Historical Perspectives of Nursing Informatics


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Historical Perspectives of Nursing Informatics



Virginia K. Saba / Bonnie L. Westra / Juliana J. Brixey



OVERVIEW



Nursing Informatics is a phrase that evolved from the French word “informatique” which referred to the field of applied computer science concerned with the processing of information such as nursing information. The computer was seen as a tool that could be used in many environments.


In the early 1960s, the computer was introduced into healthcare facilities for the processing of basic administrative tasks. Thus the computer revolution in healthcare began and led to today’s healthcare information technology (HIT) and/or electronic health record (EHR) systems.


The importance of the computer as an essential tool in HIT systems and the delivery of contemporary healthcare is indisputable. HIT is an all-encompassing term referring to technology that captures, processes, and generates healthcare information. Computerization and/or electronic processing affect all aspects of healthcare delivery including (a) provision and documentation of patient care, (b) education of healthcare providers, (c) scientific research for advancing healthcare delivery, (d) administration of healthcare delivery services, (e) reimbursement for patient care, (f ) legal and ethical implications, as well as (g) safety and quality issues.


Since the inception of the computer, there has been a shift from the use of mainframe, mini, or microcomputers (PCs) to integrating multiple technologies and telecommunication devices such as wireless, handheld, mobile computers, and smart (cell) phones designed to support the continuity of care across healthcare settings and HIT systems. There has also been a shift from storage devices to cloud storage. Furthermore, there is less need to develop written instructions for software programs as today’s applications are icon-based, user-friendly, and menu-driven. Additionally, video tutorials are available for many programs. Touch-screen devices are replacing the need for a mouse.


Today, computers in nursing are used to manage patient care information, monitor quality, and evaluate outcomes. Computers and networks are also being used for communicating (sending and receiving) data and messages via the Internet, accessing resources, and interacting with patients on the Web. Nurses are increasingly using systems for planning, budgeting, and policy-making for patient care services. Computers are also used to document and process real-time plans of care, support nursing research, test new systems, design new knowledge databases, develop data warehouses, and advance the role of nursing in the healthcare industry and nursing science. Moreover, computers are enhancing nursing education and distance learning with new media modalities.


This chapter is an updated and revised version of the chapter “Historical Perspectives of Nursing Informatics” (Saba & Westra, 2015) published in the 6th edition of the Essentials of Nursing Informatics (Saba & McCormick, 2015). In this chapter the significant events influencing the growth of nursing informatics (NI) as a nursing specialty are analyzed according to (1) seven time periods, (2) a view of the newest technological innovations used by nurses, (3) a description of Nursing Informatics Pioneers including a synthesis of lessons learned from videotaped interviews with NI pioneers, (4) electronic health records from a historical perspective, and (5) landmark events in nursing and computers, with Table 1-1 listing those events that influenced the introduction of computers into the nursing profession including key “computer/informatics” nurse that directed the activity. Also, Table 1-2 lists current organizations supporting nursing informatics.


MAJOR HISTORICAL PERSPECTIVES OF NURSING AND COMPUTERS



Seven Time Periods


Computers were introduced into the nursing profession over 40 years ago. Major milestones of nursing are interwoven with the advancement of computer and information technologies, the increased need for nursing data, development of nursing applications, and changes making the nursing profession an autonomous discipline. The key activities and events for each decade are presented to provide a background and the sequence of events to demonstrate nursing’s commitment to Computers and Nursing including Information Technology.


Prior to 1960s Computers were first developed in the late 1930s to early 1940s. As computers have evolved, computing power has increased. This was attributed to the increasing number of transistors or chips placed in an integrated circuit. In the mid-1960s Gordon Moore noted that the number doubled approximately every two years. This argument has become known as Moore’s law (Techopedia, 2019).


Use of computers in the healthcare industry did not occur until the 1950s and 1960s. During this time, there were only a few experts nationally and internationally who formed a cadre of pioneers that adapted computers to healthcare and nursing which was undergoing major changes. Several professional advances provided the impetus for the profession to embrace computers—a new technological tool. Computers were initially used in healthcare facilities for basic office, administrative, and financial accounting functions. These early computers used punch cards to store data and card readers to read computer programs, sort, and prepare data for processing. Computers were linked together and operated by paper tape using teletypewriters to print their output. As computer technology advanced, healthcare technologies also advanced. The major advances are listed chronologically in Table 1-1.



TABLE 1.1. Landmark Events and Pioneers in Computers and Nursing, and Nursing Informatics


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1960s During the 1960s the uses of computer technology in healthcare settings began to be explored. Questions such as “Why use computers?” and “What should be computerized?” were discussed. Nursing practice standards were reviewed, and nursing resources were analyzed. Studies were conducted to determine how computer technology could be utilized effectively in the healthcare industry and what areas of nursing should be automated. The nurses’ station in the hospital was viewed as the hub of information exchange; therefore, numerous initial computer applications were developed and implemented in this location.


By the mid-1960s, clinical practice presented nurses with new opportunities for computer use. Increasingly complex patient care requirements and the proliferation of intensive care units (ICUs) required that nurses become super users of computer technology as nurses monitored patients’ status via cardiac monitors and instituted treatment regimens through ventilators and other computerized devices such as infusion pumps. A significant increase in time spent by nurses documenting patient care, in some cases estimated at 40%, as well as a noted rise in medication administration errors prompted the need to investigate emerging hospital computer-based information systems (Sherman, 1965; Wolkodoff, 1963).


1970s During the late 1960s through the 1970s, hospitals began developing computer-based information systems which initially focused on computerized physician order entry (CPOE) and results reporting; pharmacy, laboratory, and radiology reports; information for financial and managerial purposes; and physiologic monitoring systems in the intensive care units; and a few systems started to include care planning, decision support, and interdisciplinary problem lists. While the content contained in early hospital information systems frequently was not specific to nursing practice, a few systems did provide a few pioneer nurses with a foundation on which to base future nursing information systems (Blackmon et al., 1982; Collen, 1995; Ozbolt & Bakken, 2003; Romano, McCormick, & McNeely, 1982). Regardless of the focus, which remained primarily on medical practice, nurses often were involved in implementing health information technology (HIT) systems.


Interest in computers and nursing began to emerge in public health, home health, and education during the 1960s to 1970s. Automation in public health agencies began as a result of pressure to standardize data collection procedures and provide state-wide reports on the activities and health of the public (Parker, Ausman, & Ovedovitz, 1965). In the 1970s, conferences sponsored by the Division of Nursing (DN), Public Health Service (PHS), and the National League for Nursing (NLN) helped public health and home health nurses understand the importance of nursing data and their relationship to new Medicare and Medicaid legislation requirements passed in 1966. The conferences provided information on the usefulness of computers for capturing and aggregating home health and public health information. Additional government-sponsored conferences focused on educational uses of computers for nurses (Public Health Service, 1976). Simultaneously, hospitals and public health agencies embarked on investigating computers and nursing; the opportunity to improve education using computer technology commenced. Bitzer (1966) reported on one of the first uses of a computerized teaching system called PLATO, which was implemented to teach classes in offcampus sites as an alternative to traditional classroom education.


The early nursing networks, which were conceived at health informatics organizational meetings, helped to expand nursing awareness of computers and the impact HIT could have on practice. The state of technology initially limited opportunities for nurses to contribute to the HIT design, but as technology evolved toward the later part of the 1970s and as nurses provided workshops nationally, nurses gained confidence that they could use computers to improve practice. The national nursing organization’s federal agencies (Public Health Service, Army Nurse Corps) and several university schools of nursing provided educational conferences and workshops on the state-ofthe-art regarding computer technology and its influence on nursing. During this time, the Clinical Center at the National Institutes of Health implemented the Technicon Data System (TDS) system; one of the earliest clinical information systems (called Eclipsys & Allscripts) was the first system to include nursing practice protocols.


In addition to the use of computers, advancement was underway for other technologies and/or devices used by nurses. For example, the first point-of-care blood glucose monitor became available for use in the clinical setting in 1970 (Clarke & Foster, 2012). The devices became smaller and more widespread in the 1980s.


1980s In the 1980s, the field of nursing informatics exploded and became visible in the healthcare industry and nursing. Technology challenged creative professionals in the use of computers in nursing. As computer systems were implemented, the needs of nursing took on a cause-and-effect modality; that is, as new computer technologies emerged and as computer architecture advanced, the need for nursing software evolved. It became apparent that the nursing profession needed to update its practice standards and determine specific data standards, vocabularies, and classification schemes that could be used for the computer-based patient record systems.


In the 1980s, the microcomputer or personal computer (PC) emerged. This revolutionary technology made computers more accessible, affordable, and usable by nurses and other healthcare providers. The PC brought computing power to the workplace and, more importantly, to the point of care. Also, the PCs served as dumb terminals linked to the mainframe computers and as stand-alone systems (workstations). The PCs were user-friendly and allowed nurses to design and program their own applications. The influence of computer technology extended to the introduction of devices to improve patient safety. For example, the automated dispensing cabinets (ADCs) were introduced in the 1980s (Grissinger, 2012). The computercontrolled ADCs replaced medication carts and drug floor stock. Tracking of medications occurred at the point of care. The use of ADCs in the clinical setting has resulted in the reduction of medication errors.


Starting in 1981, national and international conferences and workshops were conducted by an increasing number of nursing pioneers to help nurses understand and get involved in this new emerging nursing specialty. Also during the 1980s, invitational conferences were conducted to develop nursing data sets and vocabularies as well as numerous workshops were conducted at universities to introduce this new specialty into nursing education. During this period, many mainframe healthcare information systems (HISs) emerged with nursing subsystems. These systems documented several aspects of the patient record, namely, provider order entry and results reporting, the Kardex reporting, vital signs, and other systems-documented narrative nursing notes using word-processing software packages. Discharge planning systems were developed and used as referrals to community, public, and home healthcare facilities for the continuum of care.


Nurses began presenting at multidisciplinary conferences and formed their own working groups within HIT organizations, such as the first Nursing Special Interest Group on Computers which met for the first time during SCAMC (Symposium on Computer Applications in Medical Care) in 1981. As medical informatics evolved, nursing began focusing on what was unique about nursing within the context of informatics. Resolutions were passed by the American Nurses Association (ANA) regarding computer use in nursing and in 1985, the ANA approved the formation of the Council on Computer Applications in Nursing (CCAN). One of the first activities the CCAN executive board initiated was to solicit several early pioneers to develop monographs on the status of computers in nursing practice, education, research, and management. The CCAN board developed a yearly Computer Nurse Directory on the known nurses involved in the field, conducted computer applications demonstrations at the ANA annual conferences, and shared information with their growing members in the first CCAN newsletter Input-Output. During this time NI newsletters, journals, and several books, such as the first edition of this book Essentials of Computers for Nurses published in 1986, were used for educational courses introduced in the academic nursing programs, and workshops conducted on computers and nursing. The CCAN became a very powerful force in integrating computer applications into the nursing profession. In 1988, the CCAN commissioned three NI experts to prepare a set of criteria on the integration of nursing practice for EHR vendors to follow (Zielstorff, McHugh, & Clinton, 1988). In 1989, the ANA renamed the CCAN to the Steering Committee on Databases to Support Clinical Nursing Practice, which later became the Committee for Nursing Practice Information Infrastructure (CNPII). The purpose of the CNPII was to support development and recognition of national health data standards (Coenen et al., 2001).


1990s By the 1990s, large integrated healthcare delivery systems evolved, further creating the need for information across healthcare facilities within these large systems to standardize processes, control costs, and assure the quality of care (Shortliffe, Perreault, Wiederhold, & Pagan, 2003). Advances in relational databases, client-server architectures, and new programming methods created the opportunity for better application development at lower costs. Legislative activity in the mid-1990s paved the way for EHRs through the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (public-law 104-191), emphasizing standardized transactions, and privacy and security of patient-identifiable information (Gallagher, 2010). The complexity of technology, workflow analysis, and regulations shaped new roles for nursing.


In 1992, the ANA recognized nursing informatics as a new nursing specialty with a separate Scope of Nursing Informatics Practice Standards, and also established a specific credentialing examination for it (ANA, 2008). Numerous local, national, and international organizations provided a forum for networking and continuing education for nurses involved with informatics (Sackett & Erdley, 2002). The demand for NI expertise increased in the healthcare industry and other settings where nurses functioned, and the technology revolution continued to impact the nursing profession.


The need for computer-based nursing practice standards, data standards, nursing minimum data sets, and national databases emerged concurrently with the need for a unified nursing language, including nomenclatures, vocabularies, taxonomies, and classification schemes (Westra, Delaney, Konicek, & Keenan, 2008). Nurse administrators started to demand that the HITs include nursing care protocols and nurse educators continued to require the use of innovative technologies for all levels and types of nursing and patient education. Also, nurse researchers required knowledge representation, decision support, and expert systems based on standards that allowed for aggregated data (Bakken, 2006).


In 1997, the ANA developed the Nursing Information and Data Set Evaluation Center (NIDSEC) to evaluate and recognize nursing information systems (ANA, 1997). The purpose was to guide the development and selection of nursing systems that included standardized nursing terminologies integrated throughout the system whenever it was appropriate. There were four high-level standards: (a) inclusion of ANA-recognized terminologies; (b) linkages among concepts represented by the terminologies retained in a logical and reusable manner; (c) data included in a clinical data repository; and (d) general system characteristics. The Certification Commission for Health Information Technology (CCHIT) had similar criteria for the EHR certification, which was later adopted by the Office of the National Coordinator for Health Information Technology (ONC); however, nursing data was no longer included. ANA was ahead of its time in its thinking and development. The criteria are now under revision by the ANA to support nurses to advocate their requirements for the emerging HIT systems.


Technology rapidly changed in the 1990s, increasing its use within and across nursing units as well as across healthcare facilities. Computer hardware—PCs—continued to get smaller and computer notebooks were becoming affordable, increasing the types of computer technology available for nurses to use. Linking computers through networks both within hospitals and health systems as well as across systems facilitated the flow of patient information to provide better care. By 1995, the Internet began providing access to information and knowledge databases to be integrated into desktop computer systems. It revolutionized information technologies. The Internet moved into the mainstream social milieu with electronic mail (e-mail), file transfer protocol (FTP), Gopher, and Telnet, and World Wide Web (WWW) protocols greatly enhanced its usability and user-friendliness (Saba, 1996; Sparks, 1996). The Internet was used for high-performance computing and communication (HPCC) or the “information superhighway” and facilitated data exchange between computerized patient record systems across facilities and settings over time. The Internet led to improvements in networks, and a browser, WWW, allowed organizations to communicate more effectively and increased access to information that supported nursing practice. The WWW also became an integral part of the HIT systems and the means for nurses to browse the Internet and search worldwide resources (Nicoll, 1998; Saba, 1995).


2000s A change occurred in the new millennium as more and more healthcare information became digitalized and newer technologies emerged. In 2004 an executive order 13335 established the ONC and issued a recommendation calling for all healthcare providers to adopt interoperable EHRs by at least 2014 or 2015 (healthhit.gocv/topic/about-onc). This challenged nurses to get involved in the design of systems to support their workflow as well as in the integration of information from multiple sources to support nurses’ knowledge of technology. In the late 2000s, as hospitals became “paperless,” they began employing new nurses who had never charted on paper.


Technological developments that influenced healthcare and nursing included data capture and data sharing technological tools. Wireless, point of care, regional database projects, and increased IT solutions proliferated in healthcare environments, but predominately in hospitals and large healthcare systems. The use of bar coding and radiofrequency identification (RFID) emerged as a useful technology to match the “right patient with the right medication” to improve patient safety. A barcode medication administration (BCMA) system was first implemented in 2000 in an acute care hospital to electronically capture medication management (Wideman, Whittler, & Anderson, 2005). The RFID also emerged to help nurses find equipment or scan patients to assure that all surgical equipment is removed from inside patients before surgical sites are closed (Westra, 2009). Smaller mobile devices with wireless or Internet access such as notebooks, tablet PCs, personal digital assistants (PDAs), and smart cellular telephones increased access to information for nurses within hospitals and in the community. The development and subsequent refinement of voice over Internet protocol (VoIP) provided voice cost-effective communication for healthcare organizations.


The Internet which appeared in 1995 provided a means for the development of clinical applications. Also, databases for EHRs could be hosted remotely on the Internet, decreasing costs of implementing EHRs. Remote monitoring of multiple critical care units from a single site increased access for safe and effective cardiac care (Rajecki, 2008). Home healthcare increasingly partnered with information technology for the provision of patient care. Telehealth applications, a recognized specialty for nursing since the late 1990s, provided a means for nurses to monitor patients at home and support specialty consultation in rural and underserved areas. The NI research agenda promoted the integration of nursing care data in HIT systems that would also generate data for analysis, reuse, and aggregation.


A historical analysis of the impact of the Nursing Minimum Data Set (NMDS) demonstrated that continued consensus and effort was needed to bring to fruition the vision and implementation of minimum nursing data into clinical practice (Hobbs, 2011). The NMDS continues to be the underlining focus in the newer HIT systems. A new NI research agenda for 2008–2018 (Bakken, Stone, & Larson, 2012) emerged as critical for this specialty. The new agenda is built on the agenda originally developed and published by the National Institute for Nursing Research (NINR) in 1993 (NINR, 1993). The authors focused on the new NI research agenda on “3 aspects of context— genomic health care, shifting research paradigms and social (Web2.0) technologies” (p. 280).


A combination of the economic recession along with the escalating cost of healthcare resulted in the American Recovery and Reinvestment Act (ARRA) of 2009 and the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 with funding to implement HIT and/or EHR systems, support healthcare information exchange, enhance community and university-based informatics education, and support leading edge research to improve the use of HIT (Gallagher, 2010). One of the first ONC initiatives was the Healthcare Information Technology Standards Panel (HITSP) which was designed to determine what coding systems were used to process patient care data from admission to discharge. It was found that the nursing care data was missing in the existing EHRs. Initially, in 2005–2007, the Clinical Care Classification (CCC) System met the established standards as interoperable and was accepted and approved as the free, coded, nursing taxonomies that could be used for assessing and documenting nursing care to generate quality outcomes (Saba & Whittenburg, 2015). This project ended in 2009 when the HITECH Act of 2009 emerged.


2010s During 2010, the ONC convened two national committees, (a) National Committee on Health Policy and National Committee on Health Standards, which outlined and designed to address the HITECH Act of 2009. The committees designed the “Meaningful Use” (MU) program which was to be implemented in three stages of legislation consisting of regulations which built onto each other with the ultimate goal of implementing a complete and interoperable EHR and/or HIT system in all U.S. hospitals. For each stage, regulations were proposed by the national committees, developed and reviewed by the public before they were finalized, and submitted to Centers for Medicare and Medicaid (CMS) and the healthcare facilities for implementation.


In 2011–2012, MU Stage 1 was initiated focusing primarily on the CPOE initiative for physicians. Hospitals that implemented this MU regulation successfully received federal funds for their HIT systems. In 2013–2015, MU Stage 2 was introduced focusing primarily on the implementation of quality indicators that required electronic data to be collected as an integral component in the HIT systems. The quality indicators would be used to guide hospitals in patient safety and if not implemented used as indicators subject to financial penalties. The proposed MU Stage 3 that focused on care quality outcome measures was not implemented but replaced by the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. The MACRA legislation created a new Medicare Quality Payment Program that prioritized the value of healthcare received by Medicare beneficiaries and revised Medicare’s reimbursement to eligible providers. The legislation consolidated components of the Physician Quality Reporting System (PQRS), Value-Based Payment Modifier (VBM), and the Medicare Electronic Health Record (EHR) Incentive program into the Merit-Based Incentive Payment System (MIPS). The purpose of the MIPS program, initiated in 2017, was to establish Medicare payment to healthcare professional’s performance score based on a value-based healthcare model. As a result, the CMS began to focus reimbursement on a quality payment program that addressed quality outcome measures (MIPS, 2019). It is anticipated that this initiative will also minimize the payment burden on the clinicians by aggregating their patients’ health information from multiple providers into a single electronic application.


As of 2018, the CMS proposed policies to strengthen Interoperability. The ONC and CMS rebranded MU to Promoting Interoperability. It is anticipated that the initiative will make use of new technologies and for patients to aggregate their health information from multiple providers into a single electronic application. In 2019, the ONC continued to implement the latest legislation as well as Interoperability through summits, webinars, and public comment.


Nurses have always been involved with all phases of MU as well as all other legislation, from the implementation of systems to assuring usage and adaptation to the evolving health policy affecting the HIT and/or EHR systems. Thus, the field of nursing informatics (NI) continues to grow due to the MU regulations which continue to impact on every inpatient hospital in the country. To date, the majority of hospitals in the country has established HIT departments and has employed at least one nurse to serve as a NI expert to assist with the implementation of MU requirements. As the MU requirements changed they also impacted on the role of the NI experts in hospitals and ultimately on the roles of all nurses in the inpatient and outpatient facilities making NI an integral component of all professional nursing services. An example of nursing involvement is the implementation of the CCC System nursing terminologies for documenting nursing practice in the Hospital Corp of American (HCA) healthcare facilities (Saba & Whittenburg, 2015).


Electronic Health Record Systems from a Historical Perspective


In 1989, the Institute of Medicine (IOM) of the National Academy of Sciences convened a committee and asked the question, “Why is healthcare still predominantly using paper-based records when so many new computerbased information technologies are emerging?” (Dick & Steen, 1991). The IOM invited representatives of major stakeholders in healthcare and asked them to define the problem, identify issues, and outline a path forward. Two major conclusions resulted from the committee’s deliberations. First, computerized patient record (CPR) is an essential technology for healthcare and is an integral tool for all professionals. Second, the committee after hearing from numerous stakeholders recognized that there was no national coordination or champion for CPRs. As a result, the IOM committee recommended the creation of an independent institute to provide national leadership. The Computer-Based Patient Record Institute (CPRI) was created in 1992 and given the mission to initiate and coordinate the urgently needed activities to develop, deploy, and routinely use CPRs to achieve improved outcomes in healthcare quality, cost, and access.


A CPRI work group developed the CPR Project Evaluation Criteria in 1993 modeled after the Baldridge Award. These criteria formed the basis of a self-assessment that could be used by organizations and outside reviewers to measure and evaluate the accomplishments of CPR projects. The four major areas of the initial criteria— (a)management, (b) functionality, (c) technology, and (d) impact—provided a framework through which to view the implementation of computerized records. The criteria, which provided the foundation for the Nicholas E. Davies Award of Excellence Program, reflect the nation’s journey from paper-based to electronic capture of health data. The Davies Award of Excellence Program evolved through multiple revisions and its terminology updated from the computerized patient record to the electronic medical record (EMR), and more recently to the electronic health record (EHR). Today, under HIMSS management, the Davies Award of Excellence Program is offered in four categories: (1) Enterprise (formerly Organizational or Acute Care), first offered in 1995; (2) Ambulatory Care, started in 2003; (3) Public Health, initiated in 2004; and (4) Community Health Organizations (CHO), first presented in 2008 (apps.himss.org/davies/index.asp).


Usability


The usability of EHRs has received increasing attention due to the widespread implementation in both inpatient and ambulatory care. As such, the positive and negative aspects of EHR usability has been identified. Usability is defined as “the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency and satisfaction in a specified context of use” (Aydin & Beruvides, 2014; ISO, 2010). The National Institute of Standards and Technology (NIST) has been at the forefront of the initiative to establish a framework that describes and evaluates health information technology (NIST, n.d.). The initiative is in collaboration with the ONC and Agency for Healthcare Research and Quality (AHRQ).


The Health Information Management Systems Society (HIMSS, 2019) has identified nine usability principles to be used in the development and evaluation of an EHR. It is imperative that usability principles are used in the design of EHRs. Furthermore, end users of doctors, professional nurses, and other healthcare professionals must be involved in the design and upgrades of EHRs. Determination of “usability” does not end with design or implementation but should continue into the post-implementation evaluation process. The data collected can be used to inform future usability upgrades to the EHR.


Consumer-Centric Healthcare Systems Another impact of the escalating cost of healthcare is a shift toward a consumer-centric healthcare system. Consumers are encouraged to be active partners in managing their personal health. A variety of technologies have evolved to enable consumers to have access to their health information and choose whether to share this across healthcare providers and settings. Personal health records emerged as either stand-alone systems or those tethered to EHRs. Consumers are increasing in healthcare information literacy as they demand to become more involved in managing their own health.


Patient Portal


A feature of the EHR is the patient portal which replaced the personal health record. The portal is a secure online site where a patient accesses his or her health information as well as communicates with his or her team of healthcare providers. Access to the patient portal requires a user name and password. The portal is accessible at anyplace and anytime that the patient has access to the Internet. From the portal, the patient can review a provider visit, laboratory and radiology results, medications, and allergies.


Furthermore, a provider can message the patient with reminders for medical screenings, upcoming appointments, medication refills, and billing information. An emerging feature of the patient portal is the e-visit. Using an e-visit, the patient can consult with a provider regarding a non-emergent health issue. The patient portal and personal health record are sometimes used interchangeably. There is an important difference. The personal health record is patient controlled. No one can access including providers unless given permission. In contrast, the patient portal is accessible to providers to upload information.


Wearable Technology in Healthcare


The explosion of sensors has influenced the development of consumer wearable products to track health and fitness parameters. Sensors are embedded in wearable devices or fabrics to record heart rate and rhythm, respiration, oxygen saturation, body temperature, hours of sleep, glucose levels, and fitness activities. The consumer receives real-time feedback for the device. The wearable may be synched with the consumer’s smartphone. Data collected by the device is consumer controlled and shared. Data can be shared with other consumers or with healthcare professionals. There has not been widespread acceptance to store consumer-collected data in the EHR. The number of wearable devices continues to increase with the progress in research and development activities of technology companies and universities.


Nursing Knowledge Big Data Science Initiative


Nursing has a long history in informatics, developing HIT systems and data standards for capturing the practice of nursing; however, there is a dearth of IT systems that incorporate nursing data standards due to the lack of regulatory requirements and financial incentives. In 2013, the University of Minnesota School of Nursing initiated a national collaborative, bringing together nurses from practice, education, research, software vendors, informatics organizations, and other professional and governmental agencies. Over the past 7 years, annual think-tank conferences were held to report out and plan activities for 11 virtual working groups to accomplish a national agenda to achieve sharable and comparable nursing data to ensure the timely adoption of big data methodologies across all of nursing’s domains (Delaney & Weaver, 2018). Table 1-2 describes the purpose of the 11 virtual workgroups. Proceedings and all supporting documents of over the past 7 years can be found at z.umn.edu/bigdata.



TABLE 1.2. Nursing Knowledge Big Data Science Workgroups

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