In the hospital of the future, technology will be the foundation of patient care planning, organization, and delivery (Parker, 2005). Poor resource use is widespread in the U.S. healthcare system, as cited in the Institute of Medicine (IOM) report, “Crossing the Quality Chasm” (IOM, 2001). Many leaders in health care see technology as a means to facilitate decision making, improve efficacy and efficiency, enhance patient safety and quality, and decrease healthcare costs (Ball, Weaver, & Abbot, 2003; IOM, 2000, 2001, 2004). If appropriately implemented and fully integrated, technology has the potential to improve the practice environment for nurses, as well as for patients and their families. However, we are also cautioned by patient safety and quality experts that technology is not a panacea (IOM, 2004).

Good decision making for patient care requires good information. Nurses are knowledge workers, who need data and information to provide effective and efficient patient care. Knowledge work is not routine or repetitive but, instead, requires considerable cognitive activity and critical thinking (Drucker, 1993). Data and information must be accurate, reliable, and presented in an actionable form. Technology can facilitate and extend nurses’ decision-making abilities and support nurses in the following areas: (1) storing clinical data, (2) translating clinical data into information, (3) linking clinical data and domain knowledge, and (4) aggregating clinical data (Snyder-Halpern, Corcoran-Perry, & Narayan, 2001).

Types of Technologies

As nurses, we commonly use and manage three types of technologies: biomedical technology, information technology, and knowledge technology. Biomedical technology involves the use of equipment in the clinical setting for diagnosis, physiologic monitoring, testing, or administering therapies to patients. Information technology entails recording, processing, and using data and information for the purpose of delivering and documenting patient care. Knowledge technology is the use of expert systems to assist clinicians to make decisions about patient care. In nursing, these systems are designed to mimic the reasoning of nurse experts in making patient care decisions.

Biomedical Technology

Biomedical technology is used for (1) physiologic monitoring, (2) diagnostic testing, (3) intravenous fluid and medication dispensing and administration, and (4) therapeutic treatments.

Physiologic Monitoring

Physiologic monitoring systems measure heart rate, blood pressure, and other vital signs. They also monitor cardiac rhythm; measure and record central venous, pulmonary wedge, intracranial, and intra-abdominal pressures; and analyze oxygen and carbon dioxide levels in the blood.

Data about adverse events in hospitalized patients indicate that a majority of physiologic abnormalities are not detected early enough to prevent the event, even when some of the abnormalities are present for hours before the event occurs (Considine & Botti, 2004; Liewelyn, Martin, Shekleton, & Firlet, 1998). Patient surveillance systems are designed to provide early warning of a possible impending adverse event. One example is a system that provides wireless monitoring of heart rate, respiratory rate, and attempts by a patient at risk for falling to get out of bed unassisted; this monitoring is via a mattress coverlet and bedside monitor. Nurses at one hospital decreased the rate of patient falls by 60% with the use of surveillance monitoring (Matsuo et al., 2008).

Innovative technology permits physiologic monitoring and patient surveillance by expert clinicians who may be distant from the patient. The remote or virtual intensive care unit (vICU) is staffed by a dedicated team of experienced critical care nurses, physicians, and pharmacists who use state-of-the-art technology to leverage their expertise and knowledge over a large group of patients in multiple intensive care units (Breslow, 2007; Myers & Reed, 2008).

Intracranial pressure (ICP) monitoring systems monitor the cranial pressure in critically ill patients with closed head injuries or postoperative craniotomy patients. The ICP, along with the mean arterial blood pressure, can be used to calculate perfusion pressure. This allows assessment and early therapy as changes occur. When the ICP exceeds a set pressure, some systems allow ventricular drainage. Similarly, monitoring pressure within the bladder has recently been demonstrated to accurately detect intra-abdominal hypertension as measures of maximal and mean intra-abdominal pressures and abdominal perfusion pressure are made. Intra-abdominal hypertension occurs with abdominal compartment syndrome and other acute abdominal illnesses and has been demonstrated to be independently associated with mortality in these patients (Malbrain et al., 2005; Vidal et al., 2008).

Continuous dysrhythmia monitors and electrocardiograms (ECGs) provide visual representation of electrical activity in the heart and can be used for surveillance and detection of dysrhythmias and for interpretation and diagnosis of the abnormal rhythm. Although not a new technology, these systems have grown increasingly sophisticated. More important, integration with wireless communication technology permits new approaches to triaging alerts to nurses about cardiac rhythm abnormalities. Voice technology and integrated telemetry and nurse paging systems have both been demonstrated to close the communication loop and dramatically decrease response time to dysrhythmia alarms (Bonzheim, 2006).

Biomedical devices for physiologic monitoring can be interfaced with clinical information systems. Monitored vital signs and invasive pressure readings are downloaded directly into the patient’s electronic medical record, where the nurse confirms their accuracy and affirms the data entry.

Exercise 11-1

List the types of biomedical technology available for patient care in your organization. List ways that you currently use the data and information gathered by these systems. How do these help you care for patients? Can you think of other ways to use the technology? Can you think of other ways to use the data or information? For example, data from biomedical devices might be sent directly to the electronic health record, negating the need for transcription of a result into the patient’s chart. Nurses spend many hours learning to use biomedical devices and to interpret the data gained from them. Have we come to rely too heavily on technology rather than on our own judgment?

Information Technology

Health care is an information-intensive and knowledge-intensive enterprise. Information technology can help healthcare providers acquire, manage, analyze, and disseminate both information and knowledge. Health care in the twenty-first century should be safe, effective, patient-centered, timely, efficient, and equitable (IOM, 2001). Comprehensive data on patients’ conditions, treatments, and outcomes are at the foundation of such care (Stead & Lin, 2009).

Patient data displayed with computerized systems to provide meaningful information and trends.

Computers offer the advantage of storing, organizing, retrieving, and communicating digital data with accuracy and speed. Patient care data can be entered once, stored in a database, and then quickly and accurately retrieved many times and in many combinations by healthcare providers and others. A database is a collection of data elements organized and stored together. Data processing is the structuring, organizing, and presenting of data for interpretation as information. For example, vital signs for one patient can be entered into the computer and communicated on a graph; many patients’ blood pressure measurements can be compared with the number of doses of anti-hypertension medication. Vital signs for male patients between the ages of 40 and 50 years can be correlated and used to show relationships with age, ethnicity, weight, presence of co-morbid conditions, and so on.

Humans process data continuously, but in an analog form. Computers process data in a digital form, process data faster and more accurately than humans, and provide a method of storage so that data can be retrieved as needed. The Theory Box above provides key concepts of information processing, and Box 11-1 describes the development of information management skills from novice to expert.

BOX 11-1 Development of Information Management Skills

Novice to Expert Practice

Novice nurses focus on learning what data to collect, the process of collecting and documenting the data, and how to use this information. They learn what clinical applications are available for use and how to use them. Computer and informatics skills focus on applying concrete concepts.

As nurses grow in expertise, they look for patterns in the data and information. They aggregate data across patient populations to look for similarities and differences in response to interventions. Expert nurses integrate theoretical knowledge with practical knowledge gained from experience.

Expert nurses know the value of personal professional reflection on knowledge and synthesize and evaluate information for discovery and decision making.

Theory box

Information Theory

KEY CONTRIBUTOR	KEY IDEAS	APPLICATION TO PRACTICE
Tan (1995) describes the elements of information theory as the following: • Source • Transmitter • Channel • Receiver • Destination	The information source selects the message or information to be conveyed. An underlying code or set of characters represents the message to be processed by the computer. The transmitter has an encoding function that converts the message to be sent. The communication channel (cable, air waves) provides the medium necessary for the information to be transmitted. The receiver converts the information from its transmitted form. The destination is the final stage of reception, at which point the message is decoded to be understandable.	The physician enters an order for laboratory tests (source, message). The computer program converts the message (transmitter). The converted order is sent over the computer network (communication channel) to the laboratory (receiver). The order is converted and read by the computer system in the laboratory (destination).

Structured Terminologies

Collecting a set of basic data from every patient at every healthcare encounter makes sense because comparisons can be made among many patients, institutions, or countries, almost in any combination imaginable, as well as for individual patients and patient groups across time. The uniform minimum health data set (UMHDS) is a minimum set of information items with standard definitions and categories that meets the needs of multiple data users.

Since the mid-1980s, nursing has recognized the importance of demonstrating its distinct contributions to patient care. Clark and Lang (1992, p. 109) stated, “If we cannot name it (nursing), we cannot control it, practice it, research it, teach it, finance it or put it into public policy.” Werley and Lang (1988) convened a work group to define essential data elements to be collected on all patients, defining the Nursing Minimum Data Set (NMDS). Four elements in the NMDS are unique to nursing: nursing diagnosis, nursing intervention, nursing outcome, and intensity of nursing care. Box 11-2 lists the elements of the NMDS. The purposes of the NMDS are the following:

BOX 11-2

Elements of the Nursing Minimum Data Set

Nursing Care Elements

1. Nursing diagnosis

2. Nursing intervention

3. Nursing outcome

4. Intensity of nursing care

5. Patient demographic elements

Personal Identification *

6. Date of birth *

7. Sex *

8. Race and ethnicity *

9. Residency *

Service Elements

10. Unique facility or service agency number *

11. Unique health record number of the patient

12. Unique number of the principal registered nurse provider

13. Episode, admission, or encounter date *

14. Discharge or termination date *

15. Disposition of patient or client *

16. Expected payer for most of the bill

^*Elements comparable to those in the Uniform Minimum Health Data Set (UMHDS).

From Werley, H.H., & Lang, N.M. (1988). The consensually derived nursing minimum data set: Elements and definitions. In H.H. Werley & N.M. Lang (Eds.), Identification of the nursing minimum data set (pp. 402-411). New York: Springer.

1. To establish the comparability of patient care data across clinical populations, settings, geographic areas, and time

2. To describe the care of patients and families in various settings

3. To provide a means to mark the trends in the care provided and the allocation of nursing resources based on health problems or nursing diagnosis

4. To stimulate nursing research through links to existing data

5. To provide data about nursing care to influence and facilitate healthcare policy decision making

Some NMDS elements (e.g., interventions and outcomes) are not collected as easily as the demographic and service elements, which are often captured at patient registration or discharge. This is because we lack uniform or unified structured nursing terminology. Significant efforts have been made to bridge this gap. Thirteen classification systems have been recognized by the American Nurses Association (ANA) (Elfrink, Bakken, Coenen, McNeil, & Bickford, 2001). These recognized classification systems differ. Some contain vocabularies for diagnosis, interventions, and outcomes, whereas others focus on only one or two of these groups. Some terminologies are specialty specific, such as the perioperative nursing data set.

During the 1990s, a few nursing terminology leaders began to recognize the importance of nursing terminologies being computerized and connected (interoperable) with one another and with other terminologies in health care. Since 1999, terminology leaders have worked together in a series of nursing terminology summit conferences to develop a united, global, standardized reference terminology for nurses (Ozbolt & Saba, 2008). At the end of the first decade of the twenty-first century, nursing has the data and terminology tools to create patient care records that reflect what nurses have contributed and permit comparison of nursing interventions and patient outcomes. However, many challenges remain. Nurses need education to appreciate the importance and power of standard terminologies compared with locally used terms (Ozbolt & Saba, 2008).

• Nursing records must be integrated with other records so that patient information is integrated and can be communicated among the healthcare team.

• Clinical nursing experts are needed to work with terminology experts to develop standard language in areas of nursing not yet adequately developed.

• Nursing leaders must advocate for use of structured nursing terminologies with the creators and vendors of information systems.

Exercise 11-2

Examine the elements of the NMDS. Which of them would be collected by patient registration? What information do you as a nurse need to collect? For example, in an acute care setting, you have provided care to a postoperative patient today, administering pain medication several times. The nursing diagnosis was Acute Pain. You charted the medication administration and the patient’s pain rating 30 minutes after the medication was given. You have documented an intervention and an outcome—two nursing care elements of the NMDS. Can you locate the service elements in the patient record?

Standardized, computerized nursing terminology will allow us to collect, aggregate, and analyze patient data for decision support, quality improvement, and research. Data from within and across patient populations are needed to build evidence from practice and to use evidence in practice. These data are also needed to quantify and describe nursing practice and its impact on the quality of care provided and on patient outcomes.

Information Systems

A patient information system can be manual or computerized—in fact, we have collected and recorded information about patients and patient care since the dawn of health care. Computer information systems manage large volumes of data, examine data patterns and trends, solve problems, and answer questions. In other words, computers can help translate data into information. Ideally, data are recorded at the point in the care process where they are gathered and are available to healthcare providers when and where they are needed. This is accomplished, in part, by networking computers both within and among organizations to form larger systems. These networked systems might link inpatient care units and other departments, hospitals, clinics, hospice centers, home health agencies, and/or physician practices. Data from all patient encounters with the healthcare system are stored in a central data repository, where they are accessible to authorized users located anywhere in the world. These provide the potential for automated patient records, which contain health data from birth to death.

Adopting the technology necessary to computerize patient care information systems is complex and must be accomplished in stages. The Health Information and Management Systems Society (HIMSS) has described seven stages of adoption—the seventh of which marks achievement of a fully electronic healthcare record. The seven stages of adoption are listed and described in Table 11-1. It is important to note that only 1% of U.S. hospitals have achieved stage 6 and that fewer than 0.1% have achieved stage 7 (HIMSS Analytics, 2008).

TABLE 11-1

ELECTRONIC MEDICAL RECORD ADOPTION MODEL *

STAGE	DESCRIPTION
7	• The healthcare organization has a paperless electronic medical record (EMR) environment. • Clinical information can be shared via electronic transactions with all entities within the health information network (i.e., other hospitals, clinics, subacute settings, employers, payers, and patients). • The healthcare organization can share and use health and wellness information with consumers and providers. • Data warehousing and mining technologies are used to capture and analyze care data and improve care via decision support.
6	• Full physician documentation using structured templates is implemented for at least one patient care service area. • A full complement of all radiology images (digital and film) is available to providers via an intranet or other secure network.
5	• Closed-loop medication administration is fully implemented in at least one patient care service area. • The electronic medication administration record (e-MAR) and bar coding or other auto-identification technology (e.g., radio frequency identification [RFID]) are implemented and integrated with computerized order entry and pharmacy to maximize patient safety for medication administration.
4	• Computerized provider order entry (CPOE) is implemented. • Clinical decision support at the second level (related to evidence-based protocols) is implemented.
3	• Clinical documentation (e.g., vital signs, flow sheets, nursing notes, care planning, and the e-MAR) is implemented and integrated for at least one service in the organization. • First-level clinical decision support for error checking with order entry (e.g., drug/drug, drug/allergy, drug/food, drug/lab conflict checking) is implemented. • Some radiology images can be accessed from picture archive and communication systems (PACSs) via a secure network.
2	• Major ancillary clinical systems feed data to a clinical data repository that permits clinicians access for retrieving and reviewing results. • The data repository contains a controlled vocabulary and the rules and clinical decision support for rudimentary conflict checking.
1	• Major ancillary (laboratory, radiology, and pharmacy) clinical systems are installed.
0	• Some clinical automation may exist. • Laboratory and/or pharmacy and/or radiology clinical systems are not installed.

^*From HIMSS Analytics, Health Information Management Systems Society. (2008). EMR Adoption Model. Retrieved from www.himssanalytics.org/hc_providers/emr_adoption.asp.

Nurses care for patients in acute care, ambulatory, and community settings, as well as in patients’ homes. In all settings, nurses focus not only on managing acute illnesses but also on health promotion, maintenance, and education; care coordination and continuity; and monitoring chronic conditions. Ideally, information systems support the work of nurses in all settings.

Communication networks are used to transmit data entered at one computer and received by others in the network. These networks can reduce the clerical functions of nursing. They can provide patient demographic and census data, results from tests, and lists of medications. Nursing policies and procedures can be linked to the network and accessed, when needed, at the point of care. Links can be provided between the patient’s home, hospital, and/or physician office with computers, handheld technologies, and point-of-care devices. Day-to-day events can be recorded and downloaded into the patient record remotely in community nursing settings or at the point of care in the hospital or clinic.

Exercise 11-3

Select a healthcare setting with which you are familiar. What information systems are used? Make a list of the names of these systems and the information they provide. How do they help you in caring for patients or in making management decisions? Think about the communication of data and information among departments. Do the systems communicate with each other? If you do not have computerized systems, think about how data and information are communicated. How might a computer system help you be more efficient?

As an example, assume that an abdominal magnetic resonance imaging (MRI) with contrast has been ordered. In a paper-based system, handwritten requisitions are sent to nutrition services, pharmacy, and the radiology department. With a computerized system, the MRI is ordered and the requests for dietary changes, bowel preparation medications, and the diagnostic study itself are automatically sent to the appropriate departments. Radiology would compare its schedule openings with the patient’s schedule and automatically place the date and time for the MRI on the patient’s automated plan of care. The images and results of the diagnostic procedure are available online.

Nurses caring for patients in home health care and hospice must complete documentation necessary to meet government and insurance requirements. Computers assist with direct entry of all required data in the correct format. Portable computers are used to download files of the patients to be seen during the day from a main database. During each visit, the computer prompts the nurse for vital signs, assessments, diagnosis, interventions, long-term and short-term goals, and medications based on previous entries in the medical record. Nurses enter any new data, modifications, or nursing information directly. Entries can be transmitted by telephone line to the main computer at the office or downloaded from the device at the end of the day. This action automatically updates the patient record and any verbal order entry records, home visit reports, federally mandated treatment plans, productivity and quality improvement reports, and other documents for review and signature. Portable and wireless computers have made recording patient care information more efficient and have improved personnel productivity and compliance with necessary documentation.

Placing computers or handheld devices “patient-side” permits nurses to enter data once, at the point of care. Documentation of patient assessments and care provided patient-side saves time, gives others more timely access to the data, and decreases the likelihood of forgetting to document vital information. Point-of-care devices and systems that fit with nurses’ workflow, personalize patient assessments, and simplify care planning are available. Patient care areas with point-of-care computers have improved the quality of patient care by decreasing errors of omission, providing greater accuracy and completeness of documentation, reducing medication errors, providing more timely responses to patient needs, and improving discharge planning and teaching. These systems can eliminate redundant charting and facilitate patient handoffs from shift to shift or between care areas.

Exercise 11-4

Think about the data you gather as you care for a patient through the day. How do you communicate information and knowledge about your patient to others? Does the information system support the way you need this information organized, stored, retrieved, and presented to other healthcare providers? For example, if a patient’s pain medication order is about to expire and you want to assess the patient’s use and response to the pain medication during the past 24 hours, can the information system generate a graph for this patient comparing the time, dose, and pain score for this period? If your assessment is that the medication order needs to be renewed, how do you communicate that message to the prescriber?

Information Systems Quality and Accreditation

Quality management and measuring patient care efficiency, effectiveness, and outcomes are necessary for accreditation and licensing of healthcare organizations. This is demonstrated by documentation of patient care processes and outcomes. The plan of care outlines what patient care needs to occur, orders are entered to prescribe needed care, and documentation confirms that the care was provided. Computers can capture and aggregate data to demonstrate both the processes of care and the patient outcomes achieved.

The Joint Commission (TJC), an independent, not-for-profit organization, evaluates and provides accreditation and certification to more than 15,000 healthcare organizations and programs in the United States. Accreditation and certification by TJC are recognized nationwide as symbols of an organization’s commitment to meeting performance standards focused on improving the quality and safety of patient care.

The Comprehensive Accreditation Manual for Hospitals and the manuals for other healthcare programs include a chapter of standards for information management. Planning for information management is the initial focus of the chapter, since a well-planned system meets the internal and external information needs of an organization with efficiency and accuracy. The goals of effective information management are to obtain, manage, and use information to improve patient care processes and patient outcomes, as well as to improve other organizational processes. Planning is also necessary to provide care continuity should an organization’s information systems be disrupted or fail. Planning also is necessary to ensure privacy, security, confidentiality, and integrity of data and information.

A second chapter in the 2009 accreditation manuals is “The Record of Care, Treatment and Services.” This chapter provides standards and recommendations for the components of a complete medical record. It details documentation requirements that include accuracy, authentication, and thorough, timely documentation. Other standards address the requirements for auditing and retaining records (The Joint Commission [TJC], 2009).

All nurses, including nurse leaders, share responsibility to ensure that cost-effective, high-quality patient care is provided. Nursing administrative databases, containing both clinical and management data, support decision making for these purposes. Administrative databases assist in the development of the organization’s information infrastructure, which ultimately allows for links between management decisions (e.g., staffing or nurse : patient ratios), costs, and clinical outcomes.

Selection of a clinical information system and software partner may be one of the most important decisions of a chief nursing officer and the nursing leadership team (Simpson, 2003). Nurse leaders and direct care nurses must be members of the selection team, participate actively, and have a voice in the selection decision. Remember, nurses are knowledge workers who require data, information, and knowledge to deliver effective patient care. The information system must make sense to the people who use it and fit effectively with the processes for providing patient care. Box 11-3 identifies key elements of an ideal clinical information system that can guide the decision making necessary for selecting or developing health information software. It is imperative to make site visits at organizations already using the software being considered for selection. Discussions at site visits include both the utility and performance of the software and the customer service and responsiveness of the vendor.

BOX 11-3 Elements of the Ideal Hospital Information System