Discuss Informatics and Nursing Opportunities and Challenges

INFORMATICS INTRODUCTION What is informatics? Isn’t it just about comput- ers? Taking care of patients is nursing’s primary concern, not thinking about computers! It is com- mon for some nurses to have these thoughts. Transitions are always difficult, and a transition to using more technology in managing information is no exception. The use of information tech- nology (IT) in healthcare is informatics, and its focus is information management, not comput- ers. The quality of future patient care and nurs- ing practice is dependent upon nurses effectively using informatics.

Information management is an integral part of nursing. Think about your practice for a minute. What besides your nursing education and expe- rience do you depend upon when providing care for patients? You need to know the patient’s his- tory, medical conditions, medications, laboratory results, and more. Could you care for a patient without this information? How this information is organized and presented affects the care that you can provide, as well as the time you spend finding it.

The old way is to record and keep the information for a patient’s current admission in a paper chart. Today, with several specialties, consults, medi- cations, laboratory reports, and procedures, the paper chart is inadequate. A well-designed informa- tion system, developed with you and for you, can facilitate finding and using information that you need for patient care. Informatics skills enable you to participate in and benefit from this process. Informatics does not perform miracles; it requires an investment by you, the clinician, to assist those who design information systems so the systems are helpful and do not impede your workflow.

If healthcare is to improve, it is imperative that there be a workforce that can innovate and imple- ment health information technology (HIT) (American Health Information Management Association & American Medical Informatics Association, 2006, p. 3). There are two roles in infor- matics: the informatics nurse specialist and the cli- nician who must use HIT. This means that in essence every nurse has a role in informatics. Information, the subject of informatics, is the structure on which healthcare is built. Except for purely technical pro- cedures (of which there are few, if any), a healthcare professional’s work revolves around information. Is the laboratory report available? When is Mrs. X for surgery scheduled? What are the contraindications for the prescribed drug? What is Mr. Y’s history? What orders did the physician leave for Ms. Z? Where is the latest x-ray report?

An important part of healthcare information is nursing documentation. When information sys- tems designed for nursing exist, the documenta- tion can expand our knowledge of what constitutes quality healthcare. Have you ever wondered if the patient for whom you provided care had an out- come similar to others with the same condition? From nursing documentation, are you easily able to see the relationship between nursing diagnoses, interventions, and outcomes for your patients? Without knowledge of these chain events, you have only your intuition and old knowledge to use when making decisions about the best interven- tions in patient care. Observations tend to be self- selective; however, there is better information on which to base patient care. Informatics can furnish the information needed to see these relationships and to provide care based on actual patient data, which are facts stored in the computer.

If Florence Nightingale were with us today, she would be a champion of the push toward more use of healthcare IT. Information in a paper chart essentially disappears into a black hole after dis- charging a patient. Because we cannot easily access it, we cannot learn from it and use it in future patient care. This realization is international. Many countries, especially those with a national health service, have long realized the need to be able to use information buried in charts. Tommy Thompson, the former United States Secretary of Health and Human Services, is quoted as saying “the most

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remarkable feature of this 21st century medicine is that we hold it together with 19th century paper- work” (Committee on Government Reform, 2004).

The introduction of bills in the U.S. Congress backed up Thompson’s statement. The President’s Information Technology Advisory Committee (PITAC) created support for greater use of infor- matics. PITAC responsibilities transferred to the President’s Council of Advisors on Science and Technology in the Office of Science and Technology Policy in 2005 (Office of Science and Technology Policy, 2013).

In 2004, President Bush called for adoption of interoperable electronic health records (EHRs) for most Americans by 2014. He also

established the position of National Coordinator for Health Information Technology. The Office of the National Coordinator for Health Information Technology (ONC) released the first Federal Health HIT strategic plan for 2008– 2012, which focused on two goals—patient- focused healthcare and population health. The common themes for the goals included privacy and security, interoperability, adoption, and col- laborative governance. The 2011–2015 strategic plan was released with a mission to improve health and healthcare for all Americans through informa- tion and technology. The strategic plan expanded on the initial plan with five goals that affect nurses and healthcare (Box 1-1).

BOX 1-1 2011–2015 Strategic Plan Goals

1. Achieve adoption and information exchange through meaningful use of health IT.

a. Accelerate adoption of electronic medical records.

b. Facilitate information exchange to support meaningful use of electronic health records.

c. Support health IT adoption and information exchange for public health and populations with unique needs.

2. Improve care, improve population health, and reduce healthcare costs through the use of health IT.

a. Support more sophisticated uses of EHRs and other health IT to improve health system performance.

b. Better manage care, efficiency, and population health through EHR- generated reporting measures.

c. Demonstrate health IT–enabled reform of payment structures, clinical practices, and population health management.

d. Support new approaches to the use of health IT in research, public and population health, and national health security.

3. Inspire confidence and trust in health IT.

a. Protect confidentiality, integrity, and availability of health information.

b. Inform individuals of their rights and increase the transparency regarding the uses of protected health information.

c. Improve safety and effectiveness of health IT.

4. Empower individuals with health IT to improve their health and the healthcare system.

a. Engage individuals with health IT.

b. Accelerate individual and caregiver access to their electronic health information in a format they can use and reuse.

c. Integrate patient-generated health information and consumer health IT with clinical applications to support patient-centered care.

5. Achieve rapid learning technological advancement.

a. Lead the creation of a learning health system to support quality, research, and public and population health.

b. Broaden the capacity of health IT through innovation and research.

Adapted from HealthIT.gov (2011).

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To fulfill these goals, information, which is the structure on which healthcare is built, can no lon- ger be managed with paper. If we are to provide evidence-based care, we must make the moun- tains of data hidden in medical records reveal their secrets. Bakken (2001) proposed the need for five components to provide evidence-based care: 1. Standardization of terminologies and struc-

tures used in documentation. 2. The use of digital information. 3. Standards to permit healthcare data exchange

between heterogeneous entities. 4. The ability to capture data relevant to the actual

care provided. 5. Competency among practitioners to use these

data. All of these components are parts of informatics.

The Affordable Care Act (ACA), signed into law in 2010, made improvements in healthcare cover- age, lowered costs, and increased access to care (HHS.gov/HealthCare, 2014). To be able to assess ACA compliance and care outcomes, all nurses must have data analysis skills, and there is an increased need for informatics nurse specialists.

The complexity of today’s healthcare milieu, added to the explosion of knowledge, makes it impossible for any clinician to remember every- thing needed to provide high-quality patient care. Additionally, healthcare consumers today want their healthcare providers to integrate all known relevant scientific knowledge when providing care. We have passed the time when the unaided human mind can perform this feat. The changes in prac- tice that are needed as new knowledge becomes available require modern information manage- ment tools as well as a commitment by healthcare professionals to evidence-based practice.

INFORMATICS DISCIPLINE Informatics is about managing information. The tendency to relate it to computers comes from the fact that the ability to manage large amounts of information was born with the computer and progressed as computers became more powerful and commonplace. However, human ingenuity is the crux of informatics. The term “informatics” originated from the Russian term “informatika”

(Sackett & Erdley, 2002). A Russian publication, Oznovy Informatiki (Foundations of Informatics), published in 1968, is credited with the origins of the general discipline of informatics (Bansal, 2002, p. 10). At that time, the term related to the context of computers. The term “medical informatics” was the first term to identify informatics in healthcare. It meant information technologies concerned with patient care and the medical decision-making process. Another definition stated that medi- cal informatics is complex data processing by the computer to create new information.

As with many healthcare enterprises, there was debate about whether “medical” referred only to informatics focusing on physician concerns or whether it refers to all healthcare disciplines. We now recognize that other disciplines, such as nurs- ing, are a part of healthcare and have a body of knowledge separate from medicine. For this rea- son, we more commonly use the term healthcare informatics. In essence, informatics is the man- agement of information, by using cognitive skills and the computer.

Healthcare Informatics Healthcare informatics focuses on managing information in all healthcare disciplines. It is an umbrella term that describes the capture, retrieval, storage, presenting, sharing, and use of biomedical information, data, and knowledge for providing care, problem solving, and decision making (Shortliffe & Blois, 2001). The purpose is to improve the use of healthcare data, informa- tion, and knowledge in supporting patient care, research, and education (Delaney, 2001). The focus is on the subject, information, rather than the tool, the computer. This is analogous to using another data acquisition tool, the stethoscope, to gather information about heart and lung sounds (Figure 1-1). This distinction is not always obvious because mastery of computer skills is necessary to manage the information. We use the computer to acquire, organize, manipulate, and present the information. The computer will not produce anything of value without human direction. That includes human input for how, when, and where the data are acquired, treated, interpreted, manip- ulated, and presented. Informatics provides that human direction.

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Nursing Informatics Healthcare has many disciplines; thus, it is not surprising that healthcare informatics has many specialties, of which nursing is one. The American Nurses Association (ANA) recognized nursing informatics as a subspecialty of nurs- ing in 1992. The first administration of the informatics certification examination was fall of 1995 (Newbold, 1996). Managing informa- tion pertaining to nursing is the focus of nurs- ing informatics. Specialists in this area study how we acquire, manipulate, store, present, and use nursing information. Informatics nurse special- ists work with clinical nurses to identify nursing needs for information and support. These spe- cialists work with system developers to design systems that work to complement the practice needs of nurses.

Informatics nurse specialists bring to system development and implementation a viewpoint that supports the needs of the clinical end user. The objective is an information system that is not

only user friendly for data input but also presents the clinical nurse with needed information in a manner that is timely and useful. This is not to say that nursing informatics stands alone; it is an inte- gral part of the interdisciplinary field of healthcare informatics, hence related to and responsible to all the healthcare disciplines. (The nursing informat- ics subspecialty will be explored in more detail in Chapter 16.)

Definitions of Nursing Informatics The term nursing informatics was probably first used and defined by Scholes and Barber in 1980 in their address that year to the MEDINFO confer- ence in Tokyo. There is still no definitive agreement on exactly what this term means. As Simpson (1998) once said, defining nursing informatics is difficult because it is a moving target. The original definition said that nursing informatics was the use of computer technology in all nursing endeav- ors: nursing services, education, and research (Scholes & Barber, 1980). Hannah et al. (1994) wrote another early definition that followed the broad definition by Scholes and Barber. Hannah et  al. (1994) defined nursing informatics as any use of information technologies in carrying out nursing functions. Like the definition by Scholes and Barber, the one by Hannah et al. focused on the technology. The interpretations of those defi- nitions meant any use of the computer, from word processing to the creation of artificial intelligence for nurses, as long as the computer use involved the practice of professional nursing.

The shift from a technology orientation in defi- nitions to one that is more information oriented started in the mid-1980s with Schwirian (Staggers & Thompson, 2002). Schwirian (1986) created a model for use as a framework for nursing infor- matics investigators. The model consisted of four elements arranged in a pyramid with a triangular base. The top of the pyramid was the desired goal of nursing informatics activity and the base was composed of three elements: (1) users (nurses and students), (2) raw material or nursing infor- mation, and (3) the technology, which is com- puter hardware and software. They all interact in nursing informatics activity to achieve a goal. The intention of the model was as a stimulus for research.

Figure 1-1. The computer as a data acquisition tool. (shutterstock.com/JIL Photo.)

Chapter 1 Introduction to Nursing Informatics: Managing Healthcare Information 7

The first widely circulated definition that moved from technology to concepts was from Graves and Corcoran (Staggers & Thompson, 2002). They defined nursing informatics as “a combination of computer science, information science and nurs- ing science designed to assist in the management and processing of nursing data, information and knowledge to support the practice of nursing and the delivery of nursing care” (Graves & Cocoran, 1989, p. 227). This definition secured the position of nursing informatics within the practice of nurs- ing and placed the emphasis on data, information, and knowledge (Staggers & Thompson, 2002). Many consider it the seminal definition of nursing informatics.

Turley (1996), after analyzing previous defini- tions, added another discipline, cognitive science, to the base for nursing informatics. Cognitive science emphasizes the human factor in informatics. Its focus is the nature of knowledge, its components, development, and use. Goossen (1996), thinking along the same lines, used the definition by Graves and Corcoran as a basis and expanded the mean- ing of nursing informatics to include the thinking that is done by nurses to make knowledge-based decisions and inferences for patient care. By using this interpretation, he felt that nursing informat- ics should focus on analyzing and modeling the cognitive processing for all areas of nursing prac- tice. Goossen also stated that nursing informatics should look at the effects of computerized systems on nursing care delivery.

In 1992, the first ANA definition added the role of the informatics nurse specialist to the defini- tion by Graves and Corcoran. The 2014 ANA defi- nition of the specialty of nursing informatics (NI) has expanded from the original 2001 definition. Originally, it stated that this specialty combines nursing, information, and computer sciences for the purpose of managing and communicating data, information, and knowledge to support nurses and healthcare providers in decision mak- ing (American Nurses Association, 2001). An update in 2008 included the term wisdom to the data, information, and knowledge continuum (American Nurses Association, 2008). The 2015 definition states that “NI supports consumers, patients, the interprofessional healthcare team, and other stakeholders in their decision making in

all roles and settings to achieve desired outcomes. This support is accomplished through the use of information structures, information processes, and information technology” (American Nurses Association, 2015, p. 12). ANA states that the goal of NI is to optimize information management and communication to improve the health of individu- als, families, populations, and communities.

Staggers and Thompson (2002), who believe that the evolution of definitions will continue, pointed out that in all of the current definitions, the role of the patient is underemphasized. Some early definitions included the patient, but as a passive recipient of care. With the advent of the Internet, more and more patients are taking an active role in their healthcare. This factor not only changes the dynamics of healthcare but also permits a defini- tion of nursing informatics that recognizes that patients as well as healthcare professionals are consumers of healthcare information. For exam- ple, patients may participate in keeping their medi- cal records current. Staggers and Thompson (2002) also pointed out that we overlooked the role of the nurse as an integrator of information. They recom- mended including it in future definitions.

Despite these definitions, the focus of much of today’s practice informatics is still on capturing data at the point of care and presenting it in a manner that facilitates the care of an individual patient. Although this is a vital first step, we must give thought to secondary data analysis, or analysis of data for purposes other than the purpose of the original collection. You can make decisions based on actual patient care data by using aggregated data, or the same piece(s) of data. For example, you can analyze outcomes of a given intervention for many patients. Understanding how informatics can serve you as an individual nurse, as well as the profession, puts you in a position to work with informatics nurse special- ists to retrieve data needed to improve patient care.

QSEN Scenario After sharing that you are learning about informatics with a nursing colleague, the colleague asks you what informatics has to do with the quality and safety of nursing practice. How would you respond?

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FORCES DRIVING MORE USE OF INFORMATICS IN HEALTHCARE

The ultimate goal of healthcare informatics is a lifetime EHR with decision support systems. These records will include standardized data, per- mit consumers to access their records, and provide for secondary use of healthcare data. Ultimately, when emergency medical services and primary care facilities have access to and can contribute to the EHR, there are immense possibilities to provide seamless care and communication with patients. Forces driving more use of informatics in healthcare include national initiatives, nurs- ing, healthcare consumer empowerment, patient safety, and costs.

National Forces Federal efforts behind a move to EHRs include the creation of the Office of the National Coordinator for Health Information Technology (ONC). Several seminal reports aimed at improv- ing healthcare, all of which foresee a large role for IT, were published by the Institute of Medicine (IOM), which is an independent body that acts as an adviser to the U.S. government to improve healthcare. Their report Health Professions Education: A Bridge to Quality (Greiner & Knebel, 2003) includes informatics as a core compe- tency required of all healthcare professionals. In the report Crossing the Quality Chasm: A New Health System for the 21st Century (Committee on Quality of Health Care in America & Institute of Medicine, 2001), HIT is seen as an important force in improving healthcare. Some of the HIT themes in this report are a national informa- tion infrastructure, computerized clinical data, use of the Internet, clinical decision support, and evidence-based practice integration. (See Chapter 14 for more information on U.S. gov- ernment efforts.)

The pervasive use of technology in health- care is another driving force. Technologies to manage care, such as electronic health records, smart beds, computerized intravenous pumps, and telehealth, are examples of technology that although it assists nurses to improve patient care outcomes (Needleman, 2013), needs to be under-

stood and managed. Other forces such as the changing healthcare environment and increas- ing patient acuity are affecting the move toward informatics.

Nursing Forces Nursing also recognized the need for informat- ics. In 1962, before conceptualization of the term informatics, Dr. Harriet Werley understood the value of nursing data and insisted that the ANA make research about nursing information a prior- ity. Nurses wrote many articles about informatics in the intervening years. In 1982, Gary Hales at the University of Texas, Austin, started the jour- nal Computers in Nursing as a mimeograph sheet. Although today it is a full-fledged journal in its fourth decade, in 1982 few nurses realized the value of and need for informatics.

The Robert Wood Johnson Foundation (2010) study revealed that nurses believe technology can improve workflow, communication, and doc- umentation; however, many technologies are still not “user-friendly.” Although technology has the potential to improve nursing, there is still work that must be done. The bedside clinician has an integral role in that work. The clinical nurse with essential nursing competencies can and must assist in designing user-friendly technologies that improve care delivery and care outcomes.

Nursing Organizations In 1993, the National Center for Nursing Research released the report Nursing Informatics: Enhancing Patient Care (Pillar & Golumbic, 1993), which set the following six program goals for nursing infor- matics research: 1. Establish a nursing language (useful in comput-

erized documentation). 2. Develop methods to build clinical information

databases. 3. Determine how nurses give patient care using

data, information, and knowledge. 4. Develop and test patient care decision support

systems. 5. Develop workstations that provide nurses with

needed information. 6. Develop appropriate methods to evaluate nurs-

ing information systems.

Chapter 1 Introduction to Nursing Informatics: Managing Healthcare Information 9

The above are still pertinent, although today num- ber three would include wisdom.

In 1997, the Division of Nursing of the Health Resources and Services Administration convened the National Advisory Council on Nurse Education and Practice. The council produced the National Informatics Agenda for Education and Practice, which made the following five recommendations (National Advisory Council on Nurse Education and Practice, 1997, p. 8):

1. Educate nursing students and practicing nurses in core informatics content.

2. Prepare nurses with specialized skills in informatics.

3. Enhance nursing practice and education through informatics projects.

4. Prepare nursing faculty in informatics. 5. Increase collaborative efforts in nursing

informatics.

The National League for Nursing (NLN) (2008) published a position paper outlining recom- mendations for preparing nurses to work in an environment that uses technology. The paper outlined recommendations for nursing faculty, deans/directors/chairs, and the NLN. Examples of recommendations included the need for faculty to achieve informatics competencies and incorporate informatics into the nursing curriculum.

The American Association of Colleges of Nursing’s (AACN’s) Essentials for baccalaureate, master’s, and doctoral education lists of core com- petencies include many recommendations in the area of information and healthcare technologies. Examples include the use of information and com- munication technologies, the use of ethics in the application of technology, and the enhancement of one’s knowledge using information technolo- gies (AACN, 2006, 2008, 2011).

The ANA has been another force moving nurs- ing toward the effective use of informatics. In 1992, they published two documents, Standards of Practice for Nursing Informatics and The Scope of Practice for Nursing Informatics. In 2008, Nursing Informatics: Scope & Standards of Practice combined the two publications into one docu- ment. The publication of the most recent edition was 2014.

The American Organization of Nurse Executives (AONE) (2012) issued a position paper on the Nursing Informatics (NI) Executive Leader. The paper identifies that nursing leaders are key to influencing healthcare reform in all set- tings where they bridge the new practice delivery models with the right technology. AONE recog- nizes the importance of clinical data captured with the EHR in decision making. AONE recom- mends master’s and doctoral education for the NI Executive Leader.

The Technology Informatics Guiding Educational Reform (TIGER) Initiative origi- nated after several years of planning, with a 2-day invitation-only conference starting October 30, 2006. TIGER’s objective is to make nursing infor- matics competencies part of every nurse’s skillset, with the aim of making informatics the stetho- scope of the 21st century (Technology Guiding Educational Reform, 2007). TIGER is working to ensure that nursing can be fully engaged in the digital era of healthcare by ensuring that all nurses are educated in using informatics, empow- ering them to deliver safer, high-quality, evidence- based care.

Patient Safety Patient safety is a primary concern and the one that drives many informatics initiatives. At least 10 patient safety databases use aggregated health- care data to identify safety issues. Aggregated data are data from more than one source and grouped for comparison. Most, such as the National Healthcare Safety Network (NHSN) from the Centers for Disease Control and Prevention (CDC) and the National Database of Nursing Quality Indicators from ANA, are voluntary. Two safety databases, the vaccine adverse event report sys- tem from the CDC and the U.S. Food and Drug Administration (FDA), are mandatory.

The Quality and Safety Education for Nurses (QSEN) Institute is an initiative initially funded by the Robert Wood Johnson Foundation. The Case Western Reserve University now hosts the QSEN Institute (QSEN Institute, 2014). QSEN Institute initiatives unfolded with four phases. Phase I addressed IOM’s five compe- tencies—patient-centered care, teamwork and

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collaboration, evidence-based practice, quality improvement, and informatics—plus safety, for six goals. Phase II integrated the competencies in pilot nursing programs. Phase III continued to promote the implementation and evaluation of knowledge, skills, and attitudes associated with the six competencies. Phase IV addressed the rec- ommendation of the 2010 Institute of Medicine report The Future of Nursing: Campaign for Action, by funding initiatives supporting academic pro- gression in nursing.

The QSEN Institute competencies devel- oped in Phase II are online at http://qsen.org/ competencies/ for prelicensure and graduate education. Many nursing programs use the com- petencies in the design of curricula. The categories for the competencies are as follows: JJ Patient-centered care JJ Teamwork and collaboration JJ Evidence-based practice JJ Quality improvement JJ Safety JJ Informatics.

Some other informatics implementations that focus on safety include barcode medication administration (BCMA) and computerized pro- vider order entry (CPOE). A well-designed CPOE system cannot only prevent transcription errors but, when combined with a patient’s record, can also flag any condition that might present a haz- ard or would need additional assessment. Clinical decision support systems that provide clinicians with suggested care information or remind busy clinicians of items easy to forget or overlook are also being pushed to improve patient safety. (CPOE will be further discussed in Chapters 17, 18 and 19.)

Costs Healthcare costs are also driving the move to using informatics. One example is the Leapfrog Group (http://leapfroggroup.org/). Upset by the rising cost of healthcare, in 1998, a group of chief executives of leading corporations in the United States discussed how they could have an influ- ence on its quality and affordability (Leapfrog Group, 2014a). The executives were spending bil- lions of dollars on healthcare for their employees,

but they lacked a way of assessing its quality or comparing healthcare providers. The Business Roundtable provided the initial funding, and this group took the name “Leapfrog Group” in November 2000. The 1999 IOM report, To Err Is Human, which reported up to 98,000 prevent- able hospital deaths and recommended that large employers use their purchasing power to improve the quality and safety of healthcare, gave further impetus to the move.

Today, the Robert Wood Johnson Foundation, Leapfrog members, and others also support the Leapfrog Group. Their mission is to support healthcare decisions by those who use and pay for healthcare and promote high-value healthcare using incentives and awards (Leapfrog Group, 2014b). Efforts toward the mission are met by collecting data voluntarily submitted by hospi- tals and posting this information on The Hospital Safety Score Web site (http://www.leapfroggroup. org/cp). Consumers can use this Web site to check the outcomes of hospitals in their areas for selected procedures.

Members of the Leapfrog Group also educate their employees about patient safety and the importance of comparing healthcare providers. They offer financial incentives to their covered employees for selecting care from hospitals that meet their standards. Healthcare provid- ers without information systems will have a difficult time providing the information that healthcare buyers demand and could see a loss of patients.

As healthcare informatics moves to solve these problems, the need for interdisciplinary, enterprise-wide, information management becomes clearer. The advances of HIT coupled with the evo- lution of the EHR create a steady progression to this end. Integration of HIT, however, is not with- out its perils. Any discipline that is not ready for this integration may find itself lost in the process. For nursing to be a part of healthcare informatics, all nurses must become familiar with the value of nursing data, how to capture date, the terminol- ogy needed to capture it, and methods for ana- lyzing and manipulating it. True integration of data from all healthcare disciplines will improve patient care and the patient experience, as well as enabling economic gains.

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THE INFORMATION MANAGEMENT TOOL: COMPUTERS

In 1850, the collection of all the medical knowledge known to the Western world would fit into two large volumes, making it possible for one person to read and assimilate the entire information. The sit- uation today is dramatically different. The number of journals available in healthcare and the research that fills them is increasing many times over. Even in the early 1990s, if physicians read two journal articles a day, by the end of a year, they would be 800 years behind in their reading (McDonald, 1994). In the early 2000s, there was an expectation that the healthcare clinician might know something about 10,000 different diseases and syndromes, 3,000 medications, 1,100 laboratory tests, and the infor- mation in the more than 400,000 articles added to the biomedical information each year (Davenport & Glaser, 2002). The number of journals, books, blogs, and news articles is growing exponentially on a daily basis. Additionally, current knowledge is constantly changing: one can expect much of one’s knowledge to be obsolete in 5 years or less.

In healthcare, the increase in knowledge has led to the development of many specialties, such as respiratory therapy, neonatology, and gerontology, and subspecialties within each of these. The prolif- eration of the specialties spawned the development of many miraculous treatments. However, the number of specialties can fractionalize healthcare, resulting in difficulty gaining an overview of the entire patient. Additionally, the pressure of accom- plishing the tasks necessary for a patient’s physi- cal recovery usually leaves little time for perusing a patient’s record and putting together the bits and pieces so carefully charted by each discipline. Even if time is available, there is simply so much data, in so many places, that it is difficult to merge the data with the knowledge that a healthcare provider has learned, as well as with new knowledge to provide the best patient care. We are drowning in data but lack the time and skills to transform it to useful information or knowledge.

The historical development of the computer as a tool to manage information is evident. The first information management task “computer- ized” was numeric manipulation. Although not

technically a computer by today’s terminology, the first successful computerization tool was the aba- cus, which was developed about 3000 bc. Although even when one developed skill and speed, the oper- ator of the abacus still had to manipulate data men- tally (Dilson, 1968). All the abacus did was store the results step-by-step. Slide rules came next in 1622 (The Oughtred Society, 2011), but like the abacus, they required a great deal of skill on the part of the operator. The first machine to add and subtract by itself was Blaise Pascal’s “arithmetic machine,” built between 1642 and 1644 ad (Freiberger & Swaine, 2013). The first “computer” to be a commercial suc- cess was Jacquard’s weaving machine built in 1803 (“Jacquard, Joseph Marie (1752–1834),” 2011). Its efficiency so frightened workers at the mill where it was built that they rioted, broke apart the machine, and sold the parts. Despite this setback, the machine proved a success because it introduced a cost-effective way of producing goods.

Early computers designed by Charles Babbage in the mid-19th century, although never built, laid the foundation for modern computers (Barile, 2007). The first successful use of an auto- matic calculating machine was the 1900 census. Herman Hollerith (who later started IBM) used the Jacquard Loom concept of punch cards to create a machine that enabled the 1900 census takers to compile the results in 1 year instead of the 10 required for the 1890 census (Bellis, 2013). The first computer by today’s percep- tion was the Electronic Numerical Integrator and Computer (ENIAC) built by people at the Moore School of Engineering at the University of Pennsylvania in partnership with the U.S. govern- ment. When completed in 1946, it consisted of 18,000 vacuum tubes, 70,000 resistors, and 5 mil- lion soldered joints. It consumed enough energy to dim the lights in an entire section of Philadelphia (Moye, 1996). The progress in hardware since then is phenomenal; today’s smartphones have more processing power than ENIAC did!

COMPUTERS AND HEALTHCARE The use of computers in healthcare originated in the late 1950s and early1960s as a way to manage financial information. The development of a few

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computerized patient care applications in the late 1960s followed. Some of these hospital informa- tion systems included patient diagnoses and other patient information as well as care plans based on physician and nursing orders. Because they lacked processing power, most of these systems were unable to deliver the needs of users and never became widely used.

Early Healthcare Informatics Systems One interesting early use of the computer in  patient care was the Problem-Oriented Medical Information System (PROMIS) begun by Dr. Lawrence Weed in 1968 at the University Medical Center in Burlington, Vermont (McNeill, 1979). The importance of this system is that it was the first attempt to provide a total, integrated sys- tem that covered all aspects of healthcare includ- ing patient treatment. It was patient oriented and used the problem-oriented medical record (POMR) as its framework. The unit featured an interactive touch screen and had a reputation for fast respon- siveness (Schultz, 1988). At its height, it consisted of more than 60,000 frames of knowledge.

The design of PROMIS was to overcome four problems that are still with us today: lack of care coordination, reliance on memory, lack of recorded logic of delivered care, and lack of an effective feedback loop (Jacobs, 2009). The sys- tem provided a wide array of information to all healthcare providers. All disciplines recorded their observations and plans and related them to a spe- cific problem. This broke down barriers between disciplines, making it possible to see the relation- ship between conditions, treatments, costs, and outcomes. Unfortunately, this system never was widely accepted. To embrace it meant a change in the structure of healthcare, something that did not begin until the 1990s, when managed care in all its variations reinvigorated a push toward more patient-centered information systems, a push that continues today.

In 1967, the development of another early system, the Help Evaluation through Logical Processing (HELP) system, was developed by the Informatics Department at the University of Utah School of Medicine. The first implementation was in a heart catheterization laboratory and a post– open-heart intensive care unit (ICU). It is today

hospital-wide and operational in many hospitals in the Intermountain Healthcare system (Gardner et al., 1999; OpenClinical, 2013). HELP is not only a hospital information system but it also inte- grates a sophisticated clinical decision support system that provides information to clinical areas. HELP was the first hospital information system that collected data for clinical decision making and integrated it with a medical knowledge base. Clinicians accepted the system. HELP demon- strated that a clinical support system is feasible and can reduce healthcare costs without sacrific- ing quality.

Progression of Information Systems As the science of informatics has progressed, changes in information systems occurred. Originally, computerized clinical information systems were process oriented. That is, imple- mentation was to computerize a specific process, for example, billing, order entry, or laboratory reports. This led to the creation of different soft- ware systems for different departments, which unfortunately could not share data, creating a need for clinicians to enter data more than once. An attempt to share data by integrating data from disparate systems is a difficult and sometimes impossible task. Lack of the use of standard ter- minology and protocols (a system of rules) com- plicates the transfer of data between different systems. Even when possible, the results are often disappointing and can leave negative impressions of computerization in users’ minds.

Newer systems, however, are organized by data. Data-designed systems use the same piece of data many times, thus requiring entry of data only once. The basis of primary design is how data are gathered, stored, and used in an entire institution rather than on a specific process such as pharmacy or laboratory. For example, when a healthcare provider places a medication order, the system has access to all the information about a patient including his or her diagnosis, age, weight, allergies, and eventually genomics, as well as the medications that he or she is cur- rently taking. The system can also match the order and patient information against knowledge such as what drugs are incompatible with the prescribed drug, the dosage of the drug, and the

Chapter 1 Introduction to Nursing Informatics: Managing Healthcare Information 13

appropriateness of the drug for this patient. If there are difficulties, the system can deliver warn- ings at the initial order time of the medication instead of requiring clinician intervention either in the pharmacy or at the time of administration. A data-driven system allows the dietician plan- ning the patient’s diet and the nurse providing patient care and doing discharge planning, access to the same information. This integration enables a more complete picture of a patient than one that would be available when separate systems handle dietetics and nursing.

Evidence-based practice will result not only from research and practice guidelines but also from unidentifiable (data minus any patient iden- tification) aggregated data from actual patients. It will also be possible to see how patients with a given genomics react to a drug, thus helping the clinician in prescribing drugs. These same aggre- gated data will help clinicians make decisions by providing information about treatments that are most effective for given conditions, replacing the current system which is too often based on “what we have always done” rather than empirical infor- mation. These systems will use computers that are powerful enough to process data so that the creation of information is “on the fly,” or imme- diately when requested. Systems that incorporate these features will require a new way of thinking. Instead of having all one’s knowledge in memory, one must be comfortable both with needing to access information, knowing how and where to find it, and with changing one’s practice to accom- modate new knowledge.

Computerization will affect healthcare profes- sionals in other ways. Some jobs will change focus. As nurses, we may find that our job as a patient care coordinator has shifted from transcribing and checking orders to accessing this information on the computer. To preserve our ability to provide full care for our patients, and as an information integrator for other disciplines, we will need to make our information needs known to those who design the systems. To accomplish this, we all need to be aware of the value of both our data and our experience. We need to be able to identify the data we need to perform our job, as well as to appre- ciate the value of the data that others add to the healthcare system.

BENEFITS OF INFORMATICS The information systems described earlier will bring many benefits to healthcare. These benefits will result in the ability to improve patient care outcomes by creating and using aggregated data, preventing errors, easing working conditions, and providing better healthcare records.

Benefits for Healthcare in General One of the primary benefits of informatics is that previously buried data in inaccessible records become usable. Informatics is not only about collecting data but also about making it useful. The capture of data electronically in a structured manner allows for retrieval and use of data in different ways, both to assimilate information easily about one patient and as aggregated data. (Aggregated data will be further discussed in Chapter 8.)

Table 1-1 shows some aggregated data for postsurgical infections sorted by physician and then by the organism. Because infections for some patients are caused by two different patho- gens, as presented in Table 1-1, you see two entries for some patients; however, this is all produced from only one entry of the data. With just a few clicks of a mouse, the system can orga- nize these same data by unit to show the num- ber of infections on each unit. This is possible because data that are structured, as in Table 1-1 and standardized, can be presented in many dif- ferent views.

When examining aggregated data, patterns emerge that might otherwise take several weeks or months to become evident or might never become evident. When patterns, such as the prevalence of infections for Dr. Smith emerge (see Table 1-1), it is possible to investigate what this physician’s patients have in common. However, one must use caution. The aggregated data in Table 1-1 are insufficient to draw conclusions; the data serve only as an indication of a problem and provide clues for where to start investigating. Aggregated data are a type of information or even knowledge, but wisdom in this case says that these data are not sufficient for drawing hard conclusions. Any shared data, outside of an agency or with those

14 Unit I Informatics Basics

who do not need to have personal information about a patient, must be deidentified, that is, there should be no way to identify the patient from the data.

Informatics through information systems can improve communication between all healthcare providers, which will improve patient care and reduce stress. Additional benefits for health- care include making the storage and retrieval of healthcare records much easier, quicker retrieval of test results, printouts or screens of needed information organized to meet the needs of the

user, and fewer lost charges because of easier methods of recording charges. Another benefit will come from saving time and money by com- puterizing administrative tasks such as staffing and scheduling.

Benefits for the Nursing Profession Each healthcare discipline will benefit from its investment in informatics. In nursing, infor- matics will not only enhance practice but also add to the development of nursing science.

TABLE 1-1 Aggregated Data First Name Last Name Unit Surgery Physician Pathogen

Charles Babbage 3 West Cholecystectomy Black E. coli

Jack Of All Trades 4 West Appendectomy Black Strep

George Washington 4 West Tonsillectomy Black Strep

John Wayne 2 East Herniorrhaphy Greene E. coli

Gloria Swanson 2 East Cholecystectomy Greene E. coli

Gloria Swanson 2 East Cholecystectomy Greene Strep

Susan Anthony 3 West Tubal ligation Jones Strep

Alexander Hamilton 2 East Cholecystectomy Smith E. coli

Florence Dayingale 4 West Hysterectomy Smith E. coli

Abigail Adams 2 East Herniorrhaphy Smith Staph

Johnny Appleseed 3 West Open reduction, left femur

Smith Staph

Davey Jones 3 West Transurethral resection Smith Staph

Alexander Hamilton 2 East Cholecystectomy Smith Strep

Florence Dayingale 4 West Hysterectomy Smith Strep

Note: Fictitious patient names are used here to help in understanding the concept; real secondary data should be unidentifiable.

E. coli, Escherichia coli; Staph, Staphylococcus; Strep, Streptococcus.

Chapter 1 Introduction to Nursing Informatics: Managing Healthcare Information 15

Informatics will improve documentation and, when properly implemented, not increase the time spent in documentation. Nurses spend more than 15% to 25% of their time docu- menting patient care (Gugerty et al., 2007; Yee et al., 2012). Entering vital signs both in nurs- ing notes and on a flow sheet wastes time and invites errors. In a well-designed clinical docu- mentation system, data entered once, retrieved, and presented in many different forms should meet the needs of users.

Paper documentation methods create other problems such as inconsistency and irregularity in charting as well as the lack of data for evaluation and research as mentioned above. An electronic clinical information system can remind users of the need to provide data in areas one is apt to forget and can provide a list of terms that can be “clicked” to enter data. There is a vast improve- ment in the ability to use patient data for both quality control and research when documentation is complete and electronic.

Despite Florence Nightingale’s emphasis on data, for much of nursing’s history, nursing data have not been valued. Florence Nightingale used data to create the predecessor of the pie graph to demonstrate that the real enemy in the Crimean War was not the Russians but poor sanitation. This communication of information in a way that was comprehended easily caused the British to understand the value of sanitation in military hospitals.

They are either buried in paper patient records that make retrieving it economically infeasible or, worse, discarded when a patient is discharged, hence unavailable for building nurs- ing science. With the advent of electronic clini- cal documentation, nursing data can be a part of the EHR and be available to researchers for building evidence-based nursing knowledge. It will also allow the inclusion of nursing informa- tion in overall healthcare evidence-based care. The Maryland report on the use of technology to address the nursing shortage demonstrated that informatics could be used to improve staff morale and the efficiency of patient care (Gugerty et al., 2007). For example, paper request forms can be eliminated, easy commu- nication of work announcements can be more

easily communicated, the time for in-services can be reduced, and empty shifts can be filled by using Internet software.

In understanding the role and value that infor- matics adds to nursing, it is necessary to recognize that the profession is cognitive, rather than one confined to tasks. Providing data to support this is a joint function of nursing informatics and clini- cians. Identifying and determining how to facili- tate data collection is an informatics skill that all nurses need.

SKILLS NEEDED BY ALL NURSES The need to manage complex amounts of data in patient care demands that all nurses, regardless of specialty area, have informatics skills (Gaumer et al., 2007; Nelson, 2007). Informatics skills for all nurses require basic computer skills as one component (American Nurses Association, 2008). Another skill needed for proficiency in informat- ics is information literacy. The ANA, NLN, AONE, and AACN have identified both computer and information literacy skills as necessary for evidence-based practice.

Computer Fluency The information age described the 20th century. The present century will be the information-pro- cessing age, that is the use of data and informa- tion to create more information and knowledge. The broad use of the term “computer literacy” means the ability to perform various tasks with a computer. Given the rapid changes in technol- ogy and in nursing, perhaps thinking in terms of computer fluency rather than literacy pro- vides a better perspective on computer use. This term implies that you have an adequate founda- tion in computer concepts to enable you to learn new computer skills and programs independently (Committee on Information Technology Literacy, 2013). Thus, an individual needs a lifelong com- mitment to acquiring new skills for being more effective in work and personal life. Computer literacy is a temporary state, whereas computer fluency is dynamic and involves being able to increase one’s ability to effectively use a computer when needed.

16 Unit I Informatics Basics

A perusal of archives in a Listserv (an e-mail discussion list that has participants who discuss various aspects of a topic) in informatics reveals periodic requests for instruments to measure the computer competency of staff. Unfortunately, there is little agreement on specific competencies needed, let alone an instrument to measure this, but there is consensus that it involves knowledge, attitude, and competencies in the use of com- puters, computer technology, and hardware and software. Nurses must be able to visualize the overall benefits to nursing practice and patient care outcomes. More than a decade and a half ago, Simpson (1998) pointed out the need for nurses to master computers to avoid extinction. A computer is a mind tool that frees us from the mental drudg- ery of data processing, just as the bulldozer frees us from the drudgery of digging and moving dirt. Similar to the bulldozer, however, we must use the computer intelligently or damage can result.

Given the forces moving healthcare toward more use of informatics, it is important for nurses to learn the skills associated with using a com- puter for managing information. Additionally, knowing how to use graphical interfaces and appli- cation programs such as word processing, spread- sheets, databases, and presentation programs is as an important an element in a professional career as is mastering technology skills. Just as anatomy and physiology provide a background for learning about disease processes and treatments, computer fluency skills are necessary to appreci- ate more complex informatics concepts (McNeil & Odom, 2000) and for learning clinical applications (Nagelkerk et al., 1998).

Ronald and Skiba (1987) were the first to look at computer competencies required for nurses. In the late-1990s and early part of this century, this issue was revisited, but the focus became the use of computer skills as part of informatics skills (McCannon & O’Neal, 2003; McNeil et al., 2003; Utley-Smith, 2004). Staggers et al. (2001, 2002) defined four levels of informatics competencies for practicing nurses. The first two pertain to all nurses, and the last two pertain to informatics nurse specialists:

1. The beginning nurse should possess basic infor- mation management and computer technology

skills. Accomplishments should include the ability to access data, use a computer for com- munication, use basic desktop software, and use decision support systems.

2. Experienced nurses should be highly skilled in using information management and com- puter technology to support their major area of practice. Additional skills for the experienced nurse include being able to make judgments on the basis of trends and patterns within data elements and to collaborate with informatics nurse specialists to suggest improvements in nursing systems.

3. The informatics nurse specialist should be able to meet the information needs of practicing nurses by integrating and applying informa- tion, computer, and nursing sciences.

4. The informatics innovator will conduct infor- matics research and generate informatics theory.

A matrix with a listing of the informatics competencies by nursing informatics functional areas is included in the Nursing Informatics: Scope & Standards of Practice (American Nurses Association, 2014).

Information Literacy Information literacy, or the ability to know when one needs information, and how to locate, evaluate, and effectively use it (National Forum on Information Literacy, 2011), is an informatics skill. Although it involves computer skills, similar to informatics, it requires critical thinking and problem solving. Information literacy is part of the foundation for evidence-based practice and provides nurses with the ability to be intelligent information creators and consumers in today’s electronic environment.

Computer fluency that enables nurses to be both information literate and informatics capable in their practice is an expectation of any educated nurse. In Figure 1-2, you can see that the skill of computer literacy is needed to develop computer fluency. Nurse clinicians need both those skills as well as information literacy and a basic knowledge of nursing informatics. The informatics nurse specialist needs all those skills, knowledge of the

Chapter 1 Introduction to Nursing Informatics: Managing Healthcare Information 17

nurse clinician’s work environment, and knowl- edge of the informatics needs of other healthcare specialties.

Unit II, addressing basic computer skills, emphasizes concepts that promote the ability to learn new applications. These chapters provide information underlying the use of informatics in professional life. The chapters in Unit III build upon these principles to allow the reader to start to gain new informatics skills, including the abil- ity to find and evaluate information from elec- tronic sources. The chapters in Units IV, V, and VI allow the reader to develop skills necessary to work with informatics nurse specialists in provid- ing effective information systems and the use of nursing data.

SUMMARY The changes of healthcare in transition affect nurs- ing. Part of these changes involves informatics. Whether the change will be positive or negative for patient care and nursing depends on nurses. For the change to be positive, nurses need to develop skills in information management, known in healthcare as informatics. To gain these skills, a background in both computer and information literacy skills is necessary.

The expansion of knowledge logarithmically limits the human minds ability to manage data and information. The use of technology tools to aid the human mind has become mandatory. Healthcare has been behind most industries in using technology to manage its data. However, government- and private-level forces are work- ing to change this. With these pressures, health- care informatics is rapidly expanding. Nursing is one of many subspecialties in healthcare infor- matics. Embracing informatics will allow nurses to assess and evaluate practice just as a stetho- scope allows the evaluation and assessment of a patient.

The use of computers in healthcare started in the 1960s, mostly in financial areas, but with the advance in computing power and the demand for clinical data, as nurses we are using computers more and more in clinical areas. With this growth has come a change in focus for information sys- tems from providing solutions for just one process to an enterprise-wide patient-centered system that focuses on data. This new focus provides the functionality that allows the use of one piece of data in multiple ways. To understand and work with clinical systems, as well as to fulfill other pro- fessional responsibilities, nurses need to be com- puter fluent, information literate, and informatics knowledgeable.

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