Nursing Informatics

Past, Present and Future

Introduction

There are several parallels in health care. As health care and nursing practice have evolved, the computer has become the most powerful tool to transform the nursing profession in the past century (Saba & Erdley, 2006). The computer, or in more general terms, information technology (IT), is used in nursing to manage data in patient care, education, administration and research.

This article will provide some brief highlights of the role nursing informatics has and will play in improving the quality of health care through information management.

Definitions of Nursing Informatics

Informatics is essentially the science and art of turning data into information (Hebda, Czar & Mascara, 2005). The term informatics can be traced back to a Russian document published in 1968 and was derived from the French term informatique, referring to “the computer milieu” (Saba, 2001, p. 177).

In the 1970’s and early 1980’s, nursing informatics was broadly defined as the use of computer technology to support all aspects of nursing practice, and it was frequently confused with computer literacy skills of the nurse (Hebda, et al, 2005).

In 1996, Turley introduced a model that accurately illustrates the intersection of the sciences that contribute to nursing informatics, adding cognitive science to Graves and Corcoran’s definition to include such topics as problem-solving, memory, language processing, mental models and visual attention (see Figure 2).

More than three decades have passed since the inception of the term informatics, and the definitions continue to be modified slightly to adjust for continuing advances in practice and technologies. However, there is general agreement that informatics is focused more on the information than on the technology (Hersh, 2009).

The Canadian Nursing Informatics Association acknowledges Staggers and Bagley-Thompson’s 2002 definition of nursing informatics:

History of Nursing Informatics

Florence Nightingale has been recognized as an early informatics nurse because of her use of data to inform knowledge and change nursing practices. In 1863 she wrote:

Nightingale was clear in her desire to collect, retrieve and analyze data to be able to recognize trends in illnesses and treatments to improve the quality of care. It would take another century before nurses would begin to realize the benefits of integrating computer systems into their practice.

1950s and 1960s

During the 1950s and 1960s many significant changes were underway for the health care industry and for the nursing profession. The image of nurses was improving, nursing practices were growing in scope and complexity and nurses were expanding in number, although by the mid 60s nursing resources and allocation started to be analyzed.

Health care facilities increased in number and the nurses’ station started to be considered the centre of communication activities and information exchange. As computer technologies advanced with the development of real-time processing and desktop terminals, research was conducted to determine how computers could be used most effectively in health care.

During this time period, computers were used primarily in health care facilities for basic business, financial and accounting operations. Progress in developing clinically-based applications continued to be slow (Saba, 2001; Saba & Erdley, 2006; Staggers, Bagley-Thompson & Snyder-Halpern, 2001).

1970s

American health care facilities were required to report statistics to local, state or federal governmental agencies, as well as third party payers to ensure program funding or reimbursements were accurately captured. Nursing staff began to recognize the value of integrating computer applications into their practices and processes, particularly for documenting care and the evaluation of the care delivered; as well as automating specific functions such as staff scheduling or statistics collection. Nurses became instrumental in the development of nursing applications for hospital information systems (Hannah et al, 2006; Saba & Erdley, 2006).

1980s

The advent of the PCs with significantly improved computing power made computers more accessible, affordable and user-friendly for nursing and other health care professionals. Hospital information systems were increasing in functionality and use.

Nursing informatics became a recognized specialty in the US and experts in the field were beginning to emerge – with job titles such as informatics nurse or nurse informatician. As computer systems were implemented in health care facilities, the need for nursing-specific software became increasingly evident – to document aspects of care including lab results, vital signs, nurses’ notes and discharge plans.

1990s and beyond

The technology revolution that was impacting all aspects of life did not leave health care untouched. Computers became smaller, faster and easier to use. The internet became a tool for web-based clinical applications, communication and access to evidence-based resources. Wireless technologies made it simpler for nursing and other health care professionals to access applications at the point-of-care – where the patient was (Saba & Erdley, 2006).

In the past two decades nurses have become more recognized as knowledge workers (Bickford & Hunter, 2006), with the emphasis of nursing work being more on knowledge than on tasks. Knowledge work is non-repetitive, non routine work that entails substantial levels of cognitive activity, involves analyzing information and applying specialized expertise to solve problems and generate ideas. (Kenney & Androwich, 2009). Nurses as knowledge workers are data gatherers, information users, knowledge users and knowledge builders (Snyder-Halpern et al, 2001 as cited in Hebda et al, 2005, p. 7). Informatics, through the use of computers, assists nurses as knowledge workers within their four domains of practice:

Nursing Practice Domain Applications:

Nursing practice is now an integral component of the electronic health record system alongside the documentation of other health care professionals. Systems are used to document assessments and interventions, and to measure the outcomes of care.

• Computer-generated nursing care plans that are frequently embedded within inter-professional plans of care
• Clinical decision-making alerts/prompts that provide indications for the nurse to avoid specific interventions or actions with the patient
• Electronic monitoring devices that record and trend vital signs, as well as alert the nurse to patient conditions that fall outside of acceptable parameters
• Patient-specific discharge instructions to assist the patient to provide self-care once home
• Online evidence-based nursing resources – e.g. information about administering medications (CNA, 2001;Hebda et al, 2005; Saba, 2001; Saba & Erdley, 2006)

Nursing Administration Domain Applications:

Nursing managers and administrators are required to report on any number of indicators and statistics within their departments, and use IT extensively for planning resources and budgeting that drives patient services. Departments of Nursing are responsible for providing leadership and consistent standards of practice.

• Workload measurement systems that collect statistics for internal and external reporting requirements
• Online computer policy and procedure manuals that guide organizational practices
• Staff scheduling systems that either automate schedules or allow for self-scheduling through rules-based protocols
• Internal email and/or systems for improved communication
• Cost analysis of specific patient populations
• Patient tracking systems to ensure timely movement through the health care facility (CNA, 2001; Hebda et al, 2005; Saba, 2001; Saba & Erdley, 2006)

Nursing Education Domain Applications:

Computer applications have almost revolutionized the educational process (Riley, 1996 as cited in Saba, 2001, p 183). A variety of media are used to educate nursing students in universities or colleges, and staff nurses who require ongoing professional development to stay current with changes in practices and processes.

• Online registration, scheduling, attendance tracking, test administration and grade management of courses through learning management systems
• Computer-based tutorials that enhance or replace didactic lectures
• Remote access to libraries or online publications
• Presentation software
• Webcasting capabilities and other distance education technologies to share knowledge between centres
• Computer labs or resource centres
• Simulation labs with lifelike mannequins that mimic real patient scenarios and respond to nurses’ interventions and actions (CNA, 2001;Hebda et al, 2005; Saba, 2001; Saba & Erdley, 2006)

Nursing Research Domain Applications:

Nurse researchers are experts at gathering, analyzing and using data to inform practice and improve patient outcomes.

• Computerized literature searches
• Software that processes quantitative and qualitative information to find trends in data
• Collaboration with other nurse researchers
• Evaluation of nurse-sensitive outcomes (CNA, 2001; Hebda et al, 2005; Saba, 2001; Saba & Erdley, 2006)

Current Issues in Nursing Informatics

Electronic Health Record

In 1974 Marc Lalonde indicated in his landmark report: “there is a lack of a uniform and integrated system for maintaining health records of individuals; essential data are scattered in many locations: in physicians’ offices, hospital records, clinics, etc.” (p. 28).

In 2002, Roy Romanow wrote: “to take full advantage of the potential of information, evidence and ideas in the health care system, the necessary information infrastructure must be in place” (p. 76). In support of his recommendation for Canada Health Infoway to implement an electronic health information base, Romanow indicated: “Electronic health records are one of the keys to modernizing Canada’s health system and improving access and outcomes for Canadians.” (p. 77).

For more than 30 years Canadians have been anticipating the implementation of a pan-Canadian electronic health record – the documented health status of an individual or the health care provided to an individual (Fischetti & Deering, 2006). Canada Health Infoway’s vision is “better care through timely access to secure health information when and where needed” (Canada Health Infoway, 2009). Their primary mandate is to contribute to the development and adoption of electronic health records through setting health information and communication standards that build off existing electronic health record system initiatives (Wieners et al, 2006).

Patient Safety

Patient safety has been at the forefront of quality indicators and hospital accreditation surveys since the landmark publications:

a) To Err is Human: Building a Safer Health System (Corrigan, Kohn & Donaldson, 1999)

b) Crossing the Quality Chasm: A New Health System for the 21st Century (Institute of Medicine, 2001)

c) The Canadian Adverse Events Study: The Incidence of Adverse Events Among Hospital Patients in Canada (Baker et al, 2004).

These studies revealed that adverse events (injuries caused through medical management) occurred in between 2.9 and 7.5 % of American and Canadian hospital admissions. Recommendations have consistently called for adoption of information technologies to assist with the reduction of adverse events (Hebda et al, 2005; Gassert, 2006; Duke & Bowers, 2006). Electronic health records (EHR) allow for timely access to patient data, whenever and wherever needed. Computerized provider order entry (CPOE) requires the physician or other regulated health care professional to enter orders directly into the computer system to prevent the errors associated with hand-written orders (illegibility, inaccurate abbreviations). Clinical decision support software provides dose calculations and warns the prescriber of any patient drug allergies, drug:drug interactions, drug contraindications and can provide relevant lab results that may impact medication administration. Most CPOE systems include an electronic medication administration record – the direct transcription of the medication order onto an electronic nursing record, resulting in the elimination of errors that result from nurses manually transcribing medication orders onto a paper record. Bar coding technologies provide nurses a mechanism to match a unique bar code on a patient’s ID band to an ordered medication prior to the administration. If the match is not verified by the system (the medication is incorrect, too little time has elapsed since the last dose), an alert is triggered prompting the nurse to not administer the dose and to check the orders.

Nurses are present in every health practice setting and are knowledgeable about patient care processes and workflows of members of the health care team. Nurses practicing in all four domains of nursing practice, as well as nurses in informatics roles, play key roles in the design, development, implementation and evaluation of the clinical information systems that incorporate patient safety software and form the electronic health record (Nagle & Shaw, 2006; Bickford, 2006).

What does the Future Hold?

The past three decades have brought unprecedented advancements in the use of technology throughout the world, and the impact on health care has been monumental. Nurses have incorporated tools into their daily work that have transformed the way they practice. Continued evolution and innovation in technology development will naturally influence further advancements in health care IT and nursing informatics. The coming decades will bring technologies that will focus on providing nurses greater access to information where and when they need it (Ball, 2000). The following are likely sound assumptions for the future of health care IT and informatics:

• The quantity of electronic resources will multiply significantly, with mobile devices becoming increasingly powerful..
• The variety of devices will increase to meet the diverse needs of the four domains of practice, in all roles and settings that nurses work in.
• Clinical decision support software will become increasingly sophisticated, recognizing when automatically documented patient assessments fall outside of normal ranges, prompting automatic communication to the nurse or physician via email, texting or paging – e.g. an abnormal blood result from the lab initiates a text message to the nurse identifying the patient, the abnormal result and the impact on any current interventions or aspects of care.
• Smart cards that authenticate the user’s identity (through close proximity to a reader) will be popular for nurses and other health care providers, allowing quick access to computers and all required computer applications.
• Increasingly life-like simulation and the use of virtual reality for educating students and staff.
• Developments in telecommunications and telehealth will allow for more sophisticated distance patient visits that will save practitioners time and improve care for housebound patients.
• Bioinformatics will continue to unravel information related to gene functions and will help to uncover individual gene therapies that nurses will readily apply to their patients.
• Speech recognition will improve dramatically, providing opportunities for health care providers to dictate to a system, which will accurately document in the patient’s record – saving significant amounts of time.
• Consumers of health care will demand more online health care services, as they expect from their banks and other service industries. Patients will have personal health records, have the ability to schedule their own appointments, retrieve test results with some associated analysis, communicate with their health care practitioner without having to leave the house, participate in social network forums that provide a supportive element through sharing, and have at their fingertips personalized health information that assists with self-management. (Ball, 2000; McCormick, 2006, Sensmeier, 2006).

Conclusion

Nursing is influenced by environmental, political, economic and professional forces, while changes in health care needs are influenced by emerging concepts of health and illness, advancements in science, patterns of disease, demographic configurations and the ever-increasing ability to meet those needs through new technologies and knowledge. Technologies allow for the collection, use, storage, distribution and mining of information that is essential for clinical care, research, health services administration and education. As our health care environment becomes increasingly data-rich nursing informatics will continue to be the science and art that translates the data into information that contributes to new nursing knowledge and ultimately improves and enhances the quality of patient care.

Update

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This presentations only scratchd the surface in identifying current issues being faced in nursing informatics. What other issues do you think are current priorities that are being addressed or need to be addressed in nursing informatics? - Helen Edwards