ENHANCING CLINICAL CARE THROUGH NURSING INFORMATICS

DECEMBER 14, 2009
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QUOTE OF THE DAY

"Computers are incredibly fast, accurate and stupid. Human beings are incredibly slow, inaccurate and brilliant. Together they are powerful beyond imagination."
- Albert Einstein
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DO YOU KNOW WHAT A TOILET BOWL CAN DO?

• can redden faces • can measure sugar levels in urine • can measure blood pressure, heartbeat, body fat and weight • can do nearly everything
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REDDEN FACE?

An American diplomat was at a dinner party in a Japanese home when he excused himself to go to the bathroom. He did his business, stood up and realized he didn't have a clue about how to flush the toilet.
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REDDEN FACE?

The diplomat speaks Japanese, but he was still baffled by the colorful array of buttons on the complicated keypad on the toilet. So he just started pushing. He hit the noisemaker button that makes a flushing sound to mask any noise you might be making.

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REDDEN FACE?

He hit the button that starts the blowdryer for your bottom. Then he hit the bidet button and watched helplessly as a little plastic arm, sort of a squirt gun shaped like a toothbrush, appeared from the back of the bowl and began shooting a stream of warm water across the room and onto the mirror.

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REDDEN FACE?

And that's how one of America's promising young Foreign Service officers ended up frantically wiping down a Japanese bathroom with a wad of toilet paper. "It was one of my most embarrassing experiences in Japan," said the embassy employee who asked not to be identified.

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NEOREST 600

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NEOREST 600 The Neorest 600 from Japanese plumbing manufacturer Toto is a tankless toilet and personal cleansing unit. Its lid automatically opens when a person approaches it. When a person walks away from the Neorest 600, it automatically flushes and closes the seat and lid. There's a remote control for operating features including water spray temperature, pressure and direction; seat heater; air dryer; and deodorizer. List prices for the Neorest 600 start at US$5,200.

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FRIENDLY RESTROOM

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FRIENDLY RESTROOM
Built-in assistance: The Friendly Rest Room combines a slew of high-tech features including a contactless smart card to store users' preferences, voice activation interface, and sensor systems for detecting falls and emergency situations. Users can control settings including seat height and tilt with a remote control or voice-activated commands. Researchers affiliated with Vienna University of Technology in Austria conceived the Friendly Rest Room as a way to provide greater independence to elderly and disabled people who might otherwise rely on assistance from a caregiver to use a toilet.

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INTELLIGENT TOILET

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INTELLIGENT TOILET

Japanese homebuilder Daiwa House Industry collaborated with Toto to design the Intelligent Toilet, which doubles as an in-home health monitor. The design includes devices for measuring sugar levels in urine, blood pressure, body fat and weight.

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WHO AMONG US ARE LIKE THIS FELLOW?

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ARE YOU FRIENDLY OR “TOXIC” TO COMPUTERS?

Let Computers Help You, Not Break You!
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HOW?

BY IMPROVING YOUR COMPUTER LITERACY…
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COMPUTER LITERACY

Computer literacy is commonly used today to denote some kind of basic knowledge and an understanding of computers combined with the ability to use them effectively.
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COMPUTER LITERACY On the least specialized level, computer literacy involves knowing how to turn on a computer, start and stop simple application programs, and save and print information. It also refers to the attitude about computers and the actual ability to do some tasks or programs on the computer.
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COMPUTER LITERACY The relationship between computer literacy, technological competence and a nurse's ability to care is congruent for quality care. Computer literacy represents a proactive response to technology which enhances caring in nursing (Delaney, 1990).
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COMPUTER LITERACY

AM I COMPUTER LITERATE?
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HOW FAR DO YOU KNOW?

• • • • • •

ANIA BCMA CI CPOE CPU CPRS

• • • • • •

EHR EMR HIS PC PDA RAM

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HOW FAR DO YOU KNOW?
• • • • • • • • • ANIA - American Nursing Informatics Association BCMA - Bar Code Medical Administration CI - Clinical Informatics/Informaticist CPOE - Computerized Physician Order Entry CPRS - Computerized Patient Record System EHR - Electronic Health Record EMR - Electronic Medical Record HIS - Hospital Information System PDA - Personal Digital Assistant
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TOP BUSINESS ISSUES IMPACTING HEALTHCARE

1. Increasing Patient Safety/Reducing Medical Errors 2. Patient (Customer) Satisfaction 3. Nursing Shortage
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CURRENT IT PRIORITIES

1. Reduce Medical Errors/Promote Patient Safety 2. Implement an EMR 3. Connecting IT at Hospital and Remote Locations
Source: Healthcare Information and Management Systems Society (HIMSS)
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CHALLENGES FOR NURSING
• Fragmented, frequently interrupted, in chaotic work environment
– Interrupted mid-activity 8 times per every 8 hours*

• Switch patients every 11 minutes* • Average activity time – 3.1 min/care activity* • Average of 8.1 operational failures per 8 hours*
– – – – Missing med Missing supplies Missing order Missing/ broken equipment

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CHALLENGES FOR NURSING
• 9% of time spent on resolving system failures or errors*
– Most common was missing medications

• Direct patient care tasks done in 2:43 minutes chunks • Average 44 minutes overtime • Only 30% of shift time is in direct patient care** • Medication administration errors
– in 1999, ADE cost the U.S. $2 billion annually

Sources: * Tucker and Spear. Operational Failures and Interruptions in Hospital Nursing. HSR 41:643-662, 2006 ** Hendrich A., George V. Random work sampling of Medical Surgical nurses using PDAs. Reported at Health Management Academy, May 20, 2004. Unpublished Data

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CHALLENGES FOR CLINICIANS • We practice with incomplete information • We have alarming error rates • We spend 30-50% of time on administrative activities • Errors are associated with surveillance, change in venues, and patient handoffs • Fragmented, incomplete records can cause confusion, communication breakdown, and the opportunity for error. • We need to reduce burdens related to 27 documentation

LEARNING OBJECTIVES
• Define nursing informatics • Demonstrate how NI supports nursing process • Explain the value of NI to nursing practice and healthcare • Identify roles for NI practice • Identify practice areas and settings • Identify education paths and certifications
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THE IMPORTANCE OF INFORMATION
• The healthcare of your clients is largely dependant on information. • Every action taken depends on previous information and knowledge. • The delivery of health care requires information about:
– Science of type of care (nursing) – Patient or client – Provider – Outcomes – Process and systems for delivery of care
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THE IMPORTANCE OF INFORMATION
• Information about each of these areas have an impact on the type and the amount of care given. • Information must be: accurate timely accessible understandable

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WHAT IS INFORMATION? The structure of information • Delivered in conversation, handwritten notes, stored in a computer. • Regardless of the form, the same basic principles apply to the structure and the use of information. • Words are often used interchangeably to describe information.
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WHAT IS INFORMATION?
The structure of information • Data: discrete entities objectively described, without interpretation or context.
– Example: 110

• Information: data processed into a structured form. Data that are interpreted, organized, structured and given meaning are referred to as information.
– Example: When combining 110 with other data, it becomes information. Systolic blood pressure of 110 mmHg and diastolic blood pressure of 70 mm Hg. This information can be captured in a form, on a graph in a report.

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WHAT IS INFORMATION? • Knowledge: synthesized information derived from the interpretation of data. It provides a logical basis for making decisions.Essential to decision-making and to new discoveries. – Example: When the blood pressure reading is combined with information about anatomy and physiology, pharmacology, pathophysiology, knowledge is used to decide about further care and treatment.

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THE FIVE RIGHTS OF INFORMATION

Information has five rights: Right information Right person Right time Right place Right amount
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USING INFORMATION “Up-to-date, accurate information of each step of the Nursing Process is the Power behind safe, high quality patientcentered care!”
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USING INFORMATION
• Evidence-based practice leads to:
– Determining standards and guidelines – Guide for decision-making process – Determines best practice

• Nursing informatics can enable dissemination of new knowledge.
– Practitioners update themselves of new developments through journals, conferences, continuing education sessions. – The information is varied and copious. – There is a need to find the relevant evidence in a timely way.
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WHAT IS HEALTHCARE INFORMATICS? • With the knowledge of the importance of information in healthcare, healthcare informatics has become a specialty. • Healthcare informatics is a combination of computer science, healthcare science, information science and cognitive science.

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WHAT IS HEALTHCARE INFORMATICS?
• Computer science: development, configuration, architecture of computer hardware and software. • Healthcare science: body of knowledge on which healthcare profession bases their practice. The sciences of anatomy, physiology and knowledge specific to each profession. • Information science: also includes information technology which involves the process of sending and receiving information. • Cognitive science: the process of human thinking, understanding and remembering.
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HOW FAR HAVE WE COME? • 1992 – First Scope of Practice for Informatics Nurse • 1992 – Informatics Nursing recognized as a specialty by ANA • 1994 – First Informatics Nursing Certification exam offered by ANCC • 2007 – 3rd Version of Informatics Nursing Scope of Practice • 2007: AONE identifies Information Management and Technology as a core competency for Nurse Executives

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WHAT IS NURSING INFORMATICS (NI)?
“Nursing Informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. Nursing informatics facilitates the integration of data, information, knowledge, and wisdom to support patients, nurses and other providers in their decision-making in all roles and settings. This support is accomplished through the use of information structures, information processes, and information technology.”
(ANA Scope & Standards of Nursing Informatics Practice, 2008)
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WHAT IS NURSING INFORMATICS (NI)? • Like any knowledge-intensive field these days, nursing is greatly impacted by the explosive growth of computer technology. Nursing informatics is a new and exciting specialty that combines nursing skills with computer expertise. Nurse informatics specialists manage and communicate nursing data and information to improve decision making by consumers, patients, nurses and other health care providers.
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SCOPE & STANDARDS OF PRACTICE

• • • • • •

System Lifecycle Human Factors Information Technology Information Management Professional Practice Models and Theories
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IN vs. INS

• IN – Informatics Nurse:
– RN who works in the area of informatics – This RN is not formally prepared in informatics but has an interest and/or experience working in the area.

• INS – Informatics Nurse Specialist:
– RN with advanced, graduate education in nursing informatics or information management
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NURSING INFORMATICS JOB TITLES – 14% “clinical analysts” – 14% “informatics nurse specialist” or “nursing informatics specialist” – 9% “consultant” – 40% identified “other”
• Director of Clinical Informatics, Clinical Informatics Coordinator, Clinical Systems Analyst, Clinical Informatics Specialist
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NI SPECIALIST SALARY • In 2007, the Healthcare Information and Management Systems Society (HIMSS) conducted a major survey of nurse informatics specialists. The average salary earned by respondents to this survey was $83,675, compared to $69,500 in the 2004 survey. This is strong evidence of the increasing maturity and value of the specialty.
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NURSE INFORMATICS CAREER OUTLOOK • The demand for all types of nurses is expected to increase significantly over the next ten years. In general, the more training, certifications and experience a nurse has, the more demand there will be for his or her skill set.

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HEALTHCARE INFORMATION AND MANAGEMENT SYSTEMS SOCIETY (HIMSS) LEVEL 7
STAGECUMMULATIVE CAPABILITIES % OF HOSPIT ALS

7Medical record fully electronic; care delivery organization 0.0% able to contribute to electronic health record as byproduct of electronic medical record 6Physician documentation, full clinical decision support system (variance and compliance), full PACS 5Closed-loop medication administration 4CPOE, clinical decision support system (clinical protocols) 3Nursing documentation, eMAR , clinical decision support system (error checking), PACS 0.1% 0.5% 1.9% 8.1%

2Clinical data repository, controlled medical vocabulary, 49.7% clinical decision support interface engine, document imaging 1Ancillaries: laboratory, radiology, pharmacy 0All three ancillaries not installed 20.5% 19.3%

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WHY IT IS IMPORTANT?
• Nurses need to develop competencies in informatics. • Informatics enables Technology nurses to use information and communications Nursing technologies in the:
– collection of data, – use of information – generation of knowledge to support nursing practice
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WHY IT IS IMPORTANT?  the trend in hospitals are computerizing nursing documentations  for effective and efficient data management such as workload statistics, performance monitoring, etc.  promotes and improves evidence-based nursing practice and patient outcomes.

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WHY IT IS IMPORTANT?  Nursing informatics enables nurses to quickly move to the synthesis of nursing knowledge and the development of nursing wisdom. Gone were the days of manual documentation that consumes most of your time, now, more time are used in applying nursing knowledge and wisdom to everyday care because of informatics.
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WHY IT IS IMPORTANT? NURSING INFORMATION SYSTEMS (NIS) includes: 1. Patient Charting 2. Staff Schedules 3. Clinical Data Integration 4. Decision Support

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WHY IT IS IMPORTANT?
• Patient Charting: A patient’s vital signs, admission and nursing assessments, care plan and nursing notes can be entered into the system either as structured or free text. These are the stored in a central repository and retrieved when needed. • Staff Schedules: Nurse can self schedule their shifts using scheduling rules provided in shift modules. The shifts can later be confirmed or changed by a scheduling coordinator or manager. Shift modules are designed to handle absences, overtime, staffing levels and cost-effective staffing.
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WHY IT IS IMPORTANT?
• Clinical Data Integration: Here clinical information from all the disciplines can be retrieved, viewed and analyzed by nursing staff and then integrated into a patient’s care plan. • Decision Support: Decision support module can be added to NIS , and they provide prompts and reminders, along with guides to disease linkages between signs/symptoms, etiologies/related factors and patient populations. Online access to medical resources can also be made available.

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ROLE OF THE NURSE INFORMATICIST
– Nurse programmers who write or modify computer programs for use by nurses – Nurse communicators who work with other nurses to identify computer system needs or to assist in the training and implementation of those systems – Informatics nurse managers who manage or administer information systems – Nurse vendor representatives who demonstrates systems to potential customers
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WHAT CAN AN INFORMATICS NURSE DO? 1. Support nursing work processes using technology
– Design systems to match clinical workflows
• • • • • • • Telehealth Homehealth Ambulatory care Long-term care Acute care – all specialties Outpatient settings Software development
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WHAT CAN AN INFORMATICS NURSE DO? 2. Increase the accuracy and completeness of nursing documentation 3. Improve the nurse’s workflow
– Eliminate redundant documentation

2. Automate the collection and reuse of nursing data 3. Facilitate analysis of clinical data
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WHAT CAN AN INFORMATICS NURSE DO?

• Admitting a patient
– Admission Assessment in computer
• • • • • • • • Placing orders Requesting consults Sending data to NIS/HIS Resolving clinical reminders Take V/S Give medications Consent for surgery Make the bed

– These things involve a computer as well

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WHAT CAN AN INFORMATICS NURSE DO?

Prepare/provide workload statistics
• How many new orders written on Ward X in a day? • How many medications given on Ward X in a week? • Nurses bypassing BCMA by using Manual Medication Entry • Show me all restraint orders for the past month
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WHAT CAN AN INFORMATICS NURSE DO?

6. Information system management 7. Documenting patient education
– Incorporated into daily charting

6. Training/educating
– New employees – Student nurses

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COMPETENCIES REQUIRED

• Most theorists also emphasize the need for every nurse whether employed in the practice or education setting, to develop a minimum of a "user" level in computer literacy and informatics theory.

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TECHNICAL COMPETENCIES • Related to the actual psychomotor use of computers and other technological equipment. Specific nursing informatics competencies include the ability to use selected applications in a comfortable and knowledgeable way. It is important that nurses feel confident in their use of computers and software in the practice setting, especially at the bedside, in order to be able to attend to the client at the same time.

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LEVEL OF COMPETENCIES

• beginner, entry or user level • intermediate or modifier level and; • advanced or innovator level of competency.

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COMPUTER APPLICATIONS

All three levels of competencies - users, modifiers and innovators need to develop a working knowledge of the following computer programs and processes: • Word processing • Keyboarding • Spreadsheets • Presentation Graphics

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COMPUTER APPLICATIONS

• • • • • • • • • •

Databases (simple to complex) Desktop Publishing World Wide Web E-mail programs Expert data systems Multimedia Telecommunication devices Nursing information systems Hospital information systems Peripherals (Printers, CD/DVD)

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USER LEVEL TECHNICAL COMPETENCIES INCLUDE: • • • • • • • uses word processing applications demonstrates keyboarding skills uses spreadsheet applications uses telecommunication devices to communicate with other systems uses e-mail systems to communicate with other health care professionals uses presentation applications to create slides, displays, overheads (PowerPoint, Corel Presentation, etc.) 66 uses multimedia presentations

USER LEVEL TECHNICAL COMPETENCIES INCLUDE: • • • • • uses internet resources to locate client support groups, online resources uses sources of data that relate to nursing practice and care accesses, enters and retrieves data related to client care via available hospital or nursing information systems uses database management programs to develop and access databases and tables uses database applications to enter and retrieve data and information 67

USER LEVEL TECHNICAL COMPETENCIES INCLUDE: • conducts online and database literature searches • uses decision support systems, expert systems and other aids for clinical decision making and care planning • uses computer applications to document client care • uses computer applications to plan client care, including discharge planning • uses computer applications to enter client data (demographic, V/S, physiological data) 68

USER LEVEL TECHNICAL COMPETENCIES INCLUDE: • • • • • • uses information management systems for client education uses technology based client monitoring systems operates peripheral devices (bedside and hand held) uses operating systems uses computer peripheral devices (CD ROMs, DVD, zip drives) uses computer technology safely
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USER LEVEL TECHNICAL COMPETENCIES INCLUDE: • • navigates in Windows environment effectively demonstrates basic technology skills (load paper, change toner, unjam printers, print)

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MODIFIER LEVEL TECHNICAL
COMPETENCIES INCLUDE: • • • • applies technology support to provide evidenced based practice synthesizes data from more than one source and applies to practice demonstrates awareness of and ability to access data and information from multiple sources uses decision support systems in practice

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MODIFIER LEVEL TECHNICAL
COMPETENCIES INCLUDE: • • accesses pertinent literature resources and incorporates into practice and professional development creates and accesses research and other documents electronically

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INNOVATOR LEVEL TECHNICAL COMPETENCIES INCLUDE: • • • • participates in the design and development of information systems for nursing practice develops inventive ways to access data and interact with information systems participates in the design and develop design and development of new applications for nursing practice participates in developing new methods for data and information organization
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INNOVATOR LEVEL TECHNICAL COMPETENCIES INCLUDE: • • • • • collaborates with information technology consultants and other members of information system development team collaborates, negotiates with and directs information technology vendors proficiency in diverse computer application programs manipulates and enhances nursing data sets organizes and directs applications of shared data sets 74

INNOVATOR LEVEL TECHNICAL COMPETENCIES INCLUDE: • • • develops data gathering tools and processes for literature search access for nurses develop charting and documentation templates for use in nursing practice design and development of evidenced based practice documentation and processing within practice area

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CERTFICATION AND EDUCATION
• AMERICAN NURSES CREDENTIALING CENTER (ANCC) – Informatics Nurse (23%)
is the official certifying organization for informatics nurses. The prerequisites for certification include a baccalaureate or higher degree in nursing or a baccalaureate degree in a relevant field, an active registered nurse (RN) license in the United States, and 2 years of RN practice plus 2,000 hours of informatics nursing practice within the previous 5 years or 12 hours of academic credit in a graduate program in nursing informatics and 1,000 hours of nursing informatics practice within the previous 5 years.
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CERTFICATION AND EDUCATION • HEALTHCARE INFORMATION & MANAGEMENT SYSTEMS SOCIETY (HIMSS)
– Certified Professional in Healthcare Information and Management Systems (CPHIMS – 3%)

• OTHER – 9% • NONE – 55%
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SUMMARY • Informatics can make nursing practice visible in local, national, and international health care data sets, thus empowering nurses with information to influence policy. • Information is a critical component of effective decision-making and high quality nursing practice. The information and knowledge gained through nursing informatics can bring increased awareness and understanding of nursing and health 78 care issues.

SUMMARY • Nursing Informatics is committed to maintaining a clinical perspective and promoting research that would bear directly on improving patient care. • Recognition of Nursing Informatics team value in support of clinical excellence is crucial to any healthcare organization’s success.

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FRIENDLY ADVICE… • Work towards achieving the INNOVATOR LEVEL of technical competency • Keep abreast of “latest greatest” technology trends • Assess newest technology for “fit” and potential applicability in your nursing profession

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NURSING INFORMATICS ORGANIZATIONS
A short list of examples includes: • • • • • • • • • American Nursing Informatics Association (ANIA) Australian Nursing Informatics Council (ANIC) Brazilian Nursing Association Nursing Informatics Group British Computer Society Nursing Specialist Group European Nursing Informatics (ENI) International Medical Informatics Association Nursing Informatics Special Interest Group (IMIA-NI) NURSINFO: Hong Kong Spanish Society of Nursing Informatics and Internet (SEEI) Swiss Special Interest Group Nursing Informatics (SIG-NI)
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CONCLUSION

• Computers cannot replace a nurse, they cannot replace your intuition, and they cannot replace your intelligence and certainly not your TLC. Nurses cannot become robots, doing only what the computer tells them to do.
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QUOTE OF THE DAY

"Computers are incredibly fast, accurate and stupid. Human beings are incredibly slow, inaccurate and brilliant. Together they are powerful beyond imagination."
- Albert Einstein
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REFERENCES • • • • • http://nursing-informatics.com http://ojni.org http://www.ania.org/ http://www.himss.org http://www.cna-nurses.ca

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