At the crossroads of technology and patient care stand the nurses who have chosen nursing informatics (NI) as their specialty. Nursing informatics is a well-established specialty within nursing, which today has evolved to be an integral part of health care delivery and a differentiating factor in the selection, implementation, and evaluation of health IT that supports safe, high quality, patient-centric care.
Healthcare Information Management Systems Society (HIMSS) Position Paper: Transforming Nursing Practice through Technology & Informatics, June 17, 2011
Computer technology is pervasive today. Everywhere we turn technology is in evidence. The neighborhood grocery store has automated scanners and checkout lines. Your bank has automated tellers, check scanners, wire transfers, and online services. The school and local libraries have automated catalogs, interlibrary lending, and online books. From our homes and smartphones, we can access the world through the Internet, researching any question, texting and e-mailing, watching streaming videos, and purchasing just about anything. You can complete an advanced degree without ever stepping foot on a campus with a faculty and fellow students who can be literally half a world away. A litany of computerized marvels could fill volumes.
Technology has impacted our culture in multiple ways. When answering machines were first introduced, many people considered their use to be quite rude. Now, just the opposite is true—it is rude if your voice mailbox is full. Sending handwritten invitations with an RSVP has been replaced with online invites with automatic tracking of accepts.
The explosion of new technology since the early 1980s that makes all this possible is truly phenomenal. What is even more incredible, and perhaps a bit frightening to some, is that this seems just to be the beginning. The time has come when the thoughts, communications, creations, manuscripts, learning material, and financial assets of the civilized world will exist primarily in electronic form. If the lights went out, civilization as we know it would cease to exist, as most of modern society depends on the electrical and information infrastructure.
Health care is not immune. Some of the most complex automated systems, and certainly some of the most complex requirements for these systems, can be found in the health care environment. Systems to serve the diverse needs of the health care industry—from the administration and financial departments to the many clinical disciplines—need to be implemented and integrated across the continuum of care within modern health care organizations. As a result, the demand for health care professionals who are knowledgeable in the application of this technology is growing rapidly.
Even with technology all around us, some users do not always feel comfortable with it, especially in the patient care environment where everything may be new to us. Health care technology is sometimes confusing, intimidating, and—in large part because it changes so rapidly—downright bewildering to some. Even so, there are some relative constants that make the field less confusing and easier to manage. The goal of this chapter is not to make you a computer guru or even an entry-level informatics nurse. As Hovenga, Kidd, Garde, and Cossio (2010) pointed out so aptly:
You don’t need to be a computer genius to use a computer effectively in your professional life. You just need to understand the basic concepts. It’s like driving a car; you don’t need to know exactly how the engine works but you do need to learn how to drive the machine, to identify when something is wrong and to understand the road rules so that you minimize the risk of getting into trouble. (p. 14)
The goal of this chapter is to explore how nursing and health care are embracing, harnessing, and using technology to increase the quality of patient care in all health care settings.
Always remember that technology is only a tool to help us care for our patients. It should never replace our critical thinking and nursing judgment!
Nursing Informatics: Why Do I Care?
In the back of your mind you may be thinking, “So why do I care about nursing informatics and technology? I’m still learning to take care of patients.” Well, in today’s world, technology and patient care are completely interwoven. From the electronic medical record, to the devices you will use to monitor and care for your patients, to the accumulation of data that will allow you to provide care most effectively, technology and informatics are a part of our daily nursing practice whether we realize it or not. Look at Fig. 23.1 and see how many technology-enabled items you can pick out. And who knows? Maybe someday you will decide that nursing informatics is the specialty for you.
What Is Nursing Informatics?
In 1994, the American Nurses Association (ANA) recognized the field of nursing informatics. In 2015, the ANA updated the definition of nursing informatics (NI) as “the specialty that integrates nursing science with multiple information management and analytical sciences to identify, define, manage, and communicate data, information, knowledge, and wisdom in nursing practice” (ANA, 2015, p. 1).
The ANA further identified two distinct roles in nursing informatics: the informatics nurse (IN) and the informatics nurse specialist (INS). The informatics nurse has experience in nursing informatics but does not have an advanced degree in the specialty. The informatics nurse specialist has graduate-level education in informatics or a related field (ANA, 2015). Nurses in both IN and INS roles “support 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” (ANA, 2015, p. 2).
With the advent of both specialty and integrated clinical information systems (CIS), the longitudinal electronic health record (EHR) has become the ultimate goal of health care organizations and is now supported by federal mandate. The EHR will reflect a record of patients’ health care throughout their lives. Although this realization of 100% integrated patient data in one longitudinal electronic record is becoming more technologically feasible, few organizations have actually reached this goal. There are still outstanding issues regarding how to handle outside information that comes into a facility; for example, old systems may not be able to interface with new ones, corrupt data may be received from old systems, and resources may be unavailable to enter all the data from old paper charts. Although solutions are being developed to solve some of these problems, it will take time to reach the ultimate goal.
Information is power. The extensive clinical background of the IN/INS is invaluable to the success of the implementation of the hardware and software applications needed to transform health care. Nurses have a unique understanding of workflow, the hospital and clinical environment, and the specific procedures that are necessary for effective health care information infrastructure. Moreover, the IN/INS is critical to the translation of standard information into practical models that can be applied to improve the health care work environment (Delany, 2004).
The 2009 Healthcare Information Management Systems Society (HIMSS) Informatics Nurse Impact Survey asked organizational leaders to provide input on the roles and impact of informatics nurses in their organizations. Organizations responding included hospital or health systems (75%), vendor or consulting firms (11%), and other organizations such as home health, ambulatory care facilities, and academic or government facilities. Nearly all respondents noted that informatics nurses play a significant role in user education. Informatics nurses are also widely involved in workflow analysis, patient safety, compliance with policies and regulations, quality outcomes, system implementation, user support, workflow analysis, and gaining buy-in from end users (HIMSS, 2015). In short, the focus of nursing informatics is to improve patient care with health care technology that encourages clinicians to make more accurate and timely decisions.
So how does one become an expert in this unique field of nursing? What does a nurse specializing in nursing informatics do on a daily basis? And how does informatics impact the work of a clinical nurse?
Experience and Education
In the past, many nurses in informatics roles did not have formal education beyond their nursing preparation. They were “recruited” by their employers to help build and implement an electronic medical record application. These nurses learned as they went along, and advanced degrees were not required. However, this is no longer true. According to the 2011 HIMSS Nursing Informatics Workforce Survey, “Fifteen percent have received on-the-job training and more than half of the 2011 respondents reported having a postgraduate degree (56 percent), which includes Masters in Nursing or other field/specialty and PhD in Nursing or other field/specialty.”
Informatics nurses who want to hold leadership roles in nursing informatics will need graduate-level preparation. A student who held a leadership role in NI and was enrolled in a nursing informatics master’s program once said that she thought she knew all about nursing informatics, but she learned that she only knew about it at her own organizational level. Her graduate-school education had broadened her perspectives and introduced her to new concepts and ways of thinking (C. Parker, 2011, personal communication).
Role of the IN/INS
The IN/INS must have a basic knowledge of how computers and networks work as well as an understanding of system analysis, design principles, and information management. It is important for the IN/INS to converse with both the clinical staff and the technology staff regarding hardware, software, communications, data representation, and security. An IN/INS will be comfortable with software and hardware implementation, training, testing, presenting, and facilitating knowledge (Critical Thinking Box 23.1). During the publication of this textbook, the majority of IN/INSs are working with EMR/EHR development and implementations. Typical job responsibilities consist of (1) product evaluation; (2) system implementation, including preparing users, training, and providing support; (3) system development and quality initiatives, including system evaluations/problem solving and quality improvement/patient safety; and (4) other duties as assigned (HIMSS 2011 Nursing Informatics Workforce Survey, 2015).
CRITICAL THINKING BOX 23.1
What has been your experience and exposure to the use of technology in the hospital? Your school? At home? Think of ways to become more familiar with the use of computers and other technology.
But not all nurses in IN/INS roles work on implementation of the EMR/EHR. Some work for health care product vendors in both the hardware and software areas. They help to inform the next generation of existing products, and they work with engineers/design teams to create new products, always bringing the patient care viewpoint and the needs of the end user to the design process. Others work for consulting firms and specialize in workflow improvement using technology, whereas still others work for government, third-party payers, and educational institutions (HIMSS Nursing Informatics Workforce Survey, 2015). The variety is seemingly endless.
The Certification Process
In 1994, the American Nursing Credentialing Center (ANCC) provided a method for nurses to become certified in this specialty. The baccalaureate degree is the minimum requirement needed to take the certification exam. Nurses can obtain RN-BC certification in informatics nursing through the ANCC.
Professional Practice, Trends, and Issues
What Are Regulatory and Accreditation Requirements?
Although there are many regulatory and governmental agencies instituting health care policy, the Health Insurance Portability and Accountability Act (HIPAA) and The Joint Commission (TJC) impact the daily work of every clinician and organization. The nurse must have a clear understanding both of HIPAA regulations and of TJC requirements to be able to provide safe nursing care.
Privacy and Confidentiality
Every health care organization has a responsibility to itself, to its patients, and to the community at large to have good control of its information systems. Because the internal workings of health care rely on accurate and current data and information, personal data about employees and patients must be kept safe and confidential. A corporate security plan is important to an organization.
Maintaining confidentiality implies a trust of the individuals who handle that data and information. These health care workers ensure the privacy of this information and use it only for the purpose for which it was disclosed.
Security policies must be explicit and well defined. Confidentiality agreements should be reviewed and signed when starting employment and yearly thereafter. Breaches of security, confidentiality, or privacy should be addressed and resolved quickly, and the offender should be charged accordingly. Every lapse should be treated openly and made an example for others to note. The informatics nurse may be involved in the investigation process and the writing of the policies and procedures.
In 1996, the HIPAA was signed into law. The law defines standards that were developed to ensure that health care organizations collect the right data in a common format so that the data can be shared, as well as protect the privacy and security of patient data (Simpson, 2001). The major impact from this regulatory legislation is in these areas:
▪ Health information privacy law
▪ Data security standards
▪ Electronic transaction standards
Among many requirements, health care entities must adopt written privacy policies and procedures that define how they intend to abide by the highly complex regulations and how they will protect individually identifiable health information. Each health care organization must ensure that all staff members who have access to patient information have an understanding of the consequences of noncompliance (Gale Group, 2001).
In 1998, it was proposed that all health plans, health plan providers, and health care clearinghouses that maintain or transmit health information electronically be required to establish and maintain responsible and appropriate safeguards to ensure the integrity and confidentiality of the information. Although this seems logical, it is a very difficult and time-consuming task when using automated systems that did not previously meet these requirements (Critical Thinking Box 23.2).
CRITICAL THINKING BOX 23.2
How have your clinical facility and/or school made changes to accommodate the Health Insurance Portability and Accountability Act (HIPAA) requirements?
The year 2013 brought another wave of “sweeping change” to the HIPAA Privacy, Security, Enforcement and Breach Notification Rules according to Leon Rodriguez, director of the HHS Office for Civil Rights. HHS Secretary Kathleen Sebelius stated, “The new rule will help protect patient privacy and safeguard patients’ health information in an ever expanding digital age.” According to the January 17, 2013, press release issued by the U.S. Department of Health and Human Services:
The changes in the final rulemaking provide the public with increased protection and control of personal health information. The HIPAA Privacy and Security Rules have focused on health care providers, health plans and other entities that process health insurance claims. The changes announced today expand many of the requirements to business associates of these entities that receive protected health information, such as contractors and subcontractors. Some of the largest breaches reported to HHS have involved business associates. Penalties are increased for noncompliance based on the level of negligence, with a maximum penalty of $1.5 million per violation. The changes also strengthen the Health Information Technology for Economic and Clinical Health (HITECH) Breach Notification requirements by clarifying when breaches of unsecured health information must be reported to HHS.
Individual rights are expanded in important ways. Patients can ask for a copy of their electronic medical record in an electronic form. When individuals pay by cash they can instruct their provider not to share information about their treatment with their health plan. The final omnibus rule sets new limits on how information is used and disclosed for marketing and fundraising purposes and prohibits the sale of an individual’s health information without their permission.
The final rule also reduces burden by streamlining individuals’ ability to authorize the use of their health information for research purposes. The rule makes it easier for parents and others to give permission to share proof of a child’s immunization with a school and gives covered entities and business associates up to one year after the 180-day compliance date to modify contracts to comply with the rule. (U.S. Department of Health & Human Services, 2013a)
Violation of HIPAA standards is no laughing matter. Violations of health information privacy can lead to termination of employment and even indictment and prison time. In 2010, a former researcher at the UCLA School of Medicine was sentenced to 4 months in federal prison and was fined $2000 for violations of the HIPAA privacy rule. He accessed 323 confidential patient records, including celebrities Drew Barrymore, Arnold Schwarzenegger, Tom Hanks, and Leonardo DiCaprio, without a valid reason or authorization but without profiting from it through the sale or use of the information (Dimick, 2010). If a data breach affects more than 500 individuals, Section 13402 (e) (4) of the HITECH Act requires that the secretary of the U.S. Department of Health and Human Services post notification of the covered entity on the HHS website found at www.hhs.gov/hipaa/for-professionals/breach-notification/index.html.
HIPAA and the Use of Mobile Computing Devices
Knox and Smith (2007) encourage everyone to think about patient privacy and HIPAA compliance in the clinical area, especially because of the growing use of laptops, tablet PCs, and cell/smartphones that take pictures and record videos (Critical Thinking Box 23.3). According to a research study by Ponemon Institute (2014) on patient privacy and data security, top threats to patient records are the Affordable Care Act, criminal attacks, employee negligence regarding unsecured mobile devices (smartphones, laptops, and tablets), and third parties.
CRITICAL THINKING BOX 23.3
Do you know your clinical facility’s policies on cell phone/smartphone use in patient care areas? How about picture taking, Internet use, Internet access policy, information security access, and user-ID/password agreement?
You can violate an organization’s HIPAA policies and not even realize it!
The influx of new mobile computing technology, such as tablet computers or smartphones, is creating new implications for protection of privacy and security. How to protect confidential information is something that we learn at the beginning of our nursing careers; however, protecting that same information on a mobile device may not be so easily understood. The following is a list of some simple precautions to take to help secure patient information that may be stored on a mobile device. These recommendations should be followed as standard practice.
▪ Keep careful physical control of the device at all times.
▪ Use a password or other user authentication and a time-out to reactivate the authentication.
▪ Install and enable encryption.
▪ Install and activate remote wiping and/or remote disabling.
▪ Disable and do not install or use file-sharing applications.
▪ Disable the infrared ports and Wi-Fi except when they are actually being used.
▪ Do not send infrared or Wi-Fi transmissions in public locations.
▪ Keep your security software up-to-date.
▪ Research mobile applications (apps) before downloading.
▪ Use adequate security to send or receive health information using public Wi-Fi networks.
With the use of new technologies there is potential to improve patient safety and outcome, as well as to reduce potential injury; however, at the same time there is an increased risk for exposing confidential patient information. A cautionary approach along with assuming the responsibility for safeguarding the confidentiality of information should be used if you download patient information into a mobile device.
The Joint Commission
TJC wrote the information management (IM) standards in the mid-1990s. The 10 standards outline the need for information management regulation (Clark, 2004). Since that time, information management has been woven throughout the various standards and the National Patient Safety Goals. An example of this is noted in Standard IM.02.01.03 of the revised requirements for the Laboratory Accreditation Program, where the lab must have a “written policy addressing the integrity of health information against loss, damage, unauthorized alteration, unintentional change, and accidental destruction” (The Joint Commission, 2012, p. 1).
TJC sends out a team of experts for a review of every health care organization that wishes to be certified. This team inspects and reviews a variety of areas within each organization. The IN/INS may be called on to lead the effort for preparing for a TJC visit and for maintaining ongoing compliance (Critical Thinking Box 23.4).
CRITICAL THINKING BOX 23.4
Have you had the opportunity to be in clinical during a visit by The Joint Commission? If so, what did you observe? How was the staff prepared for the visit?
Models and Theories
Nomenclature, Classification, and Taxonomy
The quote from Dr. Lang at the beginning of the chapter has never been truer. Traditionally, nurses documented care using personal preference, unit standards, or facility policy. Standardized nursing languages, sometimes called nomenclatures, offer a recognized, systematic classification and consistent method of describing nursing practice. Nomenclatures act as descriptors or labels; classifications are group or class entities; and taxonomy is the study of the classifications.
In 1995, the ANA approved the establishment of the Nursing Information and Data Set Evaluation Center (NIDSEC) to review, evaluate against defined criteria, and recognize information systems from developers and manufacturers who support documentation of nursing care within automated nursing information systems (NISs) or within computer-based patient record systems (CPR). They recognized the following 12 nursing practice classification systems (ANA, 2012). Note that the Patient Care Data Set (PCDS) was retired in 2003.
1. North American Nursing Diagnosis Association International (NANDA) Nursing Diagnoses, Definitions, and Classification
2. Nursing Interventions Classification System (NIC)
3. Nursing Outcomes Classification System (NOC)
4. Nursing Management Minimum Data Set (NMMDS)
5. Clinical Care Classification (CCC) (formerly Home Health Care Classification [HHCC])
6. Omaha System
7. Perioperative Nursing Dataset (PNDS)
8. SNOMED CT
9. Nursing Minimum Data Set (NMDS)
10. International Classification of Nursing Practice (ICNP)
11. ABC codes
12. Logical Observation Identifier Names and Codes (LOINC)
If the unique nomenclature of these classification systems is used consistently, gathered data elements can be captured, stored, and manipulated accurately in the electronic medical record. Without a common language, data cannot be aggregated into useful language (Simpson, 2000). The need for consistency causes problems for software vendors as they attempt to produce unique and robust software packages that still use the recognized labels and groupings of nursing practice elements. So what happens?
Currently, each software vendor uses a unique, possibly patented naming convention for their specific functionality and then must “explain and define” these names and labels in their literature or presentations by relating them back to recognized nursing practice or data elements. This causes confusion to the user community.
Learning about and working with standardized nursing languages will ensure nursing contributions are an integral part of any electronic medical record. Understanding those contributions through research and teaching will help to define further the scope of nursing practice. Until complete standardization occurs, nurses must be prepared to use different classification systems at different facilities or even with systems from different vendors within a single facility (Critical Thinking Box 23.5).
CRITICAL THINKING BOX 23.5
What has been your experience or exposure to these different standard nursing languages? What does your clinical agency use?
Although there multiple theories that are applicable to nursing informatics practice, the three most common are
▪ General Systems Theory—This theory organizes interdependent parts working together to produce a product that none used alone could produce. Key elements are input, process, output, control, and feedback.
▪ Rogers’ Diffusion of Innovation Theory—A 5-step process of an individual’s decision to adopt an innovation includes knowledge, persuasion, decision, implementation, and confirmation (Rogers, 2003).
▪ Change Theory—Kurt Lewin’s change theory is discussed in Chapter 10.
Clinical Information Systems
Every day, nurses encounter technology, and this technology is changing the ways that health care is delivered in the hospital, physician’s office, or the patient’s home. Clinical information systems (CISs) have replaced pencil and paper charting. Florence Nightingale expressed a desire for medical records that were standardized, organized, and legible, and these goals are equally valid today.
In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any comparison.
Florence Nightingale (Notes on a Hospital, 1873)
A 2001 Institute of Medicine (IOM) report, Crossing the Quality Chasm: A New Health System for the 21st Century, identified the development and application of CISs as essential for health care to be able to leverage state-of-the-art technology to deliver the highest quality, lowest cost patient care.
The e-World Is Coming … Wait, It’s Here
Although most “e-words” come from the commerce or business sector, the term is generally understood, despite its lack of precise definition, because of the dynamic environment of the Internet. E-health has come to characterize not only a technical development but also a state of mind, a way of thinking that focuses on improvement of health care via information and communication technology.
The World Health Organization (WHO) provides the following definition: “eHealth is the cost-effective and secure use of information and communications technologies for health and health-related fields” (WHO, 2016). WHO (2016) goes on to define mHealth as “a component of eHealth, and involves the provision of health services and information via mobile technologies, such as mobile phones, tablet computers and Personal Digital Assistants (PDAs).” However, despite its appearance in 2000, by 2015 there is no single consensus definition nor is it included in MeSH taxonomy (www.nlm.nih.gov/mesh/MBrowser.html).
Eysenbach (2001) feels that it stands not only for “electronic” but implies a lot of other e’s, which he feels represent what e-health is all about (Box 23.1). He states that it should also be easy to use, entertaining, exciting, and most of all, it should exist (Critical Thinking Box 23.6)!
BOX 23.1THE 10 E’s IN “E-Health”
1. Efficiency leading to decreasing costs by avoiding duplicate or unnecessary diagnostic or therapeutic interventions, through enhanced communication possibilities among health care establishments, and through patient involvement.
2. Enhancing quality of care by allowing comparisons among different providers, involving consumers as additional power for quality assurance, and directing patient streams to the best quality providers.
3. Evidence-based intervention effectiveness and efficiency should not be assumed but proven by rigorous scientific evaluation.
4. Empowerment of consumers and patients by making the knowledge bases of medicine and personal electronic records accessible to consumers over the Internet; e-health opens new avenues for patient-centered medicine and enables evidence-based patient choice.
5. Encouragement of a new relationship between the patient and health professional, toward a true partnership where decisions are made in a shared manner.
6. Education of physicians and health care providers through online sources (continuing education) and consumers (health education, tailored preventive information for consumers).
7. Enabling information exchange and communication in a standardized way among health care establishments.
8. Extending the scope of health care beyond its conventional boundaries.
9. Ethics e-health involves new forms of patient–physician interaction and poses new challenges and threats to ethical issues such as online professional practice, informed consent, privacy, and equity issues.
10. Equity to make health care more equitable is one of the promises of e-health, but at the same time there is a considerable threat that e-health may deepen the gap between the “haves” and “have nots,” deepening the “digital divide”.
A June 2009 survey from the Pew Internet & American Life Project estimates that 61% of American adults surf the Web for health information. How have you (or your family) used the Internet for your own health or medical care? What about your patients? How will you help them use the Internet to better their understanding of their health?
Electronic Medical Record and Electronic Health Record
There is still some debate about whether an electronic health record (EHR) and an electronic medical record (EMR) are the same or different. HealthIT.gov defines EMR as “a digital version of the paper charts…. An EMR contains the medical and treatment history of the patients in that office, clinic or hospital” (HealthIT.gov, 2015, para 1).
They go on to describe an EHR as all that and more. EHRs focus on the total health of the patient—going beyond standard clinical data collected in a single event such as a provider’s visit or hospitalization. They provide a broader view on a patient’s care. EHRs are designed to reach out beyond the health organization that originally collects and compiles the information. They are built to share information with other health care providers so they contain information from all the clinicians involved in the patient’s care (HealthIT.gov, 2015, para 2).
Figs. 23.2 and 23.3 illustrate screenshots from a patient’s EMR.
For example, a patient is seen in a primary care provider (PCP) office for complaints of indigestion. The PCP completes a history and physical, does an ECG and basic lab studies. All data are in the computer at the office comprising one EMR for that patient. The patient is sent home with instructions. Later that evening, the patient feels worse and goes to the emergency department (ED). Using standalone EMRs, the following would occur: because it is after hours, the data in the patient’s EMR at the PCP office are not available. A new EMR is begun. The next day the PCP would have no idea that the patient was seen in the ED.
Using an integrated EHR, the ED would be able to access the information from the PCP’s system, and the next day the PCP would be notified that the patient was seen in ED and would have access to all the data collected during the ED visit.
Advantages of the EHR are listed in Box 23.2. This patient-centric approach to documentation of care is becoming the new standard of care.