monitor patient with chronic illness such as congestive heart failure (CHF) or

Congestive obstructive pulmonary disease (COPD) in the home. This will allow more closely

monitoring of vital signs and weight daily to prevent unnecessary MD visits or hospital stays.

Procedure:

1. Identify all patients that could be a good candidate for the telemonitor program since it

has shown a 34% reduction in mortality and 21% reduction in admission to the hospital

for CHF patients (Cowie & Acosta, 2012). The order should already be in place to set-up

monitor but if not contact patients primary care physician for an order

2. Document your set-up of the monitor including education given. If patient refuses also

document this in your nursing notes and make physician aware,

3. Patient to be assigned to telemonitor nurse to review vital signs weekly follow

telemonitor guidelines on when and how to report to physician.

4. Weekly visit to patient home to continue education on disease management until patient

stable and using their own equipment in the home. Patient also will be able to verbalize

signs and symptoms to report to physician and disease management strategies as per care

plan in place for telemonitor program,

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The use of informatics in nursing is something that is used every day. It not just the

technology part of it but the sharing of ideas and information. As a nurse, it keeps our

patients safer with the use of barcoding medications in medication administration, it allows

us to chart quickly to accurately get patient medical information and to have best practice

findings. It can be used to educate our patients and as with the telemonitor in the home it can

empower our patients to better manage their disease and produce better outcomes.

Informatics can also assist in creating a better work flow process and nursing policies. It is

also important to remember that we must protect our patient’s rights and share information

responsibly.
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References

Cowie, M. R. (2012). Telemonitoring for patients with heart failure. CMAJ.

Ethics. (n.d.). Retrieved from https://www.nursingworld.org/practice-policy/nursing-

excellence/ethics/

Finkelman, A. (2016). Leadership and Management for Nurses: Core competencies for quality
care (3rd Ed.). Pearson.

HHS Office of the Secretary, Office for Civil Rights, & OCR. (2017, February 01). Your Rights
Under HIPAA. Retrieved from https://www.hhs.gov/hipaa/for-individuals/guidance-
materials-for-consumers/index.html

Long, G., Babbitt, A., & Cohn, T. (2017). Impact of Home Telemonitoring on 30-day Hospital
Readmission Rates for Patients with Heart Failure: A Systematic Review. MEDSURG
Nursing, 26(4).

Sewell, J. P. (2016). Informatics and nursing: Opportunities and challenges. Philadelphia, PA:
Wolters Kluwer Health/Lippincott Williams & Wilkins.

Suter, P., Suter, W. N., & Johnston, D. (2011). Theory-Based Telehealth and Patient
Empowerment. Population Health Management, 14(2), 87-92. doi:10.1089/pop.2010
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