ISSUES IN NURSING INFORMATICS

1. Nursing Informatics and Healthcare Policy

Policy is defined as a course of action that guides present and future decision

Healthcare Policy is established on local state and national levels to guide the implementation of
solutions for the population’s health needs.

Events affecting informatics

1. Nursing shortage
2. Concern for patient safety
3. National informatics initiatives
4. Delivery of services through telehealth

NI (Nursing Informatics) (graves and Corcoran, 1989) was defined as the combination of nursing,
information and computer sciences to manage and process nursing data into information and
knowledge for use in nursing practice

(Most recent) described more broadly as a specialty that integrates nursing sciences, computer science,
and information sciences to manage and communicate data, information and knowledge in nursing
practice.

IS – information system

IT – information technology

NI – nursing informatics

ANA – American Nurses Association

A. Healthcare Policy and Nursing Informatics as a Specialty

 1992, ANA recognizes NI as a specialty
 NI had to demonstrate
Differentiated practice base
Identify the existence of educational programs in the field
Show support from nationally recognized organizations
Develop a research agenda

Differentiated and Interdisciplinary Practice

Informatics Nurses
-all nurses must process information, informatics nurses demonstrate specialized knowledge of
information and technology
-assist with the development and implementation of technology tools
-evaluation of effectiveness of technological tools on nurses’ work
-help prepare nurses to use information technologies
NI has been described as one of a specific domain of informatics that falls under the umbrella of health
informatics

Other examples if domain specific informatics practice are medical informatics, dental informatics and
consumer informatics

The NI community believes it is essential to practice within an interdisciplinary team,

An interdisciplinary health professions education summit hosted by IOM (institute of medicine)
produced a vision “all health professionals should be educated to deliver patient centered care as
member of an interdisciplinary team, emphasizing evidenced-based practice, quality improvement
approaches and informatics”
And example of interdisciplinary education is the collaborative effort between the medical informatics
(MI) and NU programs at the University of Utah

Preparation for a Specialty Practice

To become a specialty, it was necessary for NI to show that educational programs are available to
prepare nurses to practice in the field.

1988 and 1992, Division of Nursing (DN), Health and Human Services Administration (HRSA), funded two
Master’s NI Programs, University of Maryland and University of Utah, and one doctoral program in NI at
the University of Maryland.

Healthcare Policy Impact on Nursing Informatics Practice

Nursing Shortage and Nursing Informatics
2002, AAN (American Academy of Nurses) Commission on Workforce Launched a multiphase project
develop IT that will help support nurses in their day to day work, thereby reducing the demands of their
jobs.
Phase I, creative thinkers were assembled to determine how technology could be used to facilitate
nurses’ work.

2003, Kennedy stated that healthcare and nursing would benefit from decision support technology,
streamlined and integrated documentation support , measurement capability built into systems for
determining intensity of care and outcomes, and workflow management tools.

2003, Bradley indicated that technology solutions should improve existing care process and outcomes,
increases through the use of portable and handheld devices, incorporate internet capability to
overcome distance barriers of care and improved access to knowledge acquisition.

Phase II
Technology project began, staff nurses form three hospitals in Virginia and California were asked to
identify and/or verify that most difficult aspects of their practice and how technology would improved
task.
Patient Safety and Nursing Informatics
The IOM report issued in 1999
IOM determined that adverse events occurred in 2.9 and 3.7% of admission when applied to hospital
admission it was estimated that between 44,000 and 98,000 patients die each year from medical errors.

Among other strategies the report recommended the implementation of computerized physician order
entry (CPOE) system requiring the prescriber to enter data directly into computer system to reduce
medication errors

Surveys confirm that concern for patient safety is the biggest factor driving IT
California law 1875, passed 2003, applies pressure to hospital to install IT to help healthcare
professionals reduce errors.

National Alliance for Health Information Technology (NAHIT) is a partnership of diverse health care
leaders who are working to influence the use of technology to improve patient safety, quality and
efficiency.

Connecting for Health (CFH), another public-private collaborative, was established by the Markle
Foundation with additional support from Robert Wood Foundation. The Markle Foundation is a private
philanthropy that works to enable technology to improve people’s lives. This group addresses barriers
to developing an interconnected health information infrastructure and is concerned with reducing
medical errors, improving quality of care, lowering costs, and empowering patients.

B. Nursing Informatics Initiatives and Nursing Informatics

Executive Order for national interoperable Information System

IOM report states even more emphatically that electronic health records, using standard data elements
are a critical tool to improve patient safety.
A 2001 report from the President’s information technology Advisory Committee (PITAC) indicated that
the US lacks a broadly disseminated and accepted national vision for IT in healthcare and recommended
an appointment of a senior IT person to provide strategic leadership. It recommended this individual to
be assigned to the Department of Health and Human Services (DHHS).

April 27, 2004, President George W. Bush issued an executive order “incentives for the use of
information technology and establishing the position of the National Health Information Technology
Coordinator” that has the potential to impact every health care entity, provider and NI professional in
the United States (Executive Order, 2004)
Components of the order:
1) Establish a national health information technology coordinator position
2) Work to develop a nationwide interoperable health IT infrastructure of a strategic plan to guide
3) Develop, maintain and direct implementation of a strategic plan to guide implementation of
interoperable health IT in both public and private sectors.

National Health Information Infrastructure (NHII)

Another national initiative that will impact NI, a voluntary initiative, involving a three-stage process over
10 years, is intended to improve the effectiveness, efficiency and overall quality of health and healthcare
in the United States.

Health Insurance Portability and Accountability Act (HIPAA) was passed in 1996 and is intended to
improve public and private health programs by establishing standards to facilitate the efficient
transmission of electronic health information.

2. The role of Technology in the Medication – Use Process

A. Computerized Prescriber Order Entry

99% of the time that handwritten prescription are used to communicate orders

Factors demonstrate the need for a shift from traditional paper based system is assessing patient
information spread across multiple organization that maybe unavailable especially in a large
organization, thus medical care would be provided without pertinent patient information.

Barriers to communication of medication orders:

Illegible hand writing

50% of all written orders takes extra time to interpret
16% have illegible hand writing,
Could lead to errors, and delay in medication delivery
Use of dangerous abbreviation and dose designation
Verbal and faxed orders
CPOE advantages
Improve quality
Patient outcomes
Safety by variety of factors
Increasing preventive health guidelines compliance
Identifying patients needing updated immunization or vaccinations
Suggesting cancer screening and diagnostic reminders and prompts
Reduction in the variation in care
Reminder system to improve patient management
Automating evidenced based protocols
Adhering to clinical guidelines
Providing screening instrument to help diagnose order
CPOE Disadvantages or Roadblock
The cost of implementation
Errors may occur due to lack of integration between CPOE and Pharmacy system
Complex and time-consuming order entry process lead to practitioners’ frustration

B. Bar Code-Enabled Point-of-Care Technology

One study showed that 38% of medication errors occur during the drug administration process.
While about half of the ordering, transcribing and dispensing errors were intercepted by the nurse
before the medication error reached the patient,
Almost none of the errors at the medication administration errors in 36 healthcare facilities.
The number of medication have reached the market grown 500% over the last 10 years
One form of technology that will have a great impact on medication safety during the administration
process BPOC technology.

At basic level, the systems helps to verify the right drug is being administered to the right patient at the
right dose by the right route at the right time.

The system can verify the dispensing authority of the nurse,

Confirm the patient’s identity,
Match the drug identity with their medication profile in the pharmacy information system and
electronically record the administration of the medication on online MAR (Medication Administration
Record)

The use of an online MAR is likely to be more accurately than traditional hand written MARS

On admission, patients are issued and individualized barcode wristband that uniquely identifies their
identity.
When a patient is to receive a medication, nurses scan their barcode employee identifier and the
patient’s barcode wristband to confirm their identity,
Prior to medication administration each barcoded package of medication

C. Automated Dispensing Cabinets

Hospital pharmacies provided medications for patients by filling patient-specific bins of unit dose
medications, which were then delivered to the nursing unit and stored in medication carts.

The ADC is a computerized point-of-use medication-management system that is designed to replace or

support the traditional unit-dose drug delivery system

The device require the staff to enter a unique log on and password to access the system by using a touch
screen monitor or by using finger print identification
Various level of system level access can be assigned to staff members, depending on their role in
medication-use process
Once logged into the system, the nurse can obtain patient-specific medications from drawers or bins
that open after a drug is chosen from the pick list

Rationale of acceptance
Improving pharmacy productivity
Improving nursing productivity
Reducing cost
Improving charge capture
Enhancing patient quality and safety

D. “Smart” Infusion Pump Delivery System

Are primarily used to deliver parenteral medications through IV or epidural lines

Medication errors with effusion pumps can also occur due to incorrect, inappropriation or miscalculation
of an order for the medication.
To implement the smart pump infusion technology, use a proactive technique to assess for he risk of
error to determine issues with IV drug administration.
Established team should institute changes in policies and procedures that reflect the smart infusion
technology is installed.

Theories, Model and Frameworks

1. Data, Information and Knowledge

Data – discrete entities that are described objectively without interpretation
Eg. Blood pressure, nursing intervention, patient problem, or an outcome

Information – reflects interpretation, organization or structuring data

-is the result of processing data
-data processing occurs when raw facts are transformed through the application of
context to give those facts meaning or via organization of data into a structure that connotes meaning

Knowledge – emerges from transformation of information

-is information that is synthesized so that relationships are identified and formalized

2. Electronic Health Record

- Simple perspective, EHR is a client health record supported by computer, electronic ad
communication technologies.
- Merged initially as a computer-based patient record or CPR and was given significant impetus by
1991
- Other terms for CPR are used, such electronic medical record (EMR), electronic patient record
(EPR) computerized patient record, or computerized medical record (CMR), before gradually
adopted as HER
- Defind as any information related to the past, present or future physical/mental health or
condtion of an individual.

3. Implementing and Upgrading Clinical Information Systems

Clinical Information System (CIS)
- Assist clinician with data necessary for decision making and problem solving
Major CIS requirements for nursing are
1. Administer a nursing department
2. Assist the management of nursing practice
3. Assist the nursing education
4. Support nursing research

A clinical information system (CIS) is an information system designed specifically for use in the critical
care environment, such as in an Intensive Care Unit (ICU). It draws information from all
these systems into an electronic patient record, which clinicians can see at the patient's bedside.

4. Eight Phases of Design, Implementation, and Upgrading

Planning
System Analysis
System Design / System Selection
Development
Testing
Training
Implementation
Evaluation

A. Planning – the information requirements necessary to solve the problem or accomplish the goal are
assessed.
- Excellent planning is time consuming and costly
- Can take up to 2 years to design and develop or select and implement a new system
- Critical phase whether a system is actually being developed or existing are being evaluated for
selection
The planning phase involves the following steps:
 Definition of the problem
 Feasibility study
 Documentation and negotiation of project scope agreement
 Allocation of resources

B. System Analysis Phase – second phase of developing a CIS, is a fact finding phase
- all data related to the problem defined in the project scope agreement are collected and analyzed to
gain sound understanding of the current system
The system analysis phase consist of the following steps
 Data collection
 Data analysis
 Data review
 Benefits identification
 System proposal development

C. System Design Phase – the design details of a system and the detailed plans for implementing are
developed for both the functional and technical components
The three major steps in system design phase
 Functional Specification
 Technical specification
 Implementation Planning

D. Testing Phase
Any system, newly developed or commercially available, must be tested to ensure that data are
processed correctly and desired outputs are generated.
Testing verifies that the computer programs are written correctly and ensures that when implemented
in the production environment, the system will function as planned.

Development scenario, 3 level of testing

 Unit testing – conducted by individual programmers as the program is being coded,
- system is tested to determine if the program protocol are used correctly and if the
program execute correctly

 Alpha testing- accomplished by testing (system assurance) with development organization

 -done in a development lab, focused only in the correct execution of programs
 Beta testing occurs at the first client site
- Representative of the development team assist the client in testing program for
the first time in real life situation

Commercially available software, three levels of testing

 First Level called functional test – the department teams test and verify the database, ensuring
that correct data have been entered into the files and tables
 Second level of testing called integrated system testing – the total system is tested. Include
interfaces between system as well as interplay between applications within the same system

E. Training Phase – essential to train the end user on how to use the system properly
- Training takes place before and during the activation of a new system
- Training is most effective when hands-on, interactive instruction is provided

F. Implementation Phase – organizes all the steps into a detailed plan describing the series of events
required to begin using the system or application in the production

G. Evaluation Phase – described and assesses, in detail, the new system’s performance
- summarizes the entire system, identifying strength and weakness of the
implementation process
- To determine if it has accomplished the stated objectives
-is the final and ongoing step in implementation process

PRACTICE APPLICATION

The critical importance of nursing informatics in patient care, “decision making must be based upon the
use of accurate data” said Florence Nightingale