A summary, like frosting, may cover a splendid cake when it is cool, or it may become transparent and clear when applied to a warm cake. We hope this summary, created before the cake has cooled, will help clarify the major conclusions that were drawn from the participants at the Invitational Postconference following the Nursing Informatics 1997 Conference in Stockholm, Sweden. Concluding remarks from all five groups have been used to synthesize this summary. The five groups were charged with examining nursing informatics issues related to clinical practice guidelines (from development to implementation), patient preferences, patient information and education, and patient decision support. The challenges were to establish the state of our knowledge and a vision for informatics and to clarify the best thinking of our international informatics colleagues on the topic.
In general, it became readily apparent that our thinking had moved beyond just the implementation and deployment of systems and was now focused on the fundamental issues of providing systems to support evidence-based nursing care. In fact, it was concluded that the clinical guidelines and patient preferences should be included as part of the information in the clinical record. Informatics should provide the infrastructure for facilitating use of this information by clinicians. Taken together, these represent major challenges for both nursing and health care informatics in the future, especially with respect to the computerized patient record and the associated tools for health care organizations delivering care.
The most critical issue addressed was that of identifying data that could be used to examine clinical practice and establish evidence for improving the quality of clinical practice. Maintaing cost-effective care while attending to patient preferences was an essential part of this “best practice quality” continuum. An important aspect of identification of this data was the explicit statement that care strategies be consistent with patient preferences that have been elicited as care progresses over time. A call for revision of the International Code for Nurses was proposed to make patient preferences an explicit part of the values and customs of care. A suggestion was make to amplify the Structure-Process-Outcome model by adding three dimensions—clients, providers, and setting—to each element for consideration. For example, the structure element would include identifying the structure for clients, providers, and setting, thus adding a rich description to these evidence-based inquiries.
The need for informatics tools to support inquiry for evidence-based practice was clearly identified repeatedly. Some of these essential tools would elicit preferences so that care could be individualized and made unique for patients and groups over time. Once developed, these tools could be used to compensate for some of the current human barriers in care, enhancing the interactive component of care. In essence, the tools must support inquiry for identifying best practice.
The importance of including patient preferences in the automated patient record of the future and of making all health care professionals sensitive to patient preferences was identified as an important goal that informatics nurses (indeed, all nurses as patient advocates) must recognize and find ways to accomplish. A crucial aspect of effecting such change was identified as clearly understanding the context of care and making relevant and appropriate changes to support patients' preferred levels of participation in their care. The moral and ethical imperative of this goal is implicit in the current International Council of Nurses code, but it needs to be made explicit.
Additional informatics tools are necessary so that a convergence of clinical data with evidence-based inquiry can occur. While at the moment outcomes and quality are the focus of much inquiry, an essential feedback loop to both patients and nurses is absent and should be corrected. Currently, little information about the “processes of care” is evident; even less information is available about the satisfaction of individual patients or groups with their courses of care. In fact, preferences are rarely taken into account in most health care systems, while the aggregate satisfaction indicators with service are used.
An important aspect of enabling usage of patient preferences is dissemination of timely information on practice guidelines with attention to the full range of patient preferences and choices. The absence of clinicians and patients in the feedback loops of attempts to measure care and its effects is a major weakness that detracts from the quality of the effort. Thus, guidelines for care that have little input from clinicians and patients have little chance of improving care. The continuing cycle of understanding, using, and improving clinical practice guidelines based on evaluation of care and its outcomes is fractured, with a valuable information resource lost. The informatics arena cannot allow such an occurrence and must provide leadership in providing the infrastructure for evidence-based practice, including tools for evaluating clinical practice.