Nursing Curriculum Reform and Healthcare Information Technology


Nursing Curriculum Reform and Healthcare Information Technology

Eun-Shim Nahm / Mary Etta Mills / Marisa L. Wilson

Nursing informatics education focuses on the use of health information technologies (IT) and data to promote the health of individuals and populations. To provide efficient, effective, and safe care in this rapidly changing and technology-laden healthcare environment, nurses must be prepared to optimally use the technologies in their practice and either participate in or lead groups that develop, implement, maintain, evaluate, and optimize technologies. It is vital to understand that health IT encompasses a wide variety of technologies including electronic health records (EHR), personal health records, mobile applications, devices, communication technologies, and telehealth/telenursing. To prepare clinicians who can effectively use the technologies and data, educational programs constantly update informatics content to support current nursing and clinical practice at all levels of nursing education.


In the past few years, health IT has revolutionized various aspects of healthcare delivery, including the way health data is generated, the use of that data to drive care, and patients’ use of their health data for self-care. Currently, healthcare providers gather a significant amount of digitally stored data that is used to create information about their patients even before they visit their providers. Patients receive previsit assessment forms through their patient portals prior to outpatient visits. When patients go to a clinic or hospital, they are admitted to a registration system and complete check in assessments even before they see their providers. After that, the amount of personal data within the electronic care system incrementally increases as patients receive care. Eventually, the patient’s health data collected by a provider at the point of care is then stored within the healthcare system. Many data are forwarded to finance systems, and sent to necessary insurance companies and other regulatory organizations. Currently, some selected data are exchanged with appropriate public health agencies and other healthcare providers through health information exchange services to deliver better care.

Another notable change is the increasing use of various health IT devices. With the advancement of the Internet of Things (IOT) era, various electronics, software, and sensors are embedded into networks, which enable these devices to collect and exchange data (Zanellam, Bui, Castellani, Vangelista, & Zorzi, 2014). With these changes, health information exchange and interoperability have become national priorities (Bloomfield, PoloWood, Mandel, & Mandl, 2017; Massoudi, Marcial, Tant, Adler-Milstein, & West, 2016). While more patient data are gathered online and health data is being exchanged, it is becoming increasingly difficult to maintain the safety and security of health data. The HIPAA Omnibus Rule was introduced in 2013 to protect patient privacy and safeguard patients’ health information in an ever-expanding digital age (U.S. Department of Health and Human Services, 2013). The 2013 HIPAA rules are then revisited and strengthened in the 2019 DHHS proposed new rules which promote immediate access to health information for patients and providers within a safe and secure system that is not subjected to information blocking, all of which sets up unsafe care environments for patients and populations (Department of Health and Human Services, 2019).

At the systems’ level, healthcare providers must ensure the accuracy and completeness of data, as well as appropriate interoperability between systems, while safeguarding patients’ data. Implementation and maintenance of health IT are complex and dynamic processes, and an increasing number of health IT experts and clinicians are becoming involved. An enormous challenge for healthcare organizations and educational institutions is the preparation of competent healthcare informaticians and clinicians competent in the use of health information technologies.


In the past three decades, there have been a few major efforts to transform healthcare. The seminal healthcare report To err is human, published by the Institute of Medicine (IOM) in 2000, revealed a serious healthcare problem related to medical errors in the United States and emphasized the importance of health information technology (IT) to prevent medical errors and improve healthcare quality (Institute of Medicine, 2001; Newhouse, Dearholt, Poe, Pugh, & White, 2007). Since then, the use of health IT and electronic healthcare records (EHR) has become a national priority. Title XIII of the ARRA Health Information Technology for Economic and Clinical Health Act (HITECH) accelerated the spread of EHRs through incentive payments by Medicare and Medicaid to clinicians and hospitals when providers used EHRs privately and securely to achieve specified improvements in care delivery (Blumenthal, 2009; Blumenthal & Tavenner, 2010). The main goals of the original “Meaningful Use” (MU) regulations were to : (1) improve quality, safety, efficiency, and reduce health disparities; (2) engage patients and families; (3) improve care coordination, and population and public health; and (4) maintain privacy and security of patient health information. Since then, the name of “MU” evolved to “EHR Incentive Payment Program,” and then to “Promoting Interoperability (PI) Program,” in 2018 (Centers for Medicare & Medicaid Services, 2019). In particular, the recent change, the PI program, reflects current changes in the healthcare model. In 2016, the MU requirements were folded into the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA supports the movement from the fee-for-service reimbursement model to value-based care by incentivizing quality, clinical practice improvement activities, and cost containment (Office of the National Coordinator for Health Information Technology [ONC], 2019).

To achieve the successful adoption of health IT in the dynamically changing healthcare landscape, it is critical to ensure clinician competency to use healthcare IT. Nurses’ competency in using health IT and the data is particularly important because they are the largest group of direct healthcare providers in the United States, accounting for 19% of all healthcare workers in 2017 (approximately 2.9 million employed) (U.S. Bureau of Labor Statistics, 2018). Recognizing the importance of informatics and nurses’ competency in the use of health IT and informatics processes, the Essentials for Baccalaureate, Masters and Doctor of Nursing Practice Education developed by the American Association of Colleges of Nursing (AACN) have included mandates for competency in Informatics and Healthcare Technology for over a decade (American Association of Colleges of Nursing [AACN], 2019). Moreover, the Quality and Safety Education for Nurses (QSEN) project has also described knowledge, skills, and attitudes related to informatics for all nurses (QSEN, 2019a). These and other professional organizations drive the content of nursing curricula and graduate outcome expectations.

In addition, nursing as a healthcare discipline has been at the forefront of educating healthcare professionals who are specialized in healthcare IT and informatics theory. For instance, nursing informatics (NI) was created as an area of graduate specialization at the University of Maryland School of Nursing (UMSON) in 1988, and NI was officially recognized as a specialty practice area by the American Nurses Association (ANA) in 1992 (Gassert, 2000). Since then, informatics has become a core course in many programs, and many nursing schools offered graduate degree programs focusing on nursing and healthcare informatics.

Despite the promotion of informatics and health IT competency, many nursing schools struggle with the inclusion of informatics and health IT content in their programs of study at all levels since many faculty members are unfamiliar with informatics content. This significant gap has been recognized by several organizations who are working to fill the gap in educator knowledge as it relates to informatics and heath IT use in care. The Nursing Knowledge Big Data Science Initiative’s Education Workgroup is tackling this problem by developing resources and tools for educators (University of Minnesota School of Nursing, 2019). In addition, the Technology Informatics Guiding Education Reform (TIGER) project, under the Health Information and Management Systems Society (HIMSS), is also aiming to address the faculty competency gap through the collaborative efforts of the Scholars Workgroup (HIMSS, 2019a). TIGER is described in more detail later in the chapter. These collaborative and open efforts should provide solid foundations for faculty who support the competency development of nurses.

The advancement of available information communication technologies and simulation environments has also changed nursing education drastically. Many nursing schools have high-fidelity simulation labs allowing students more opportunities to learn about critical components of practical cases from school. Stakeholders expect nursing students to be competent in using health IT when they arrive in practice settings. Nursing as a profession has recognized the major reform of nursing education, and significant efforts have been made in many areas of the nursing domain, including revision of essentials for all levels of nursing education (American Association of Colleges of Nursing, 2008, 2011, 2014). Since then, the healthcare environment has changed drastically, and the AACN is in the process of further revising the essentials (American Association of Colleges of Nursing, 2019b).

Efforts in Nursing Informatics Curriculum Revisions

An increased awareness of patient safety and the increasing use of health IT in healthcare called for changes in the nursing curriculum. The IOM report Health professions education: A bridge to quality (Institute of Medicine, 2003) is a result of a 2002 summit followed by the IOM’s report, Crossing the quality chasm (Institute of Medicine, 2001). This interdisciplinary summit was held to discuss reforming education for health professionals to enhance quality and patient safety (Institute of Medicine Committee on Health Education Profession Summit, 2002). The report proposed five core competencies for healthcare professionals; one of these core competencies is the use of informatics (Institute of Medicine, 2001; Institute of Medicine Committee on Health Education Profession Summit, 2002). Since then, many efforts have been made by nursing professional organizations and the AACN to revise the nursing curriculum to be aligned with the IOM competencies.

Quality and Safety Education for Nurses (QSEN). The overarching goal of the three phases of the QSEN project, which was supported by the Robert Wood Johnson Foundation (RWJF), is to address the competencies necessary to continuously improve the quality and safety of healthcare systems in which nurses work (Cronenwett et al., 2007; QSEN, 2019a, 2019b). Phase I of the project identified six competencies that needed to be developed during pre-licensure nursing education (Table 44.1). The group also proposed clarified competencies in the areas of knowledge, skills, and attitudes (KSAs).

TABLE 44.1. QSEN Competencies


Phase II work of QSEN was focused on competencies for graduate and advanced practice nurses (APNs). The QSEN faculty members collaborated with APNs who practiced in direct patient care and worked on the development of standards of practice, accreditation of educational programs, and certification (Cronenwett, Sherwood, Pohl, et al., 2009). The workgroups that participated in Phase II generated KSAs for graduate-level education. In Phase III, the AACN worked on developing the capacity of faculty engaged in pre-licensure nursing education to mentor their colleges’ faculty integration of the evidencebased content on the six QSEN competencies (QSEN, 2012). Phase IV supports the Institute of Medicine’s recommendation of increasing the number of nurses with an advanced degree. These efforts are being led by the Tri-Council for Nursing, consisting of the American Association of Colleges of Nursing, National League for Nursing, the American Nurses Association, and the American Organization of Nurse Executives (AONE). The IOM/QSEN competencies and the pre-licensure KSAs are embedded in the AACN Essentials for nursing education (Cronenwett, Sherwood, & Gelmon, 2009; Cronenwett et al., 2009; Dycus & McKeon, 2009).

The American Association of Colleges of Nursing Essentials for Nursing. In response to the calls to transform healthcare delivery and to better prepare today’s nurses for professional practice, the AACN convened a task force on essential patient safety competencies in 2006 (American Association of Colleges of Nursing, 2006). The taskforce recommended specific competencies that should be achieved by professional nurses to ensure high-quality and safe patient care. Those competencies were identified under the following areas: (1) critical thinking; (2) healthcare systems and policy; (3) communication; (4) Illness and Disease Management; (5) ethics; and (6) information and healthcare technologies. Since then, the AACN revised the Essentials of Baccalaureate Education for Professional Nursing Practice in 2008 (American Association of Colleges of Nursing, 2008).

In regards to the essentials for graduate programs, the AACN made a decision to migrate advanced practice nursing programs (APN programs) from the master’s level to the doctorate level (doctor of nursing practice [DNP] program) by the year 2015 (American Association of Colleges of Nursing, 2014). Currently, most master’s programs that prepare advanced practice registered nurses (APRNs) have transitioned to DNP programs. The Essentials of Doctoral Education for Advanced Nursing Practice were developed in 2006 (American Association of Colleges of Nursing, 2006), and the informatics competency is one of the essentials for this education program. This has a major impact on education at the graduate level. Some non-APRN master’s specialty programs (e.g., informatics, healthcare leadership and administration, and community-health nursing) still maintain master’s programs. The essentials for master’s education were revised in 2011 and a new revision process initiated in 2019 to establish educational benchmarks to advance nursing practice across the healthcare system and continuum of care (American Association of Colleges of Nursing [AACN], 2019b).

Among various changes regarding essentials in nursing education, major emphasis had been on patient safety and healthcare IT. This chapter focuses on nursing curriculum from the context of health IT, and Table 44.2 describes AACN essentials in the area of information management and technology.

TABLE 44.2. Information Management and Technology-related Essentials for Nursing



HIMSS Technology Informatics Guiding Educational Reform (TIGER) Initiatives. The recent Technology Informatics Guiding Educational Reform (TIGER) Initiatives epitomize nurses’ efforts to translate highlevel initiatives on nursing education reform to a practice level (TIGER, 2014). TIGER is an education reform initiative that strives to foster interprofessional community development and global workforce development by maximizing the integration of technology and informatics into seamless practice, education, and research resource development.(Healthcare Information and Management Systems Society (HIMSS), 2019c). In Phase I of the TIGER summit, stakeholders from various fields, including nursing practice, education, vendors, and government agencies, developed a 10-year vision and 3-year action plan for transforming nursing practice and education (HIMSS, 2019c). In Phase II, TIGER formalized cross-organizational activities/action steps into nine collaborative TIGER teams (TIGER, 2009) addressing specific topic areas. In 2014, TIGER transitioned to HIMSS and is now under professional development with an interprofessional, interdisciplinary, and international focus. Some of the important activities include offering learning opportunities and support for clinicians, educators, and informaticians through: (1) the Virtual Learning Environment Center (VLE); (2) the Health Information Technology Competencies tool (; and (3) the Informatics Education Resource Navigator (IERN). The VLE, HITComp, and the IREN are interactive Web-based learning environments where the learners can develop knowledge and skills in the area of health information technology.


The IOM, AACN, QSEN, and TIGER addressed essential competencies that need to be addressed in educational programs. A great deal of effort also has been made in developing more executable competency lists that can be used in practice settings.

American Nurses Association

Nursing informatics: The scope and standard of practice addressed an NI-specific domain. Nursing informatics is an essential component for any nurse. The second edition of the NI Scope and Standards matrix, containing a new set of recommended competencies, was published in 2015 (American Nurses Association, 2015). This comprehensive edition outlines the nursing informatics competency levels expected of informatics nurses and informatics nurse specialists (master’s prepared INS). It also details the nursing informatics competencies needed by any clinical nurse, spanning all nursing careers and roles. The scope of practice addresses the context of the who, what, where, when, why, and how of NI practice. That detailed scope of practice covers the following topics:

•   Metastructures, concepts, and tools of nursing informatics

•   Functional areas of nursing informatics

•   Preparation for nursing informatics specialty practice

•   Ethics in nursing informatics

•   The future of nursing informatics

•   Trends in regulatory changes and quality standards

The 16 nursing informatics standards, which provide a framework for evaluating practice outcomes and goals, are accompanied by a set of specific competencies for each standard. With the recent changes, the ANA recently solicited a working group to revise the scope and standards to reflect the recent advancement of technology, changing healthcare landscape, and the requirements of policy and regulation.

TIGER Informatics Competencies Collaborative Recommendations

In the second phase of the TIGER initiative, the TIGER Informatics Competency Collaborative (TICC) recommends specific informatics competencies for all practicing nurses and graduating nursing students (TIGER, 2014). The TIGER NI competencies model consists of the following three areas: (1) basic computer competencies; (2) information literacy; and (3) information management. For the basic computer competencies, the TICC adopted the European Computer Driving License (ECDL) competencies and made its recommendations. The European Computer Driving License (ECDL)/International Computer Driving License (ICDL) is an internationally recognized information and communication technology and digital literacy certification (European Computer Driving License [ECDL] Foundation, 2019). The specific recommendations made by the TICC were based on the old ECDL/ICDL Syllabus 5.0. As a further refinement of the TICC, the TIGER International Committee has conducted further far-reaching work to synthesize informatics competencies that have been produced for interprofessional and international consumption. In 2015, the TIGER International Task Force began comprehensive activities to compile all recommended international informatics competencies. These efforts resulted in a set of recommendations that fall under ten core competency areas within five role types, including Clinical Nursing (Direct Patient Care), Quality Management, Coordination of Interprofessional Care, Nursing Management, IT Management in Nursing (Hübner et al., 2018).

Nursing Informatics as a Specialty Program at the Graduate Level

The ANA defines Nursing informatics (NI) as: “a specialty that integrates nursing science with multiple information and analytical sciences to identify, define, manage, and communicate data, information, knowledge, and wisdom in nursing practice. NI supports nurses, 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).

The NI Scope and Standards of Practice clearly differentiate between informatics nurses (INs) and informatics nurse specialists (INSs). The INSs are those formally prepared at the graduate level in informatics and who also are certified, while INs are generalists who have gained on-the-job training in the field but do not have educational preparation at the graduate level in an informaticsrelated area.

With the national emphasis on HIT education, various types of informatics-related educational programs have become available at the graduate level, such as nursing informatics, healthcare informatics, biomedical informatics, etc. Most informatics educational programs are moving toward online programs and/or hybrid (mainly online with some face-to-face classes) programs. The curriculum and credits vary a great deal depending on the program. The nursing informatics field also has unique characteristics. For instance, the roles the INSs assume vary. In 2017, as part of the Nursing Informatics Workforce survey (N = 1,2) conducted by the Healthcare Information and Management Systems Society (HIMSS), participants were asked to indicate the title of the position they assumed (HIMSS, 2017). Findings showed a wide range of positions, including nursing informatics specialist (20%), director of clinical informatics (7%), clinical analyst (5%), consultant (4%), educator/instructor (3%), and clinical application specialist (2%). The areas of practice also varied, including hospital, health system, academic, vendor, government, ambulatory, and other settings. More than half (57%) had a postgraduate degree in one of a variety of fields, and the majority were highly satisfied with their job and career in clinical informatics.

In addition to the findings from the HIMSS 2017 survey, recent scientific discoveries in biomedical informatics and genomics, as well as rapid growth in big data and mHealth/eHealth research, have made a significant impact on healthcare informatics and the roles of nursing informatics specialists. Considering these varying roles and areas of practice, it is logical that each program may have a different emphasis or strength. Assurance of quality standards of each program, however, is particularly concerning, considering that there is no regulatory body or specialty organization responsible for setting standards for educational programs in nursing informatics.

Certification in Nursing Informatics and Related HIT

Currently, the American Nurses Credentialing Center (ANCC), an accredited agency, offers the generalist nursing informatics certification (RN-BC) (American Nurses Credentialing Center, 2019). The minimum academic degree required to take the examination for this certification is a bachelor’s or higher degree in nursing or a bachelor’s degree in a relevant field. The test content outline for the nursing informatics certification examination can be found on ANCC’s Web site (; American Nurses Credentialing Center, 2014). The main content as of October 2019 includes:

1.   Foundations of practice (77 items, 51%)

2.   System design life cycle (SDLC) (42 items, 28%)

3.   Data management and healthcare technology (31 items, 21%)

Nursing informaticians’ primary responsibilities vary a great deal depending on their job and work environments, and each job or setting may require a different certificate, such as project manager or information administrator. In the 2017 HIMSS Nursing Informatics Workforce Survey, 47% of respondents had some type of certificate, and 27% held a certificate in nursing informatics offered through the ANCC (HIMSS, 2011, 2017). Other certificates include a Project Management Certificate and the Certified Professional in Healthcare Information and Management Systems (CPHIMS) certificate. The American Medical Informatics Association (AMIA) is also in the process of developing an advanced health informatics certification (AHIC) for nonphysician informaticians. The AMIA AHIC will be similar to that developed by AMIA for physicians holding clinical informatics subspecialty training that is currently active. Eligible professionals for AHIC will hold graduate-level degrees from an accredited institution reviewed by the Commission on Accreditation for Health Informatics and Information Management (CAHIIM) (Gadd, Williamson, Steen, & Fridsma, 2016). Table 44.3 summarizes information for selected certifications relevant to nursing informatics.

TABLE 44.3. Selected Certifications Relevant to Nursing Informatics

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Jul 29, 2021 | Posted by in NURSING | Comments Off on Nursing Curriculum Reform and Healthcare Information Technology

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