White Paper
Guideposts to the Future—An Agenda for Nursing Informatics
K
ATHLEEN
A. M
C
C
ORMICK
, P
H
D, RN, C
ONNIE
J. D
ELANEY
, P
H
D, RN,P
ATRICIA
F
LATLEY
B
RENNAN
, RN, P
H
D, J
UDITH
A. E
FFKEN
, P
H
D, RN, K
ATHIE
K
ENDRICK
, MS, CS, RN,J
UDY
M
URPHY
, RN, BSN, D
IANE
J. S
KIBA
, P
H
D, J
UDITH
J. W
ARREN
, P
H
D, RN,C
HARLOTTE
A. W
EAVER
, RN, P
H
D, B
ETSY
W
EINER
, P
H
D, RN, B
ONNIE
L. W
ESTRA
, P
H
D, RN
A b s t r a c t
As new directions and priorities emerge in health care, nursing informatics leaders must prepareto guide the profession appropriately. To use an analogy, where a road bends or changes directions, guidepostsindicate how drivers can stay on course. The AMIA Nursing Informatics Working Group (NIWG) produced thiswhite paper as the product of a meeting convened: 1) to describe anticipated nationwide changes indemographics, health care quality, and health care informatics; 2) to assess the potential impact of genomicmedicine and of new threats to society; 3) to align AMIA NIWG resources with emerging priorities; and 4) toidentify guideposts in the form of an agenda to keep the NIWG on course in light of new opportunities. Theanticipated societal changes provide opportunities for nursing informatics. Resources described below within theDepartment of Health and Human Services (HHS) and the National Committee for Health and Vital Statistics(NCVHS) can help to align AMIA NIWG with emerging priorities. The guideposts consist of priority areas foraction in informatics, nursing education, and research. Nursing informatics professionals will collaborate as fullparticipants in local, national, and international efforts related to the guideposts in order to make significantcontributions that empower patients and providers for safer health care.
J Am Med Inform Assoc.
2007;14:19–24. DOI 10.1197/jamia.M1996.
Background
Nursing informatics has been defined by McCormick as “. . .an applied science”
and by the 2001 American NursesAssociation Scope and Standards of Nursing Informatics asa specialty that:
integrates nursing science, computer science, and informa-tion science to manage and communicate data, information,and knowledge in nursing practice. Nursing informaticsfacilitates the integration of data, information, and knowl-edge to support patients, nurses, and other providers in theirdecision-making in all roles, and settings. This support isaccomplished through the use of information structures,information processes, and information technology.
The roles of health care providers, including nurse informa-ticians, are diversifying. Nurses with advanced education ininformatics work as project managers, consultants, productdevelopers, decision support and outcomes managers, chiefinformation officers (CIOs), advocates/policy developers,entrepreneurs, and business owners in industry. In aca-demic environments, nurses with advanced informaticseducation include researchers, educators, and advocates/policy developers. Administrative nurses and nurse-CIOspurchase large information systems within all health caremarkets. Health information technology vendors employnurses in senior executive roles, such as Chief NursingOfficer (CNO), to provide vision and management forimplementation of clinical systems. Nurses work in privatesector and clinical environments as systems analysts, re-quirements analysts, content developers, database adminis-trators, implementation specialists, information system liai-sons, trainers, and use case scenario managers. The Websites of the American Medical Informatics Association(AMIA), the Healthcare and Information Management Sys-tems Society (HIMSS), and the Capital Area Roundtable inNursing Informatics (CARING) post many job offerings fornurses with informatics knowledge.
Context—The Environment
Nursing professionals must recognize and monitor environ-mental changes that generate new markets and domains forhealth care informatics. The anticipated changes relate to:demographics, health care quality and costs, health careinformatics, the potential impact of genomic medicine onclinical practice, and the impact of new threats to society.
Affiliations of the authors: SAIC Health Solutions (KAM), FallsChurch, VA; School of Nursing, University of Minnesota (CJD),Minneapolis, MN; College of Engineering, University of Wisconsin-Madison (PFB), Madison, WI; School of Nursing, University ofWisconsin-Madison (PFB), Madison, WI; College of Nursing, Uni-versity of Arizona (JAE), Tucson, AZ; Office of Performance Ac-countability, Resources and Technology, Agency for HealthcareResearch and Quality (KK), Rockville, MD; Aurora Health Care(JM), Milwaukee, WI; School of Nursing, University of Colorado(DJS), Denver, CO; School of Nursing, University of Kansas (JJW),Kansas City, KS; Cerner Corporation (CAW), Kansas City, MO;Vanderbilt University (BW), Nashville, TN; The University ofMinnesota (BLW), Minneapolis, MN.Correspondence and reprints: Kathleen A. McCormick, PhD, RN,SAIC Health Solutions, Brown Operation, 5203 Leesburg Pike, Suite1477, Falls Church, VA 22041; Tel: (703) 575-7209; Fax: (703) 824-8547; e-mail:
kathleen.a.mccormick@saic.com
.Received for review: 10/20/05; accepted for publication: 10/16/06. Journal of the American Medical Informatics Association Volume 14 Number 1 Jan / Feb 2007
19
Demographics
Future demographic changes will alter the face of healthcare. The U.S. Census Bureau in March 2004 predicted that, between 2010 and 2020, the U.S. population aged 65 or olderwill increase by 14,388,000 persons, while the number of 20-to 64-year-olds will grow by 6,830,000.
In addition, provid-ing care to a more culturally diverse population will chal-lenge traditional health care delivery mechanisms. Projectedpopulation shifts from 2010 to 2020 include fewer non-Hispanic whites (decreasing from 65.1% to 61.3% of the U.S.population) and increases in all other groups.
Thus, themajor demographic shifts are for an older and more diversesociety.
Health Care Quality
Improving the quality of health care will continue to be anational priority. Consumers will continue to demand ac-countability from providers. For example, CMS’s HomeHealth Compare Web site indicates differences in outcomesamong care providers in different health care facilities.
Efforts to use Medicare, its Quality Improvement Organiza-tions (QIOs), and its demonstration projects to tie paymentto improved quality for beneficiaries will continue. Many believe that Medicare can be a catalyst for measuring andimproving health care quality across the country, withinformation technology facilitating quality measurementand enhancement. MedPAC’s recommendation of budgetneutral pay for performance programs isa step towardrewarding providers who improve quality.
Cost of Delivering Health Care
Persistent health care problems include: inequities in thecost of care, practice variations, less than ideal capacity toprovide care, duplication of efforts, and unequal access tocare. The total costs of health care are currently a burden toindividual patients and to society as a whole. Current costswere estimated at $1.7 trillion by Centers for Medicare andMedicaid Services.
In 2004, 15.6% of the U.S. populationwas uninsured.
As the cost of health care continues toincrease, the numbers of uninsured will likely increase aswell. The need for nurses will intensify, with some states likeOhio and California projected to have huge demands formore nurses, ranging from an anticipated shortage of 32,000in Ohio to 122,000 in California by 2020.
Health Care Informatics
Ongoing technological developments will influence healthcare delivery. Experts in nursing discussed anticipated im-pacts of worldwide changes in hardware (such as greateruse of laptops and PDAs), software (such as computerizeddecision support software, CDSS), and other technologiesused by nurses.
Bioinformatics, including computa-tional biology and biotechnology, will evolve to supportnew developments in the genetic, genomic, proteomic,metabolomic, and comparative translational sciences.
More nurses will need to be trained in the use of biomedicalinformatics and computational biology.
Genetic Discoveries
Advancing knowledge of genes, genomes, and proteomeswill certainly influence future health care at all levels:prevention of disease, diagnosis of disease, and personalizedtreatment of individuals’ diseases. New models must inte-grate biomolecular information into the electronic healthrecords used by caregivers and patients. Personal healthrecords (PHRs) replete with patients’ self-provided informa-tion, such as family histories, will inform predictions ofrisks, selections of cures, prevention ofadverse events, andoptimizing responses to treatments.
Integration ofgenomic information into health care will require dramaticchanges that create new, robust informatics infrastructures.
Threats to Society
Two major threats to society include bioterrorism andinfectious disease pandemics. Events following 9/11/2001 have increased the need for an information infra-structure for disease-outbreak-related communicationand detection. The Centers for Disease Control and Pre-vention (CDC) proposed information infrastructure, Pub-lic Health Information Network (PHIN), recommendsstandards for interoperability at the local, state, andnational level.
The CDC is also developing the NationalElectronic Disease Surveillance System (NEDSS) to detectoutbreaks.
The Agency for Healthcare Research andQuality funds new informatics solutions, including deci-sion support systems, syndromic surveillance systems,Regional Health Information Organizations (RHIOs), andclinician response networks.
The Health Resources andServices Administration (HRSA) has promoted informat-ics educational solutions.
Additional resources to ad-dress threats to society have recently been described.
Informatics applications for biodefense can be utilized andexpanded at the state and local levels to monitor andrespond to naturally occurring outbreaks, such as pandemicinfluenza.
In related developments, syndromic surveil-lance systems are being linked to convey electronic healthdata from emergency rooms to regional laboratories and theCDC.
Within society, health care challenges will shift from acuteconditions, such as infections, to more chronic health condi-tions related to cardiovascular diseases, cancer, behavioraldisorders, and lung disease. Much of health care delivery in2020 will be ambulatory and community based for thesechronic health conditions.
Resources to Align Informatics Locally andNationally
Since passage of the Health Insurance Portability and Ac-countability Act in 1996, actions by the U.S. Congress, thefederal government, and its advisory bodies, especially theNational Committee on Vital and Health Statistics(NCVHS), have exerted a steadily increasing influence onhealth care informatics. The provisions of the MedicareModernization Act of 2003 and the 2004 Presidential ap-pointment of a National Coordinator for Health InformationTechnology continued this trend. Previously described CDCand AHRQ initiatives, such as PHIN and RHIOs, are repre-sentative of new government-funded informatics solutions.In 2005, the Hurricane Katrina–related disaster highlightedthe need for an information infrastructure for communica-tion and the value of electronic health records in ensuringcontinuity of care for displaced populations. Recent efforts by the Secretary of Health and Human Services and theOffice of the National Coordinator to promote developmentof the National Health Information Network and to establish
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MCCORMICK et al.,
Guideposts to the Future
sustainable processes for harmonizing standards, certifyingelectronic health record systems, and promoting widespreadadoption of electronic health records impact health careinformatics priorities.
Several health information technol-ogy bills emphasizing health data standards have beenintroduced in the current Congress. Recent legislative effortsalso include financial incentives for the use of electronichealth records.
Guideposts toward the Future
Figure 1summarizes the authors’ view of the currenthealthcare environment, with targets and guideposts forfuture nursing informatics initiatives. The guideposts canhelp to 1) identify required informatics solutions, 2) describeeducation and research needs for nursing informatics prac-tice and administration, and 3) encourage nurses to collab-orate as full members in local, national, and internationalactivities. The guideposts will change over time, and meritdiscussion by the broader health care informatics commu-nity. Subsequent meetings are planned to refine recommen-dations made in this white paper.
Nursing Guideposts to Contribute in DevelopingInformatics Solutions
Group consensus at the meeting emphasized that nursesmust play key roles in developing information systems sothat the systems improve the quality of care. Authors agreedthat health care would remain patient-focused, with relevantemerging activities such as development of personal healthrecords (PHRs).
Nurses have had longstanding involve-ment in developing consumer-focused applications, includ-ing decision support tools. They will contribute to develop-ment of PHRs as individually held and controlled life-longhealth information repositories. Projects are underway in theindustry to establish PHR for employees to monitor theirlaboratory and medication profiles. Anticipated PHR-re-lated advances include 1) capturing all clinical encounters; 2)health promotion activities; 3) monitoring personally valuedhealth parameters such as exercise, nutrition, and spiritualwell-being; 4) implementing decision support, risk manage-ment, and professional advice; 5) providing consumer-focused health information and education; 6) managinghealth-related benefits and financial resources; and 7) mon-itoring environmental exposures and other communityhealth information.
Future activities that must involvenurses include development of frameworks and templatesfor the PHR; issues of electronic health record and decisionsupport system content; system-delivered guidelines; devel-opment and distribution of consumer best practice informa-tion; health informatics-related education; and, issues ofhealth care and information system access control.Nursing informatics should encompass emergency pre-paredness, biodefense, and public health nursing.
Thefuture of nursing informatics will be impacted by thegenomic revolution.
Since nurses serve as genetic counsel-ors in many environments, nurses must stay informed aboutcomputational biology, genomics, and proteomics to helpengineer emerging bioinformatics applications.
Guideposts for Nursing Informatics Education
Many future nursing informatics guideposts involve educa-tion. Educational programs must prepare nursing studentsto work in multidisciplinary teams. Future nurse informati-cians will be professional knowledge workers who willemploy advanced information technologies and new healthcare information content to help to create and evaluateinnovative solutions that coordinate future health care de-livery by care teams. New nursing information managementsystems must be developed to help nurses evaluate work-flow, assess risk, plan care strategies, and evaluate out-comes. Inherent in this process is a critical need to developEvidence Based Nursing (EBN) knowledge, which is under-way through numerous collaborations with university andother health care organizations and industry. The electronichealth record vendor community can contribute by partner-ing with academic centers, to create curriculums that teachEBN embedded in EHR-related content and processes. Thiswill enhance nurses developing new skills as knowledge
F i g u r e 1.
Targets and guideposts for future nursing informatics initiatives.
Journal of the American Medical Informatics Association Volume 14 Number 1 Jan / Feb 2007
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