**3. Conclusions**

This chapter introduces the ongoing need to make risk assessment tools available in an electronic medium. Advances in patient care and the clinicians' need for full availability of patient information, require the conversion of risk assessment tools from paper to electronic. This chapter outlines a process for achieving this conversion. The process described is one organization's method for conversion, although most organizations use a similar process for preparing to move any clinical documentation to an electronic environment. The tools that have been converted are those that this organization has chosen to use to assess health risks on hospitalized patients.

Transforming Risk Assessment Tools from Paper to Electronic 295

made the transition of clinical assessment tools and instruments to an electronic health record. Our clinical community is indebted to their skills and expertise. It is their ability to

AHRQ (2011), Workflow Assessment for Health IT Toolkit. November 14, 2011, Available

Berner, ES. Clinical decision support systems: State of the Art. AHRQ Publication No. 09-

Brettle, A. (2003) Information skills training: a systematic review of the literature. *Health Information and Library Skills Journal,* Vol. 20, No. s1. (June, 2003) pp. 3-9 Carayon, P. Schoofs Hundt, A. Karsh, B-T. Gurses, A. Alvarado, C. Smith, M. Flatley-

SEIPS model. *Quality and Safety in Healthcare,* Vol. 15 (2006) (Suppl 1) i50-i58. Chapman J., Bachand D., Hyrkäs K. (2011) Testing the sensitivity, specificity and feasibility

Clarke M. (2007) *Evidence-Based Nursing: Monographs. Pressure Ulcers*. Mosby's Nursing

Courtney KL, Demiris G, Alexander GL. (2005) Information technology: changing nursing

Gunningherg, L. Fogelberg-Dahm, M. Ehrenberg, A. (2009) Wound Care and Pressure

Hersh, W. (2009) A Stimulus to Define Informatics and Health Information Technology.

Karsh, B-T. (2009) Clinical Practice Improvement and Redesign: How Change in Workflow

Kenney-Weeks S. Bijkersma F. Hubbeartt E. Murphy B. Anderson, M. (2004) Failure Mode

Kocher, R. Emanuel, E. DeParle, N-A. (2010) The Affordable Care Act and Future of Clinical

Lopez K., Gerling G., Cary M. & Lanak M (2010) Cognitive work analysis to evaluate the

Consult. Date of access: September 16, 2011. Available from:

*Journal of Clinical Nursing*, Vol. 18, (2009), pp. 1557-1564.

*American Journal of Nursing* 2004; 104(4)"72a-72d.

*Informatics Association* 17:312-321. ISSN 1527-974X

Nos. 8, (October 19, 2010) pp. 536-539.

0069-EF. Rockville, Maryland: Agency for Healthcare Research and Quality. June

Brennan, P. (2006). Safety by Design: Work system design for patient safety: the

of four falls risk assessment tools in a clinical setting. *Journal of Nursing Management* 

processes at the point-of-care. *Nursing Administration Quarterly*.;Vol. 29, No. 4 (2005

Ulcers: Improved quality and comprehensiveness in nursing documentation of pressure ulcers after implementing an electronic health record in hospital care.

*BMC Medical Informatics and Decision Making*, Vol. 9, No. 24. doi: 10.1186/1472-6947-

Can Be Supported by Clinical Decision Support. Department of Industrial and Systems Engineering University of Wisconsin—Madison AHRQ Publication No.

and Effects Analysis: a search for ways of preventing patients from falling.

Medicine: The Opportunities and Challenges. *Annals of Internal Medicine,* Vol. 153,

problem of patient falls in an impatient setting. *Journal of the American Medical* 

work closely with our clinicians that has made these transitions occur easily.

from: http://healthit.ahrq.gov

Vol 1, No 1, 133-142. ISSN 0966-0429

http://www.nursingconsult.com.library

Oct-Dec) pp.315-22.

09-0054-EF June 2009

9-24.

**5. References** 

2009.

Perhaps the most critical phase of this process is the workflow analysis. Successful conversion to electronic documentation requires a good understanding of the processes of risk assessment, both in physical and cognitive terms. A complete understanding of any workflow provides a solid foundation for the design and configuration of tools in a computerized format. In our organization this process has been successfully repeated in the conversion of several risk assessment tools. Only in one instance, noted earlier in the chapter, the users found the converted tool less efficient, when in fact the tool's security settings made it less efficient. The initial workflow analysis did not include the associated selection of targeted interventions. In fact, a critical part of the complete workflow for risk analysis and risk prevention was missed. Revisiting the review of workflow confirmed the flaw in the tool's electronic design and build and access was provided to unlicensed workers assisting the Registered Nurse.

Although these conversions represent a change in how work is performed, there are numerous benefits to the patient, clinician and organization's leadership. For the patient, the outcome of the risk assessment is increased safety, because the electronic information is available to all members of the care team. This ensures continuous, high awareness among team members regarding different types and levels of risk and allows interdisciplinary contributions to prevention, when appropriate. For example, it is beneficial for all members of the care team to know that a patient is at risk for falling. Any team member can prevent falls, when assisting patients to chairs, bathrooms, or merely ensuring that the nurse call device is within the patient's reach. For the bedside nurse, this represents an interdisciplinary collaborative approach to preventing falls. Nurses are no longer the sole clinician responsible for assessing different types of risks and keeping patients safe. For the organization's leaders, electronic tools provide an opportunity to perform comprehensive, on-time monitoring and improved oversight of risk assessment and management. Electronic tools allow for more efficient auditing for compliance of policies regarding risk assessment, particularly if these are mandated by regulatory or accrediting organizations. Reports can also indicate the organization's progress toward its safety goals and decreasing risks for hospitalized patients. Many risk assessments are related to nursing sensitive indicators, and thus the data from the electronic IT system can provide a snapshot of an organization's performance in meeting the nursing quality measures.

Moving forward, it is likely that many risk assessment tools will be initially developed in an electronic medium. Conversion may become unnecessary, although attention to nursing workflow and practice will still need to be a part of the process. Development of risk assessment tools in an electronic medium will allow for more efficient testing of the tool, eliminating manual data review, and enabling greater efficiency of scientific research, and expedient statistical analysis of the tool's sensitivity, specificity, reliability and validity in different patient populations.

#### **4. Acknowledgment**

The authors would like to acknowledge the Analyst and Training Teams of the Information Services Department at Maine Medical Center in Portland, Maine, USA. These teams have made the transition of clinical assessment tools and instruments to an electronic health record. Our clinical community is indebted to their skills and expertise. It is their ability to work closely with our clinicians that has made these transitions occur easily.

#### **5. References**

294 Novel Approaches and Their Applications in Risk Assessment

Perhaps the most critical phase of this process is the workflow analysis. Successful conversion to electronic documentation requires a good understanding of the processes of risk assessment, both in physical and cognitive terms. A complete understanding of any workflow provides a solid foundation for the design and configuration of tools in a computerized format. In our organization this process has been successfully repeated in the conversion of several risk assessment tools. Only in one instance, noted earlier in the chapter, the users found the converted tool less efficient, when in fact the tool's security settings made it less efficient. The initial workflow analysis did not include the associated selection of targeted interventions. In fact, a critical part of the complete workflow for risk analysis and risk prevention was missed. Revisiting the review of workflow confirmed the flaw in the tool's electronic design and build and access was provided to unlicensed workers

Although these conversions represent a change in how work is performed, there are numerous benefits to the patient, clinician and organization's leadership. For the patient, the outcome of the risk assessment is increased safety, because the electronic information is available to all members of the care team. This ensures continuous, high awareness among team members regarding different types and levels of risk and allows interdisciplinary contributions to prevention, when appropriate. For example, it is beneficial for all members of the care team to know that a patient is at risk for falling. Any team member can prevent falls, when assisting patients to chairs, bathrooms, or merely ensuring that the nurse call device is within the patient's reach. For the bedside nurse, this represents an interdisciplinary collaborative approach to preventing falls. Nurses are no longer the sole clinician responsible for assessing different types of risks and keeping patients safe. For the organization's leaders, electronic tools provide an opportunity to perform comprehensive, on-time monitoring and improved oversight of risk assessment and management. Electronic tools allow for more efficient auditing for compliance of policies regarding risk assessment, particularly if these are mandated by regulatory or accrediting organizations. Reports can also indicate the organization's progress toward its safety goals and decreasing risks for hospitalized patients. Many risk assessments are related to nursing sensitive indicators, and thus the data from the electronic IT system can provide a snapshot of an organization's performance in meeting the nursing quality

Moving forward, it is likely that many risk assessment tools will be initially developed in an electronic medium. Conversion may become unnecessary, although attention to nursing workflow and practice will still need to be a part of the process. Development of risk assessment tools in an electronic medium will allow for more efficient testing of the tool, eliminating manual data review, and enabling greater efficiency of scientific research, and expedient statistical analysis of the tool's sensitivity, specificity, reliability and validity in

The authors would like to acknowledge the Analyst and Training Teams of the Information Services Department at Maine Medical Center in Portland, Maine, USA. These teams have

assisting the Registered Nurse.

measures.

different patient populations.

**4. Acknowledgment** 


**1. Introduction**

rigor.

quantitatively described.

into a human health impact via a dose-response model.

product-pathogen pair (Hald et al., 2004).

Monte Carlo simulation is a commonly used tool for constructing foodborne pathogen risk assessment models. Monte Carlo simulation enables an analyst to construct a probabilistic model of almost any desired complexity. It requires relatively little mathematical rigor and the models can be presented in an intuitive manner. It has some drawbacks, however. For example, Monte Carlo simulation requires that each parameter, as well as its uncertainty, be

**A Bayesian Approach for** 

Jennifer A. Hoeting2 and James L. Withee3

Michael S. Williams1, Eric D. Ebel1,

*1Food Safety and Inspection Service,* 

*3GigaYeast Inc., Belmont, California* 

*USA* 

**16**

**Calibrating Risk Assessment Models** 

*United States Department of Agriculture, Fort Collins, Colorado* 

*2Department of Statistics, Colorado State University, Fort Collins, Colorado* 

The models are typically used to make a projection of possible outcomes. In food-safety risk assessment applications, we typically construct a model to predict the number of human illnesses in the population. These calculations are based on the prevalence of contaminated production units and their microbial load. These are tracked through food production, consumer handing and consumption. The final step is converting predicted contamination

Foodborne illness is often the result of an acute microbial pathogen exposure. More than 75 countries have implemented surveillance systems to monitor occurrences of these illnesses (Allos et al., 2004; de Jong B & K., 2006; Herikstad et al., 2002). These surveillance systems do not capture every case of foodborne illness, so scaling factors are developed to estimate the total number of illnesses for the pathogen of interest (Ebel et al., 2012; Scallan et al., 2011). Additional scaling factors can be developed to extend these estimates to a specific

A conundrum for risk assessors occurs when the illness estimates from a Monte Carlo-based risk assessment model do not match the estimates based on the surveillance data. When these two estimates do not match the risk assessment model must be calibrated. A common approach to calibrating the model is to adjust the parameters of the dose-response function to match predicted to observed illnesses. Alternative calibration approaches are to replace components of the model, such as changing the models used to calculate pathogen attenuation during cooking. The concern with these calibration approaches is their lack of objectivity and

