Medicine

Nursing profession as new graduate nurses

Nursing profession as new graduate nurses

Computers, Informatics, Clinical Information, and the Professional Nurse

NURSING INFORMATICS

The prevalence of computers in society has made it imperative for nurses to integrate the use of computers into professional practice. Because it is no longer an option, nurses must make good use of computer technology to work toward the goal of improved patient care and positive patient outcomes. Students, clinical nurses, educators, researchers, and administrators are all benefiting from computer technology. Students are using word processing programs to prepare course assignments and accessing course assignments via the Internet; they also learn nursing skills using computer-assisted instruction (CAI) programs. Educators use computers to post course assignments for access via the Internet and to prepare audiovisual materials for class presentations, papers for publication, and posters for display at professional conferences. Administrators plan their budgets with spreadsheet programs to manage costs for sound financial management. Researchers are collecting data via the Internet and then analyzing the data with statistics programs. Nurses in clinical settings retrieve patient data, document their interventions, and view laboratory and other results through electronic patient records. These are just a few examples of how computers and their associated technology are influencing nursing practice.

 Although all nurses are involved with computers to some degree, there are nurses who have chosen to specialize in the area of nursing practice that relates to computers. This field is known as nursing informatics. This is a new specialty within the profession of nursing. It is only within the past 10 years that it has been named, recognized as a specialty, and defined by the nursing profession. Academic programs to prepare nurses with expertise in informatics have been established; the American Nurses Credentialing Center (ANCC) has developed a certification examination to allow nurses who demonstrate beginning levels of competency to be certified as an informatics nurse (IN) (Gassert, 2000; Newbold, 1996). There is tremendous potential for nurses within this specialty to have a major impact on the way care is planned and delivered in the current tumultuous health care environment.

What Is Nursing Informatics?

Informatics was coined from the French word informatique. It was first defined by Gorn (1983) as computer science plus information science. Informatics is more than just computers—it includes all aspects of technology and science, from the theoretic to the applied. Learning how to use new tools and building on capabilities provided by computers and related information technologies also are important parts of the field of informatics (Ball, Hannah, and Douglas, 2000).

Nursing informatics refers to that component of informatics designed for and relevant to nurses. Several definitions of nursing informatics have been developed since 1984, but the one that generally is accepted has been set forth by the American Nurses Association (ANA), which states:

Nursing informatics is the specialty that integrates nursing science, computer science, and information science in identifying, collecting, processing, and managing data and information to support nursing practice, administration, education, research, and the expansion of nursing knowledge (ANA, 1994).

Embedded in this definition are the many components of nursing informatics: information processing, language development, applications of the system's life cycle, and human computer interface issues. In addition, the definition provides guidance for content that is relevant to curricula for nurses studying to become informatics specialists (Gassert, 2000).

The Specialty of Nursing Informatics

There are many specialties in nursing that cover a range of interests and clinical domains, such as perioperative nursing, community health nursing, and administration. What makes a practice area a specialty? According to Styles (1989) the following attributes are necessary.

 • Differentiated practice

• A research program

• Representation of the specialty by at least one organized body

• A mechanism for credentialing nurses in the specialty

• Educational programs for preparing nurses to practice in the specialty In 1992 the ANA acknowledged that nursing informatics possessed these attributes and designated nursing informatics as an area of specialty practice.

Differentiated Practice. For more than two decades nurses have been working in hospitals and other settings to help with the selection, development, installation, and evaluation of information systems. This early role function of the IN continues to be important, but with the constant changes in health care, the scope of practice has expanded, and job opportunities are increasing rapidly. Hersher (2000) describes several current and future roles for nurses in informatics, both traditional and nontraditional. Some of these include:

• User liaison: A nurse in this role is involved in the installation of a CIS and interfaces with the system vendors, the users, and management of the health care institution. Generally the nurse working in this role is employed by the health care institution.

• Clinical systems installation: In this role the nurse works for the vendor who has developed and sold the CIS to a health care institution. The nurse-installer helps train the users of the system and troubleshoots problems during the conversion to the new system. The nurse-installer often serves as the liaison between the health care institution and the vendor and in most cases works closely with the system coordinator for the health care institution, who may very well be a nurse.

• Product manager: A nurse in this role is responsible for constantly updating a current product and keeping abreast of new developments in the field. Product managers interface with marketing staff, clients, technical staff, and management. Applications that nurse product managers have developed include decision-support systems, nurse staffing systems, scheduling systems, acuity systems, and bedside and handheld terminals. Although product managers typically have been employed by vendors, many health care institutions are starting to develop this role.

• Systems analyst/programmer: In this role the nurse works in the information systems department, helping analyze and maintain the system or programming. To be effective in this role, the nurse needs a strong working knowledge of the CIS. In many cases the nurse will work on all aspects of the CIS, not just the nursing applications.

These are just a few examples of the types of roles nurses in informatics are filling. Other examples that Hersher (2000) describes include chief information officer, consultant, network administrator, data repository specialist, and clinical information liaison. Settings also vary, as nurses move from the hospital-based acute care sites to community-based sites that include insurance companies, utilization review organizations, integrated health networks, and health care associations. Clearly nurses working in informatics have met the criterion of differentiated practice.

Research Program. In 1986 Schwirian proposed a framework for research in nursing informatics. At that time research in the field was practically nonexistent. Since then, however, there has been rapid development; researchers have reported their studies at national and international conferences and published in a variety of peer-reviewed journals. In nursing the peer-reviewed journal Computers in Nursing serves as the premier source of published research in nursing informatics, as it has since its inception in 1984.

The National Institute of Nursing Research (NINR) has provided direction for much of the research that is ongoing in nursing; informatics is no exception. In 1988 a panel of experts was convened to establish broad priorities for the NINR; this ultimately led to the development of the National Nursing Research Agenda (NNRA). Seven specific broad priorities were identified within the NNRA, with number six being "Information Systems." Subsequent Priority Expert Panels were called together to further develop each priority area and make recommendations for future research. The Priority Expert Panel on Nursing Informatics published the results of its deliberations in Nursing Informatics: Enhancing Patient Care in 1993 (NINR, 1993). The six goals identified by the panel included:

1. Establish nursing languages, including lexicons, classification systems and taxonomies, and standards for nursing data.

2. Develop methods to build databases of clinical information (including clinical data, diagnoses, objectives, interventions, and outcomes) and management information (including staffing, charge capture, turnover, and vacancy rates) and analyze relationships among them.

3. Determine how nurses use data, information, and knowledge to give patient care and how care is affected by differing levels of expertise and by organizational factors and working conditions. Determine how to design information systems accordingly.

4. Develop and test patient care decision support systems and knowledge delivery systems that are appropriate for nurses' needs, with consideration for expertise, organizational factors, and working conditions.

5. Develop prototypes and eventually working models of nurse workstations equipped with tools to provide nurses with all the information needed for patient care, research, and education at the point of use and linked to an integrated information system.

6. Develop and implement appropriate methods to evaluate nursing information systems and applications, particularly as to their effects on patient care (NINR, 1993).

Research is ongoing in each of these priority areas. In particular, great strides have been made in the area of developing and testing standardized languages. Both the ANA and the National League for Nursing (NLN) have provided leadership and support for these efforts. In addition, the ANA has established criteria for recognizing nursing classifications and standardized nursing languages. These criteria are promulgated through the ANA Committee for Nursing Practice Information Infrastructure, which recognizes languages that have met the criteria. Currently there are 12 standardized languages that have been recognized by the ANA, including:

·       North American Nursing Diagnosis Association (NANDA) Taxonomy

·       Omaha System

·       Home Health Care Classification

·       Nursing Interventions Classification (NIC)

·       Nursing Outcomes Classification (NOC)

·       Patient Care Data Set (PCDS)

·       Perioperative Nursing Data Set (PNDS)

·       Nursing Management Minimum Data Set (NMMDS)

·       SNOMED RT

·       Nursing Minimum Data Set (NMDS)

·       International Classification for Nursing Practice (ICNP)

·       Alternative Link

These 12 languages were uniquely developed to document nursing care. They were designed to record and track the clinical care process for an entire episode of care for patients in the acute, home, and/or ambulatory care settings (ANA, 2000). Research is underway to continue to test and refine the languages so that they fulfill their stated goal of capturing nursing practice to promote positive patient outcomes.

Representation of the Specialty by an Organized Body. There are many organizations devoted to nursing informatics at the local, regional, national, international, and even virtual level. These range from small, grassroots efforts in local communities to large, formal organizations with thousands of members. No matter what the size or geographic location, these groups provide education, networking, and support for nurses interested in informatics. Annual conferences provide the opportunity for members to share their research and innovations and to meet with informatics colleagues from around the world (Newbold, 1997; Newbold, 2000).

The American Nurses Informatics Association (ANIA) was established in 1992 to serve the needs of informatics nurses in southern California. It has since grown and expanded and become a national organization with members throughout the United States. You can learn more about the ANIA at www.ania.org.

Several nursing organizations, such as the Council on Nursing Services and Informatics of the ANA and the Council on Nursing Informatics of the NLN, have established informatics work groups. In addition, nonnursing associations such as the American Medical Informatics Association (AMIA) have nursing informatics work groups. In many of these organizations, INs have taken a leadership role. For example, Dr. Patricia Flatley Brennan has served on the Board of Directors of the AMIA and is currently serving as President. Nurses are also well represented on all of the committees of the AMIA.

Credentialing Nurses in the Specialty. When nursing informatics was recognized as a specialty by the ANA in 1992, work began to establish a process by which nurses could be credentialed in informatics. The ANCC, which offers certification examinations for a variety of specialties in nursing, describes certification as a formal, systematic mechanism whereby nurses can voluntarily seek a credential that recognizes their quality and excellence in professional practice and continuing education (ANCC, 1993). For many nurses becoming certified is a professional milestone and validation of their qualifications, knowledge, and skills in a defined area of nursing practice.

To be eligible for the nursing informatics examination, which was first offered in 1995, a nurse must meet the following requirements:

• Possess an active registered nursing license in the United States or its territories

• Have earned a baccalaureate or higher nursing degree

• Practiced actively as a registered nurse for at least 2 years

• Practiced at least 2000 hours in the field of nursing informatics within the past 5 years or completed at least 12 semester hours of academic credits in informatics in a graduate program in nursing and a minimum of 1000 hours in informatics within the past 5 years

• Earned 20 contact hours of continuing education credit applicable to the specialty area within the past 2 years (ANCC, 2001)

The nurse who successfully passes the examination is certified as a generalist in informatics nursing. The ANCC is planning to offer an examination for a specialist in informatics nursing in the future. Once certified, the nurse must be recertified every 5 years. In the first year the examination was offered, 83 nurses became certified in informatics (Newbold, 1996). Since then, more than 200 additional nurses have become certified in the specialty (ANCC, 2000).

Education in Informatics. There are both formal and informal opportunities for education in informatics. The first formal educational programs that offered specific degrees in nursing informatics were established within the past decade, and the number of programs has been increasing steadily. However, because educational options were limited, many nurses are currently practicing in informatics that has been prepared for their role through on-the-job training or by receiving education for the role outside of nursing. For example, a nurse may have a Bachelor of Science degree in nursing (BSN) plus a second degree in computer science or information technology. Nurses have been successful in educating themselves using formal and informal resources. Nurses considering a career in informatics need to carefully consider options that are available and plan their educational programs accordingly.

Formal Programs. The Nursing Working Informatics Group of the AMIA (NWIG-AMIA) describes formal educational programs in nursing informatics as Category I, Category II, and Category III. Category I programs are those graduate programs with a specialist nursing informatics focus. There are currently eight Category I programs, based at the following institutions of higher learning: Excelsior College, New York University, St. Louis University, Columbia University, Loyola University-Chicago, University of Colorado Health Sciences Center, University of Maryland, and University of Utah. Although each program is unique, there are similarities. For example, students pursuing master's level education will take approximately 42 semester credit hours of course work, which are divided among core courses (such as theory, research, policy, and advanced nursing), courses in nursing informatics (such as programming, database design, systems analysis and design, clinical decision-making, informatics models, and practice activities), and support courses. Similarly, students at the University of Utah and the University of Maryland may pursue doctoral study with substantive course work in nursing informatics. Again courses are taken in nursing theory, research, statistics, and nursing informatics. As with any doctoral degree, a dissertation is required.

Category II programs are graduate and undergraduate programs and courses that allow a student to pursue a concentration (or minor) in nursing informatics. In these programs students take 6 to 12 credit hours of course work in informatics. Category II programs are available at Case Western Reserve University; Duke School of Nursing; Loyola of Chicago; Northeastern University; Slippery Rock University; and the Universities of Arizona, Iowa, Pennsylvania, and Phoenix.

Category III programs offer individual courses in nursing informatics at both the graduate and undergraduate level. The NWIG-AMIA has identified eight such programs (Georgia College and State University, Lewis University, Lewis-Clark State College, Oregon Health Sciences University, Western Michigan University, Wichita State University, University of North Carolina and University of Vermont) although it is likely that this list is incomplete. If you are interested in formal study in informatics, check with schools and colleges of nursing in your locale to see what is available.

Although these are the only formal programs available at this time, many universities have courses in computer science and information technology. Interested students are able to self-design programs that meet their individual learning needs. Programs at the University of Texas at Austin, University of California San Francisco, and the University of Wisconsin at Madison have been identified as having particularly strong concentrations of courses available in informatics (Gassert, 2000).

Informal Education. For many nurses graduate education is not an option or personal choice, but they still desire to become more knowledgeable about informatics. In this case many informal opportunities exist, including networking through professional organizations, keeping abreast of the literature by reading journals, and attending professional conferences.

Organizations vary in their scope, services offered to members, and the types of educational programs offered. Nelson andjoos (1992) describe five types of organizations.

1. Special interest groups such as the councils of the ANA and NLN. Nonnursing organizations that have special interest groups of interest to nurses include the American Hospital Association and the Healthcare Financial Management Association.

2. Information science and computer organizations such as the Association for Computing Machinery. There also are specialty organizations within this category, such as the Health Science Communications Association.

3. Health computing organizations such as the AMIA and the International Medical Informatics Association. Other organizations in this category include the Medical Records Institute and the Computer-Based Patient Record Institute (CPRI).

4. User groups, which consist of individuals working with a specific language, software, or vendor. One such group of interest to nurses is the Microsoft Healthcare Users Group (MS-HUG), which focuses on applications of Microsoft products in health care environments.

5. Local groups such as the Capital Area Roundtable on Informatics in Nursing (CARING), located in Washington, DC, or the Tri-State Nursing Computer Network, located in Pittsburgh, Pa. These groups provide local contacts, opportunities for networking, and education. CARING, for example, offers a popular review course for people preparing to take the nursing informatics certification examination.

Anyone interested in learning more about informatics should become active in at least one related organization. As a member a nurse has access to the meetings, publications, and educational offerings that the organization provides. Getting on mailing lists or visiting organizational sites on the www also allows a nurse to keep abreast of different opportunities available through each organization.

Reading journals and newsletters is another way to become more knowledgeable about informatics. Offerings range from trade magazines that are not related to health but are important sources of information, such as PC Magazine or Byte, to specialized journals in nursing such as Computers in Nursing. Since 1995 Computers in Nursing has offered continuing education credit for articles published in the journal. The AMIA publishes the Journal of the American Medical Informatics Association, a publication source for much of the research that has been conducted related to informatics. A nurse interested in informatics should become familiar with the journals that are available, subscribe to those that are most interesting, and read others in the library. Unfortunately more information is published every month than anyone could possibly hope to keep abreast of—thus the need for networking! Colleagues can alert others to articles of interest that are in journals they might not regularly read.

Finally, conferences provide an excellent source of education. At a conference the nurse is able to hear the latest information directly from experts in the field. Larger conferences usually have vendor exhibits that provide the opportunity for hands-on demonstrations for a variety of commercial products. Conferences vary in size, focus, location, and cost. For those interested in nursing informatics, nursing conferences especially are helpful. Local organizations, such as CARING, sponsor a variety of half-day or 1-day conferences. Rutgers, the State University of New Jersey, has an annual informatics conference; in 2001 they celebrated their nineteenth year of successful implementation. The University of Maryland hosts a week-long institute on informatics every summer at the Baltimore campus. In addition, nonnursing organizations such as the Health Information Management Systems Society and the AMIA have nursing sessions at their annual meetings. Nonnursing sessions also are often of great interest to nurse attendees.

CLINICAL INFORMATION

Clinical Information Systems

CISs are changing the way that health care is delivered, whether in the hospital, the clinic, the provider's office, or the patient's home. With capabilities ranging from advanced instrumentation to high-level decision support, CISs offer nurses and other clinicians information when, where, and how they need it. Increasingly CIS applications function as the mechanisms for delivering patient-centered care and for supporting the move toward the computer-based patient record (CPR).

What exactly is a CIS? Definitions vary, often from organization to organization. Semancik (1997) describes a CIS as a collection of software programs and associated hard ware that supports the entry, retrieval, update, and analysis of patient care information and associated clinical information related to patient care. The CIS is primarily a computer system used to provide clinical information for the care of a patient.

A CIS can be patient-focused or departmental. In patient-focused systems, automation supports patient care processes. Typical applications found in a patient-focused system include order entry, results reporting, clinical documentation, care planning, and clinical pathways. As data are entered into the system, data repositories are established that can be accessed to look for trends in patient care. Departmental systems evolved to meet the operational needs of a particular department, such as the laboratory, radiology, pharmacy, medical records, or billing. Early systems often were stand-alone systems designed for an individual department. A major challenge facing CIS developers is to integrate these stand-alone systems to work with each other and with the newer patient-focused systems.

Computerized Patient Records

The health care delivery system is dramatically changing, with a strong emphasis on improving outcomes of care and maintaining health. The CPR needs to be considered in a broader context and is not applicable only to patients (i.e., individuals with the presence of an illness or disease). Rather in the CPR the focus is on the individual's health, encompassing both wellness and illness.

As a result of this focus on the individual, the CPR is a virtual compilation of nonredundant health data about the person across his or her lifetime, including facts, observations, interpretations, plans, actions, and outcomes. Health data include information on allergies, history of illness and injury, functional status, diagnostic studies, assessments, orders, consultation reports, and treatment records. Health data also include wellness information such as immunization history, behavioral data, environmental information, demographics, health insurance, administrative data for care delivery processes, and legal data such as informed consents. The who, what, when, and where of data capture are also identified. The structure of the data includes text, numbers, sounds, images, and full-motion video. These are thoroughly integrated so that any given view of health data may incorporate one or more structural elements.

Within a CPR, an individual's health data are maintained and distributed over different systems in different locations, such as a hospital, clinic, physician's office, and pharmacy. Intelligent software agents with appropriate security measures are necessary to access data across these distributed systems. The nurse or other user who is retrieving these data must be able to assemble it in such a way as to provide a chronology of health information about the individual.

The CPR is maintained in a system that captures, processes, communicates, secures, and presents the data about the patient. This system may include the CIS. Other components of the CPR system include clinical rules, literature for patient education, expert opinions, and payer rules related to reimbursement. When these elements work together in an integrated fashion, the CPR becomes much more than a patient record—it becomes a knowledge tool. The system is able to integrate information from multiple sources and provides decision support; thus the CPR serves as the primary source of information for patient care.

A fully functional CPR is a complex system. Consider a single data element (datum), such as a person's weight. The system must be able to capture, or record the weight; store it, process it, communicate it to others, and present it in a different format such as a bar graph or chart. All of this must be done in a secure environment that protects the patient's confidentiality and privacy. The complexity of these issues and the development of the necessary systems help to explain why few fully functional CPR systems are in place today.

Data Capture. Data capture refers to the collection and entry of data into a computer system. The origin of the data may be local or remote from patient-monitoring devices, from telemedicine applications, directly from the individual recipient of health care, and even from others who have information about the recipient's health or environment, such as relatives and friends and public health agencies. Data may be captured by multiple means, including key entry, pattern recognition (voice, handwriting, or biologic characteristics), and medical device transmission.

All data entered into a computer are not necessarily structured for subsequent processing. For example, document imaging systems provide for creation of electronically stored text but have limitations on the ability to process that text. Data capture includes the use of controlled vocabularies and code systems to ensure common meaning for terminology and the ability to process units of information. As noted earlier, great strides have been made in the development of standardized nursing languages. These languages provide structured data entry and text processing, which result in common meaning and processing.

Data capture also encompasses authentication to identify the author of an entry and to ensure that the author has been granted permission to access the system and change the CPR

Storage. Storage refers to the physical location of data. In CPR systems health data are distributed across multiple systems at different sites. For this reason, common access protocols, retention schedules, and universal identification are necessary.

Access protocols permit only authorized users to obtain data for legitimate uses. The systems must have backup and recovery mechanisms in the event of failure. Retention schedules address the maintenance of the data in active and inactive form and the permanence of the storage medium.

A person's identity can be determined by many types of data in addition to common identifiers such as name and number. Universal identifiers or other methods are required for integrating health data of an individual distributed across multiple systems at different sites.

Information Processing. Application functions provide for effective retrieval and processing of data into useful information. These include decision support tools such as alerts and alarms for drug interactions, allergies, and abnormal laboratory results. Reminders can be provided for appointments, critical path actions, medication administration, and other activities. The systems also may provide access to consensus- and evidence-driven diagnostic and treatment guidelines and protocols. The nurse could integrate a standard guideline, protocol, or critical path into a specific individual's CPR, modify it to meet unique circumstances, and use it as a basis for managing and documenting care. Outcome data communicated from various caregivers and health care recipients themselves also may be analyzed and used for continual improvement of the guidelines and protocols.

Information Communication. Information communication refers to the interoperability of systems and linkages for exchange of data across disparate systems. To integrate health data across multiple systems at different sites, identifier systems (unique numbers or other methodology) for health care recipients, caregivers, providers, payers, and sites are essential. Local, regional, and national health information infrastructures that tie all participants together using standard data communication protocols are key to the linkage function. There are hundreds of types of transactions or messages that must be defined and agreed to by the participating stakeholders. Vocabulary and code systems must permit the exchange and processing of data into meaningful information. CPR systems must provide access to point-of-care information databases and knowledge sources such as pharmaceutic formularies, referral databases, and reference literature.

Security. Computer-based patient record systems provide better protection of confidential health information than paper-based systems because such systems support controls that ensure that only authorized users with legitimate uses have access to health information. Security functions address the confidentiality of private health information and the integrity of the data. Security functions must be designed to ensure compliance with applicable laws, regulations, and standards. Security systems must ensure that access to data is provided only to those who are authorized and have a legitimate purpose for its use. Security functions also must provide a means to audit for inappropriate access.

Three important terms are used when discussing security: privacy, confidentiality, and security. It is important to understand the differences between these concepts.

• Privacy refers to the right of an individual to keep information about himself or herself from being disclosed to anyone. If a patient has had an abortion and chose not to tell a health care provider this fact, the patient would be keeping that information private.

• Confidentiality refers to the act of limiting disclosure of private matters. Once a patient has disclosed private information to a health care provider, that provider has a responsibility to maintain the confidentiality of that information.

• Security refers to the means to control access and protect information from accidental or intentional disclosure to unauthorized persons and from alteration, destruction, or loss. When private information is placed in a confidential CPR, the system must have controls in place to maintain the security of the system and not allow unauthorized persons access to the data (CPRI, 1995).