ESSENTIALS OF NURSING

INFORMATICS

OVERVIEW OF

COMPUTERS AND

NURSING

CHAPTER ONE

NURSING INFORMATICS Represents the transition of data and

data information and knowledge into action

Represents the practice, administration, community health, nursing educational and nursing research applications

Addresses other new applications such as international aspects or peripheral to the field such as legal, consumer issues or theoretical issues

NURSING INFORMATICSaccording to ANA

A specialty that integrates› Nursing science› Computer science› Information science

To manage and communicate› Data› Information› Knowledge

Facilitates the integration of data, information, and knowledge to support patients, nurses, and other providers in their decision-making in all roles and settings› Is accomplished through the use of:

Information structures Information process Information technology

NI specialists emerged as a new specialty by the ANA (in the past 25 years)

1981› Approximately 15 nurses who identified

this new specialty as there are of interest and expertise

1990› The number increased 500% to

approximately 5,000 nurses 2000

› It increased approximately another 500%

2010› Majority of the nurses will become

computer literate› Every health care setting will employ at

least one NI specialist and will implement some type of a CIS

CIS› designed to support clinical nursing

practice› Requires not only an understanding of

professional nursing practice process but also technology

Influences degree of adoption and use

Defines/enables definition of functional requirements

Provides means for/enables functional requirements

Populates

Human factors

Clinical knowledge

Professional nursing practice process understanding Technology

Determines and impacts data and information derived from the system

Influences scope and depth

Technology adoption

Information system

Data and Information about professional nursing practice

and clinical knowledge

System utilization

Info

rms

HISTORICAL PERSPECTIVE

S OF NURSING AND

THE COMPUTER

CHAPTER TWO

COMPUTER An all encompassing term referring to IT,

computer systems In nursing

› Refer to NISs, nursing applications, and NI Purposes:

› To manage information in patient care› Monitor the quality of care› Evaluate the outcomes of care› Others:

Support nursing research Test new systems Design new knowledge databases Advance the role of nursing in the health care industry

Computers and networks

Used for communicating data and messages via the internet

Assessing resources Interacting with patients on the www

Computer technology

Emerged in nursing in response to the changing and developing technologies in the health care industry and in nursing practice

Analyzed according to:› Six time periods› Four major nursing areas› Standards initiatives› Significant landmark events› Major landmark milestone chart

Six time periods PRIOR to the 1960s

› 1950s – growth of computer use in the health care industry

› There were only few experts who formed a cadre of pioneers that attempted to adapt computers to health care and nursing

› Major changes in nursing: Improvement of nursing image Expansion of nursing practices and services Increasing number of nurses

Computer use:› Initially used in health care facilities for

basic business office functions› Examples: punch cards to store data and

card readers to read computer programs, sort, and prepare data for processing

They were linked together and operated by paper tape and used teletypewriters to print their output.

As computer technology advanced, the health care technologies improved

1960s Uses of computers were questioned

› Why computers?› What should be computerized?

Nursing standards were reviewed Nursing resources were analyzed Nurses’ station in the hospital was

viewed as the hub of information exchange

Computer technology advanced and health care facilities increased

Introduction of:› Cathode ray tube (CRT) terminals› Online data communication› Real-time processing

More accessible and “user-friendly” machines Hospital Information Systems (HISs)

› To process financial transactions› Serve as billing and accounting systems› A few HISs: documented and processed a limited

number of medical orders and nursing care activities Vendors of computer systems entered the

health care field and market software applications but progress was slow due to:› Technology limitations› Lack of standardization› Diversity of paper-based patient care records

1970s Continued integration of computers into

nursing Giant steps were taken in both dimensions:

› Nursing› Computer technology

NURSES:› Began to recognize the value of the computer

for their profession› Recognized the computer’s potential for:

Improving the documentation of nursing practice Quality of patient care Repetitive aspects of managing patient care

› Assisted in the design and development of nursing applications for the HISs and other environments where nurses functioned

Computer applications were perceived as cost-saving technologies

Early systems were funded by contracts or grants from federal agencies

Several states and large CH agencies developed and/ or contracted for their own computer-based MIS› PUBLIC HEALTH MISs – provided information required

by local, state, and federal agencies for specific program funds

› HOME HEALTH agencies – provided billing and other financial information required for reimbursement of patient services by MEDICARE, MEDICAID, and other third-party payers

1980s The field of informatics emerged in the

ehalth care industry and nursing NI became an accepted specialty and

many nursing experts entered the field Use of computers in nursing became

revolutionary Needs in nursing took on a cause-and-

effect modality Many mainframe HISs emerged with

nursing subsystems

› Documented several aspects of the patient record: Order entry emulating the Kardex Results reporting Vital signs Other systems that documented narrative nursing notes

via word-processing packages Discharge planning were developed and used as

referrals to community health care facilities in the continuum of care

MICROCOMPUTER or PC emerged› Made computers more accessible, affordable, and

usable by nurses and other health care providers› Brought computing power to the workplace and to the

point-o-care› Served not only terminals linked to the mainframe

computers but also as stand-alone systems (workstations)

› User-friendly and allowed nurses to create their own applications

1990s computer technology became an integral part

of health care setting, nursing practice and the nursing profession

Policies and legislation were adopted promoting computer technology in health care

Nursing profession became actively involved in promoting NI

1992› NI was approved by the ANA as a new nursing

specialty› Demand for NI expertise increased greatly› Technology revolution continued to impact the

profession

Emergence of needs:› Computer-based nursing practice standards› Data standards› Nursing minimum data sets› National databases› Unified nursing language› Nomenclatures› Vocabularies› Taxonomies› Classification schemes

Nurse administrators demanded use of innovative technologies for all levels and types of nursing and patient education

Laptops and notebooks to the bedside and all of the point-care settings

Workstations and LANs were developed for hospital nursing units

WANs were developed for linking care across health care facilities

Internet started to be used linking across the different systems› Brought new cyberspace tools › Used for high performance computing and

communication (HPCC) or the “information superhighway”

› Facilitated data exchange between CPRs across facilities and settings over time

1995› Email› File Transfer Protocol (FTP)› Gopher› telnet› WWW protocols

WEB› Became the means for communicating online

services and resources to the nursing community

INTERNET› Became and integral component of all IT

systems› WWW used to browse the internet and search

worldwide resources

POST 2000 Developments:

› Wireless point-of-care› Serious consideration for open source

solutions› Regional database projects› Increased IT solutions targeted at all

healthcare environments CIS became individualized in the EPR

and patient specific systems considered for the lifelong longitudinal record or the EHR

Mobile technology› Wireless tablet computers› PDAs› Cellular telephones

The development of VoIP promises to provide cheap voice communication for healthcare organizations

Europe (Germany)› Realization of smart cards› A health “smart card” has been in

existence since the early 1990s

Increasing popularity of Telenursing (late 1990s)

Health Insurance Portability and Accountability Act of 1996 (HIPAA) was enacted› To streamline health care transactions› And reduce costs

2004› Standardized transaction and code sets

The legislation recommended health care providers use PIN

Includes:› eHealth Initiative and Institute› Consolidated health Information (CHI)

initiative› National Health Information Infrastructure

(NHII) initiative These organizations are:

› Involved in promoting information technologies, standards, applications, systems, and laws that support effective health care

FOUR MAJOR NURSING AREAS

NURSING PRACTICE› An integral part of the HER› Computer systems with nursing, patient care

data and nursing care plans are integrated into one interdisciplinary patient health recording the EHR Resulted because of many initiatives proposed

and promoted by the nursing profession› Nursing terminologies used were recognized

by the ANA Used to assess problems, document care, track

the care process, and measure outcomes

NURSING ADMINISTRATION› Policy and procedure manuals are accessed

and retrieved by computer› Workload measures, acuity systems, and

other nursing department systems are online and integrated with the hospital or patient’s HER system or in separate nursing department systems

› INTERNET is being used by nurses to access digital libraries, online resources ,and research protocols at the bedside

NURSING EDUCATION› Most universities and school of nursing offer

computer enhanced courses, online courses, and/or distance education

› Campus-wide computer systems are available for students: To communicate via Email Transfer data files Access the digital libraries Retrieve online resources of millions of

internet WWW sites› Interactive teleconferencing› “face-to-face” medium› Time, distance, and cost are no longer

barriers to educational programs

NURSING RESEARCH› for analyzing nursing data› Software programs are available for

processing both quantitative and qualitative data

› Databases are used for meta-analyses to develop evidence-based practice guidelines

STANDARDS INITIATIVES

Focused on nursing practice standards. Nursing data standards, and health care data standards as well as federal legislation that impact on the use of the computer into nursing

Influenced the nursing profession and its need for computer systems, information technology, and terminologies to gain acceptance among the health care policy makers

NURSING PRACTICE STANDARDS› Developed and recommended by the ANA

Published The Standards of Clinical Nursing Practice which focused not only on the organizing principles of clinical nursing practice but also the standards of professional performance

They recommended that the nursing process serve as the conceptual framework for the documentation of nursing practice

› Have also been set by the Joint Commission on Accreditation of Hospital Organizations (JCAHO) Stressed the need for adequate records on

patients in hospitals and practice standards for the documentation of care of care by nurses

Recommended acuity systems to determine resource use as well as required care plans for documenting nursing care

Included in the recent manual the required contents of an EHR Such as what data should be collected and how the

data should be organized in the electronic database

NURSING DATA STANDARDS› Emerged as a new requirement for the EHR› 13 nursing terminologies recognized by ANA

Examples: Critical Care Classification (CCC), Nursing Information Classification (NIC)

Was developed at different times, has different characteristics, and is used for documenting different aspects of nursing practice

Only 1 or 2 terminologies were developed and coded for computer processing

Majority were designed for documenting nursing practice

HEALTH CARE DATA STANDARDS ORGANIZATIONS

AMERICAN NATIONAL STANDARDS INSTITUTE (ANSI)› A private nonprofit membership

organization› Instituted to coordinate and approve

voluntary standards efforts in the US› Combined with the Health Care Informatics

Standards Board (HISB) to form ANSI-HISB to fulfill a request by the European standards coordinating organization to represent the US standards effort

ANSI-HSB› Acts as one linking to the two major

organizations in Europe European Standardization Committee (CEN) International Standards Organization (ISO)

American Society for Testing and Materials (ASTM)› ASTM E-31 Committee on Healthcare

Informatics is an accredited committee that develops standards for health information and health information systems designed to assist vendors, users, and anyone interested in systematizing health information

Health Level Seven (HL7)› An organization accredited by ANSI› Created to develop standards for the

electronic interchange of clinical, financial, and administrative information among independent healthcare-oriented information system

SNOMED International› Serves as an umbrella of the structured

nomenclatures, and its merger with the Read Codes form the National Health Service in the UK in 1999

› SNOMED CT serves as the coding strategy and has become a national standard for the HER aspects of which are integrated into the UMLS and available to the public

National Committee on Vital and Health Statistics (NCVHS) Workgroup on computer-based Patient Records› Created to help the Department of Health and

Human Services (DHHS) investigate and approve health care standard for the federal government to use to implement federal legislation

› Evaluated and recognized medical, nursing, and other health profession nomenclatures for the DHHS to the implement of HIPAA of 1996

› Proposed standards for the electronic transmission of federally mandated reimbursement for Medicare and Medicaid patient services

› Recommended that the selected transaction and code sets primarily focus on privacy and security for the EHR

Early Computer-Based Nursing Applications

Includes:› Early HISs› Early ambulatory care information systems› Early community health nursing

information management systems› Early computer-focused nursing projects› Early educational application

Landmark Events in Nursing and Computers

Categories:› Early conferences, meetings› Early academic initiatives› Initial ANA initiatives› Initial National League for Nursing (NLN)

initiatives› Early international initiatives› Initial educational resources› Significant collaborative events

Major Landmark Milestones

CHAPTER THREE

ELECTRONIC HEALTH RECORD

FROM A HISTORICAL

PERSPECTIVE

Introduction to Davies Computer-based Patient Record Institute

(CPRI)› A nonprofit membership organization

founded in 1992› A unique organization representing all

stakeholders in healthcare focusing on clinical applications of information technology

› Was among the 1st nationally based organizations to initiate and coordinate activities to facilitate and promote the routine use of computer-based patient records (CPRs) throughout healthcare

1993› CPR project evaluation criteria was developed

by the CPRI workgroup on CPR Systems Evaluation

› The criteria formed bass of a self-assessment that could be used by organizations and outside reviewers to measure and evaluate the accomplishments of CPR projects

› 4 major areas of the initial criteria: Management Functionality Technology Impact

› The criteria also provided the foundation for the Nicholas E. Davies Award of Excellence Program

The Davies Program› Named for Nicholas E. Davies

An Atlanta-based physician President-elect of the American College of

Physicians Member of the Institute of Medicine (IOM)

committee on improving the patient record Killed in a plane crash just as the IOM report on

CPRs was being released› Modeled after the Baldridge award› Is intended to award and bring to national

attention excellence in the implementation of computerized medical records

› Founded on the belief that healthcare organizations benefit when collective experiences and lessons learned are shared

Today, under Healthcare Information and Management Systems Society (HIMSS); the Davies Award of Excellence is offered in three categories:› Organizational or Acute Care first offered in

1995› Ambulatory since 2003› Public Health initiated in 2004

In the first 9 years: 19 organizations awarded

Other awardees:› 20 healthcare organizations› 7 primary care practices› 3 public health initiatives

SIMILARITIES Effort Definition: made the EHR a key

component of the strategic vision Effort Organization: shared belief that

information management is a key tool to the clinical and business processes of the hospital› Customer service and constant consideration

of the impact of the system on the end user› Active pursuit of feedback from all users

Change management: new systems necessitate new standards operating procedures

Impact of value› Avoidance of a medication error› Nonduplication of an ordered test› Application process has included a

documentation of impact and value to the implementing organization

Still expensive: multiple millions to finance the cost of the infrastructure, hardware, and software

Focus on decision support has two forms:› Can be seen in applications that are designed

to facilitate best practices › Found in alerts and reminders that warn

clinicians about patient variables

DIFFERENCES Where winners obtained systems Timeline External agenda Technology:

› Interfaces› User agreements› Cultural changes› Workflow revisions› Window and menu customization

END OF DISCUSSIO

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