EBP, or evidence based practice, is a problem solving approach to clinical practice. Some examples of EBP are real world practice, research, and innovations that emerge through research and practice. External evidence is generated through research, and internal evidence is generated through outcome management and practice based evidence. Informatics is a concept that is needed for EBP. Many healthcare workers and clinicians hire health informatics experts to help with the EBP process in their clinic or hospital. The PICO(T) method is used to support EBP. It is also important to acquire evidence, appraise the evidence, and apply the evidence found. Quality improvement/process improvement, QI and PI, are used by informatics professionals to improve systems and processes in ord
er to improve the result.
Poorly coordinated care transitions from a hospital to other care settings cost an estimated $12 billion to $44 billion per year. A few adverse effects due to inadequate transitional care are medication errors and procedure complications. There are certain guidelines clinics have implemented that reduced readmissions and costs. One existing guideline is comprehensive discharge planning. Physicians, nurses, or other medical staff organize follow up services prior to patient discharge. They discuss any financial or psychological barriers a patient may have and use community resources to help if needed. The staff call the patient about one to three days post discharge to assess any new symptoms and answer questions.
Another successful program is the Transitional Care Model, which was practiced in six Philadelphia hospitals between 1997 and 2001. Advanced transitional care nurses visited chronically ill patients’ homes about 8 times and were on call by phone seven days a week. After one year, this practice reduced readmission rates by 36% and net costs by 38%. Informatics is a necessity for quality improvement of care transition. Storing, managing, and translating data into knowledge for the, providers, patients, and their families will improve the efficiency of care transition and cut overall costs.
Informatics professionals can use data mining to further assist healthcare workers on improving certain EBP programs. When using the transitional care model, I would gather data by conducting and comparing patient satisfaction and level of comprehension surveys after their visits I would see if there are patients with certain illnesses that need more care and education than others during and after discharge. I would use the tool Tableau to visualize the data. EHRs are a cloud-based system and have different computer format capabilities. Having EHRs is important in care transition because it gives medical staff access to patient records from all clinics and hospitals. This eliminates duplicate tests and ultimately reduces costs. I would use EMRs to clearly identify the patient medical history and any new history since the last visit. I would use EHRs to compare that data across all providers to properly assess the best care and medications needed for the patient. If EHRs are not being used it could cause problems in giving the best care to the patient.
Clinical Decision Support, or CDS, is a process used to improve health related decisions and measures. There are different opportunities that can be integrated to care transition. One is medication management to improve medication use and results. The goal is to cut extra medication costs, transition efficiently, and optimize patient care. It is crucial to educate the patient on the medication for more self-care. Usually a nurse, pharmacist, physician, patient, and other care providers will be would be following the guidelines. This data will be provided in EMRs, PHRs, and pharmacy systems. The tracking of the effects of medication can be done through the health provider website or a mobile app. Those two options would be the easiest and most effective for the patient and care providers.
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