NI LE (Chaps 19,20,32,33,51)

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Communication Skills in Health
IT, Building Strong Teams for
Successful Health IT Outcomes
Elizabeth (Liz) O. Johnson
• OBJECTIVES
1. Discuss the importance of communication in health IT to achieve adoption of
EHR technology.
2. Define the elements of effective communication plans.
3. Identify the stakeholders to consider in communications plans.
4. Describe the federal agencies, regulations, and other factors that affect health IT.
• KEY WORDS
Governance
Communication
Electronic health record
Physicians
Informaticists
Patient
for eligible physicians and healthcare providers who suc-

INTRODUCTION cessfully meet increasingly stringent requirements for
In America’s twenty-first century healthcare system, EHR implementation over the next five years.
landmark federal reform legislation enacted since 2009 is The journey to successful integration of health IT by
modernizing care-delivery organizations with new health providers industry-wide has been accompanied with chal-
information technologies (health IT) that regularly begin lenges. Tremendous complexities exist throughout health-
with the adoption of electronic health records (EHRs). care organizations working on health IT reform initiatives
Most notable of these laws are the American Recovery creating a critical need for effective communication cam-
and Reinvestment Act (ARRA) and its Health Information paigns that run throughout the lifecycles of acquiring,
Technology and Economic and Clinical Health (HITECH) implementing, and adopting EHRs in both inpatient and
Act provision, which established the Centers for Medicare ambulatory settings. Efforts such as these, with effective
and Medicaid’s (CMS) Meaningful Use of EHRs Incentive communication programs in place as a core strategy, sup-
Programs (Blumenthal & Tavenner, 2010). These programs port the goal of achieving the Institute of Medicine’s (IOM)
earmarked more than $22 billion in incentive payments six aims for improvement in care-delivery quality, making
293
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294 P art 4 • N ursing I nformatics L eadership
it safe, equitable, effective, patient centered, timely, and roles as new technologies are introduced. As a result, effec-
efficient (Institute of Medicine, 2001). tive communication programs have quickly become a high
As America’s healthcare system strives to be a “con- priority for hospitals and physician practices adopting EHR
tinuously learning” system, healthcare leaders and pro- and CPOE systems throughout the industry. The “continu-
viders realize that communication and improved patient ously learning” healthcare system in America depends
engagement are central to improving the value of health- on the involvement of all stakeholders—from patients to
care (Institute of Medicine, 2013a). Clinicians, clinical providers to management to vendors—to manage com-
informaticists, health organizations, and health IT policy- munications effectively and share them openly within the
makers serve as agents of change in the effort to involve entire healthcare community. The purpose of this chapter
patients not only in decision-making, but providing key is to provide an overview of communication strategies
pieces of health data. To enhance these efforts, IOM began that have proven effective in driving the implementation
the Evidence Communication Innovation Collaborative, of EHRs to support needs of patients, physicians, and the
which explores obstacles, solutions, and strategies to caregiver workforce. Sections in the chapter include (a) the
enhance patient involvement in healthcare (Institute of importance of communications in health IT initiatives; (b)
Medicine, 2013b). Two projects underway are “shared a focus on patient-centered, transparent care; (c) compo-
decision-making strategies for best care” and “patients’ nents of the communication plan; (d) industry consider-
attitudes on data sharing,” which should provide ways to ations (roles of federal agencies, federal regulations, and
encourage provider–patient communication and trans- the burgeoning role of mobile applications, social media,
parency in healthcare. and health information exchange); and (e) chapter review.
A number of studies have shown that good physician–
patient communication leads to improved patient satisfac-
tion as well as increased willingness of patients to share IMPORTANCE OF
pertinent data, adhere to medical treatment, and follow COMMUNICATIONS IN
advice. Under these circumstances, patients also are less
likely to lodge formal complaints or initiate malpractice
HEALTH IT INITIATIVES
suits (Ha & Longnecker, 2010). As Georgia Tech Professor William Rouse noted in a 2008
A strong communication campaign for physicians dur- article entitled “Healthcare as a Complex Adaptive System:
ing the EHR implementation is very important. Without Implications for Design and Management,” healthcare
such communication strategies, EHR adoption is far less organizations exist as complex adaptive systems with non-
likely. In 2002, for example, a major west-coast academic linear relationships, independent and intelligent agents,
medical center that heavily invested in the implemen- and system fragmentation (Rouse, 2008). While variation
tation of computerized provider order entry (CPOE) among them is gradually diminishing through increasing
encountered significant physician resistance. In large part, standardization of practices and systems, many provider
the clinician revolt occurred because physicians had been cultures still struggle with decentralization and reliance
insufficiently informed about and inadequately trained in on disparate legacy systems (Kaplan & Harris-Salamone,
the use of the clinical decision support (CDS) tool being 2009). The majority of healthcare organizations across the
implemented (Bass, 2003). According to David Bates, MD, nation have implemented EHRs, and providers are work-
in a 2006 Baylor University Medical Center Proceedings ing toward meaningful use in their health IT applications,
paper, failure to achieve leadership support or clinical creating the need for effective and tactical communication
buy-in from the large number of providers using the sys- plans. As the IOM’s Evidence Communication Innovation
tem resulted in strong resistance from an overwhelming Collaboration notes, “Communication is central to trans-
majority of physician effectively derailing the entire initia- forming how evidence is generated and used to improve
tive (Bates, 2006). the effectiveness and value of health care” (Halvorson &
Other provider organizations have encountered related Novelli, n.d.). The rapid changes in diagnostic and treat-
challenges with health IT implementations over the past ment options and the increased number of patients, with
decade (Kaplan & Harris-Salamone, 2009). Such costly, varying degrees of health literacy, turning to the Internet
high-risk experiences—especially in an increasingly for health information only serve to underscore the
patient-centric healthcare industry—have underscored the importance of clear and consistent communication. The
importance of effective, cross-enterprise, patient-focused following section provides insight into the importance of
communication plans and strategies that include physi- communications in health IT implementation programs:
cians and clinicians, administrators, clinical informaticists, in governance, the structure of a governance model, and
IT professionals, and the C-Suite—all of whom play critical rules for governance efforts.
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Chapter 19 • Communication Skills in Health IT, Building Strong Teams for Successful Health IT Outcomes 295
THE COMPLEXITY OF HEALTHCARE not want to share their practices with the other
competing group. Being cognizant of this expected
COMMUNICATIONS behavior should lead to the inclusion of collaboration
Healthcare systems face unique challenges in commu- opportunities as a part of the communication plan.
nications. Unlike corporations or other organizations, • “Agents are intelligent. As they experiment and
healthcare involves a variety of stakeholders, often with gain experience, agents learn and change their
competing goals and definitions of quality, in what is called behaviors accordingly. Thus overall system behav-
a complex adaptive system (Rouse, 2008). Complex adap- ior inherently changes over time.” Physicians, other
tive systems are described by William B. Rouse as follows: clinicians, clinical informaticists, administrators
are highly degreed professionals who are required
• “They are nonlinear and dynamic and do not
to comply with continuous education requirements
inherently reach fixed-equilibrium points. As a
result, system behaviors may appear to be random in order to maintain their certification. This pro-
or chaotic.” For example, healthcare in America vides a mechanism for sharing leading practices
is not governed by a single entity. The federal among their colleagues and changing their knowl-
government provides incentives to providers to edge, skill level, and attitudes. The challenge is that
implement EHRs, which have financial impact, but the rate of change varies across these groups where
the level and timing of compliance is still at the we find a continuum of “innovators, early adopt-
providers’ prerogative. Within a community, care ers, early majority, late majority, and laggards” as
providers have different owners and financial struc- described by Everett Rogers’ Technology Adoption
tures, i.e., for-profit, not-for-profit, single-owned Lifecycle model (Rogers, 1962).
entity, multi-provider organization, etc., which • “Adaptation and learning tend to result in self
affects how the EHR fits into their business plans. organization. Behavior patterns emerge; they are not
Communication approaches should be adaptable to designed into the system. The nature of emergent
environments which will not remain constant. behaviors may range from valuable innovations to
• “They are composed of independent agents whose unfortunate accidents.” When implementing an EHR,
behavior is based on physical, psychological, or we are not just implementing technology; we are also
social rules rather than the demands of system implementing standardized workflows. Although
dynamics.” The physician population best fits many system users adopt the new workflow, there are
this characterization. Most U.S. hospitals use also those who develop inappropriate “workarounds”
community-based physicians to service their to avoid changing their old behaviors. This requires
patients; these physicians are not employees of the the clinical leadership use clear messaging to hold
hospital and may serve patients in competing hos- their department members accountable for using the
pitals in the community. The hospital’s influence new technology in the appropriate manner.
over the compliance of these physicians to use the • “There is no single point of control. System behav-
EHR is limited to the physician-perceived ben- iors are often unpredictable and uncontrollable, and
efits of treating patients at that institution. Clear no one is ‘in charge.’ Consequently, the behaviors of
delineation and dissemination of benefits for all complex adaptive systems can usually be more easily
stakeholders is an effective approach for affecting influenced than controlled.” U.S. providers of care
independent agents. reflect a wide spectrum of structures—from small
• “Because agents’ needs or desires, reflected in their single proprietorships to limited partnerships to
rules, are not homogeneous, their goals and large multi-entity corporations. Some are privately
behaviors are likely to conflict. In response to these owned; others are government owned and operated,
conflicts or competitions, agents tend to adapt to such as the Veterans’ Administration healthcare sys-
each other’s behaviors.” Again, physicians provide a tem. Within healthcare systems decision-making is
good example of this scenario. Take the case where rarely a simple single threaded event. Creating suc-
two competing physician cardiology practice groups cessful campaigns for change require understanding
are serving a hospital that is implementing an EHR the influence structure and leveraging formal and
system that has built-in standardized decision informal communication approaches.
support to reflect leading clinical practices and to
reduce variation in care. However, the two practice Healthcare is, indeed, a complex adaptive system that
groups cannot agree on the standard of care or do cannot be directly controlled. Providers of care must be
c19.indd 295 05-02-2015 12:30:31

influenced to do the right thing and to aspire to a common the governance and communication plan to align with or
goal. Communications that are planned, strategic, broad- to evolve the culture of the organization.
based, and compelling are our best tool in effecting posi- Governance models in healthcare organizations pro-
tive changes in our healthcare environment. vide a structure that engages stakeholders to work through
critical decisions and ensure that risks associated with
changes in policy, technology, and workflow are mitigated
to maintain or improve the quality of patient care. A strong
LEADERSHIP AND GOVERNANCE example of a working model is provided by the author’s
The introduction of EHRs in healthcare organizations own health system—Tenet Healthcare Corporation.
drives transformational change in clinical and admin- Figure 19.1 illustrates the governance structure of Tenet
istrative workflows; organizational structure, i.e., that Healthcare’s IMPACT Program (IMPACT: Improving
which exists among physicians, nurses, and administra- Patient Care through Technology) and the importance of
tors; and relationships between the front-line workers, communications as it has been built into all layers.
physicians, administrators, and patients (Bartos, Butler, As shown here, a key to the success of this governance
Penrod, Fridsma, & Crowley 2006; Campbell, Sittig, Ash, structure is a three-tiered organizational structure that
Guappone, & Dykstra, 2006). Understanding the risks engages the corporation, regional operations, and the hospi-
posed by the disruptive facets of organizational and pro- tals themselves in a coordinated effort. Another key success
cess change is critical to ensuring the effective implemen- factor has been early commitment to key roles, including
tation of EHRs and mitigating risks of failure (Ash et al., clinical informaticists, physician champions, training and
2000). An essential part of risk mitigation in care-delivery communications leads, and health IT leads. Binding the
reform through health IT is the planning and implement- program together with unified, shared, and consistent mes-
ing of organizational communication initiatives that help saging continues to be a foundational strategy that supports
achieve the aims of an enterprise-wide governance team. all aspects of IMPACT’s execution (Johnson, 2012).
To succeed, responsibilities for such communications Barbara Hoehn, RN, MBA, summed up the importance
initiatives should be shared between health system lead- of communications in governance in her 2010 Journal
ers, champions, informaticists, and those charged with of Healthcare Information Management article entitled
oversight of the implementation of health IT systems, all “Clinical Information Technology Governance.” “Today, clin-
of whom should have a role to play in governance struc- ical IT is finally being universally viewed as a critical com-
tures whose processes are grounded in a strong commu- ponent of healthcare reform, and we are only going to get
nications strategy. A 2012 Hospital & Health Network one chance to do this right,” she wrote. “This means having
magazine cover story entitled “iGovernance” summarized everyone in the organization, from the Board Members to
the importance of such an approach for transforming the bedside clinicians, all focused on the same plan, the same
healthcare organizations as, “This IT governance func- tactical initiatives, and the same outcomes” (Hoehn, 2010).
tion, guided from the top but carried out by sometimes
hundreds of clinical and operations representatives, will
be evermore crucial to managing the escalation of IT in RULES FOR GOVERNANCE
healthcare delivery....” In fact, without such an informed Enabling governance committees requires a solid set of
governance process, the article states, “IT at many hos- rules, since hospitals are matrixed organizations com-
pitals and health care systems is a haphazard endeavor prised of multi-disciplinary staff and leaders from across a
that typically results in late, over-budget projects and, healthcare organization. A set of “rules to live by” in “iGov-
ultimately, many disparate systems that don’t function ernance” is identified in Table 19.1 (Morrissey, 2012).
well together” (Morrissey, 2012). Accountability begins at The following describes each role:
the hospital level and rises through the enterprise level.
Messaging through electronic, in-person, or video media 1. Hardwire the committees: Ensure that the chair of
options from chief executive officers and board mem- lower-level committees be participants on the next
bers of governance groups solidifies the importance of level of committees. Their role is to bring forward
enterprise-level health IT projects (College of Healthcare recommendations and issues needing higher-level
Information Management Executives [CHIME], 2010b). engagement for resolution.
However, both governance structures and the communi- 2. Set clear levels of successive authority: Committee
cations that support them require tailoring depending on responsibilities should be well defined so members
the nature of every health system. Communication leaders know issues they can address and issues beyond their
from the organization should be involved in developing level of authority (Hoehn, 2010).
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BOARD OF DIRECTORS
SUB-COMMITTEE
PMO/FMO
Accountability
Corporate
Global VP of Clinical Informatics EXECUTIVE

Delivery STEERING COMMITTEE
Business (EHR Implementation Lead)
Solutions
Functions
MEANINGFUL USE
COMMITTEE
HEALTH SYSTEM
Accountability
Operations
PARTNER COUNCIL
HOSPITAL STEERING OPERATIONS

COMMITTEES COMMITTEE Physician
Advisory
Council
Clinical
Leadership
Hospital Project Leads Council Clinical
Advisory
Accountability
Councils
Hospital
• FIGURE 19.1. EHR Implementation and Oversight Governance.
3. Do real work every time: Focus meetings on impor- who commands respect and possesses operational
tant issues in need of clinician engagement. If there authority to enact recommendations.
are no critical items, cancel the meeting and send
More specifically for health information technol-
out status reports electronically.
ogy, the Office of the National Coordinator for Health
4. Form no governance before its time: Recognize Information Technology (ONC), knowing that this area
that different organizations will not be prepared to requires consensus among many stakeholders, lays out
embrace a governance structure at the same time or milestones and expected outcomes for governance. In
to the same degree as others. their governance framework, ONC presents milestones
5. Put someone in charge that can take a stand: The and expected outcomes, rather than specific steps, for
leader of the top committee must be someone governance. These goals include organizational transpar-
ency and trust for all stakeholders (Office of the National
TABLE 19.1 Rules to Live by for Governance Coordinator for Health Information Technology, 2013).
Participants
1. Hardwire the committees. FOCUS ON CUSTOMERS
2. Set clear levels of successive authority. AND PLAYERS
3. Do real work every time.
Those who are engaged in EHR implementation initiatives
4. Form no governance before its time. should also be involved in communications associated
5. Put someone in charge who can take a stand. with these multi-year programs. Figure 19.2 illustrates the
spectrum of customers and players.
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that is promoted by the governing body and integrated
Patients &
Communities into practice by leadership and management working with
the organization’s health care teams” (Federal Register
II(B)(5), 2011).
Health System
Physicians
Leadership
Focus of Physicians
Communications
Nursing
As discussed in the introduction, adoption of EHRs by
IT Departments health systems or practices cannot be expected to suc-
Workforce
ceed without the endorsement and ownership of the
Multi- physician community, whose working environment must
disciplinary inevitably adapt to changes to long-established workflows.
Project Teams
Furthermore, when included from the outset of any health
IT transformation initiative, the deployment of “physician
• FIGURE 19.2. Focus of Communications. champions” can become powerful and effective commu-
nicators, assisting colleagues through health IT adoption.
In fact, a Government Health IT story reported that
In the provider setting, each of these groups has a dif- ONC itself, through its regional extension centers, has
ferent type of communications engagement. The media recruited “physician champions” who are well on their
and vehicles used may be different, but the strategic focus way to becoming meaningful users of EHRs to help oth-
is the same: improving the quality of patient care through ers in their area get over the hurdles of digitizing their
strategic adoption of health IT that is in turn enabled by medical records (Mosquera, 2011). Therefore, the need
smart communications. for communications that supports not only training ini-
tiatives and the management of new procedural require-
ments, but also an understanding of the dynamics of
Patients and Communities
legislated healthcare reform itself, is important from the
In its 2001 report, Crossing the Quality Chasm: A New earliest stages of health IT adoption.
Health System for the 21st Century, the IOM established However, such needs are often unmet. An April 2012
the need for patient-centered communications and sup- iHealthBeat article reported, for example, that the results
port as part of the six aims for improving healthcare, as of a recent survey of more than 250 hospitals and health-
noted in the introduction (Institute of Medicine, 2001). care systems demonstrated that significant percentages of
Since then, patient-centric healthcare and the emergence respondent physicians had inadequate understanding
of care-delivery models such as the Patient-Centered of Stage 1 meaningful use requirements; others cited a
Medical Home (PCMH) have become central to health lack of training and change-management issues (Providers
reform. Integral to the PCMH concept are seven joint prin- Make Progress in EHR Adoption, 2012). As a result of
ciples established in 2007, one of which calls for a “whole- improved programs and communications in organizations
person orientation.” This means each personal physician is such as regional extension centers, 72% of office-based phy-
expected to provide for all of a patient’s lifetime health ser- sicians had used an EHR by the end of 2012, and 66% were
vice needs. Lifetime engagement related to health drives planning to or had applied for meaningful use (Bendix,
the requirement for comprehensive physician-to-patient 2013). These statistics spotlight the continued need to
communications and shared decision-making (Patient- directly engage physicians in health IT implementations
Centered Primary Care Collaborative, 2007). through comprehensive communications initiatives.
Such communications are also required to support
healthcare reform at the community level, as demon-
Nursing Workforce
strated in CMS’s 2011 establishment of the Three Part
Aim for the Medicare Shared Savings Program, e.g., the For patients in both inpatient and ambulatory settings,
Medicare ACO, with its focus on “better care for individu- nurses constitute the front line of patient care. But for
als and better health for populations” (Federal Register. health systems everywhere, they are also on the front line
I.(C), 2011). In its final rule for the Medicare ACO, CMS of health IT reform. As Joyce Hahn, Executive Director
mandated the requirement for advancing patient-centered of the Nursing Alliance for Quality Care, said, “Nurses
care through accountable care organizations (ACOs), stat- represent the largest potential users of electronic health
ing, “an ACO shall adopt a focus on patient-centeredness records” (Hahn, 2011). As with their physician colleagues,
c19.indd 298 05-02-2015 12:30:32

therefore, the role of communications is not limited to IMPACT program news, features stories from successful
training nurses in the use of EHR systems, but rather hospital CPOE implementations so that upcoming hos-
preparing them to engage fully in the design, testing, and pitals can take advantage of the lessons learned (Johnson
implementation of EHRs to support improved care coor- and Browne, 2012). This has resulted in improved training
dination and continuity of care. Throughout the health- processes and has better prepared the hospitals across the
care industry, health systems CIOs are finding that “the board for changes in the system’s EHR system applications.
success of large IT implementations will depend not only The success stories also fostered healthy competition across
on the willingness of floor nurses to accept new technol- the health system to surpass previous CPOE adoption
ogy, but also on the strength of the IS-nursing manage- metrics at go-live. Newsletters should be distributed on a
ment connection” (Mitchell, 2012). Therefore, engaging consistent basis, have a recognizable template of content
nurses through communications both as champions and that is always included, and provided in a variety of com-
users of new health IT is a strategic necessity. munications mediums such as e-mail, print, and company
The clinical nurse informaticist has become a key role intranet.
in ensuring the adoption of EHR technology and the sus-
tainment of benefits. This role serves as a key change agent
Patients and Consumers
and communicator to all clinical disciplines by facilitat-
ing interdisciplinary workflows and using metrics to drive One imperative in the Patient Protection and Affordable
improvements in patient care. Care Act (PPACA) is that providers must encourage patients
Nursing Advisory Teams (NAT) can function as deci- to engage in their own care and communicate electronically
sion-making bodies—and NAT’s decisions will become with providers. This is seen as an important step in reduc-
the standard for the implementation of core clinical ing hospital re-admissions for patients who have certain
EHR applications. The consistent way that these leaders medical conditions, such as diabetes. However, hospitals
communicate their decisions has proved to be integral face some resistance from patients, who would rather speak
to promoting safe, quality patient care and improving directly with their physicians or do not understand the ben-
outcomes for patients and families while supporting the efits of reviewing and maintaining their own health records.
clinical quality initiatives (Johnson, 2012). Nurses and To combat such challenges, hospitals are creating
nursing informaticists can be key persons in the commu- patient-friendly portals where patients can check their
nication approach with physicians. Using their established appointments, see their lab results, pay bills, and send
relationships, nurses are able to remove the barriers and secure messages to their physicians. Some hospitals also
concerns physicians initially express in using EHRs, par- are interacting directly with private physician offices to
ticularly computerized physician order entry. Provision of ensure follow-up care, which often reduces the need for
key talking points and documented benefits should be for- readmission, and using telehealth services for high-risk
mally incorporated into the communication plan. patients. In addition, organizations, such as home nurs-
ing agencies, are text messaging to check in on pregnant
women and new mothers (Versel, 2013). It should be noted
IT Departments and Multi-disciplinary
that to ensure success, the language and content of patient
Project Teams
communication will be different for that used among cli-
IT departments and project teams are responsible for nicians. All of the components of health literacy such as
meeting the challenges of new-system introductions as reading level, language preference, local naming conven-
well as managing the continuous upgrades to existing tions for health conditions are critical considerations when
ones. To support this work, the teams’ roles in commu- crafting communications for the patients and consumers.
nications efforts involve engaging clinicians in staff posi- Another resource that should be considered an effective
tions, confirming commitments, managing change, and communication tool and methodology related to patient
setting EHR deployment strategies, per The CIO’s Guide engagement is the ONC Regional Extension Centers
to Implementing EHRs in the HITECH Era, a 2010 paper (RECs). These RECs serve as a communication and support
from the College of Healthcare Information Management resource for providers as they choose, implement, and use
Executives (CHIME) (CHIME, 2010a). EHRs. The centers assist in workflow analysis and help pro-
Organizational newsletters are effective communica- viders connect with their patients using tools like patient
tion vehicles for sharing best implementation practices, portal which is a window to their information in their
success stories and fostering team cohesiveness across EHR. As of July 2013, more than 147,000 providers were
the healthcare organization. For example, The IMPACT enrolled with a regional extension center. Of these, more
Insider, Tenet’s weekly cross-enterprise e-newsletter for than 124,000 had a live EHR and more than 70,000 had
c19.indd 299 05-02-2015 12:30:32

demonstrated meaningful use. Some 85% of REC-enrolled who function as subject matter experts, and champions to
providers were live on an EHR vs. 62% live on an EHR in secure buy-in for system adoption.
the general provider population (Office for the National A 2009 article by Chad Eckes, CIO, and Edgar Staren,
Coordinator of Health Information Technology, n.d.-a). MD, entitled “Communication Management’s Role In EHR
Success” offers other ideas, such as (Eckes & Staren, 2009):
Healthcare System Leadership • Fact Sheets, newsletters, and posters: collateral

tailored to clinician audiences
As noted in the section on governance, communica-
tions led by an executive-level steering committee, often • Road shows: pre-implementation educational
demos of forthcoming system capabilities
chaired by a health system’s chief executive or operating
officer, represent the beginning and the end of successful • Town hall meetings: opportunities for senior
health IT implementation processes. The top of the orga- leaders to hold question and answer sessions
nization not only establishes the size of the investment • Standard meeting reports: detailed status notes
the organization is prepared to make, but also commu- of schedules, budget, risks, and progress
nicates “the broad strategies for IT in advancing business
An e-newsletter can be used to communicate suc-
goals and, ultimately, acting on the result of a consistently
cess stories from hospitals that are further down the road
applied proposal and prioritization regimen” per the 2012
and have successfully implemented EHR systems. Such
“iGovernance” article cited earlier (Morrissey, 2012).
a vehicle is especially effective for integrated health sys-
tems whose hospitals are spread geographically across the
country.
Another perspective is provided by a 2005 JHIM article
BUILDING A COMMUNICATIONS PLAN by Detlev Smaltz, PhD, FHIMSS, and colleagues, in which
Kaiser Permanente noted in the 2011 HIMSS Davies they discuss the importance of project communication
®
Award application for their KP HealthConnect EHR that plans focused on stakeholder groups and meeting their
they credited their communication initiatives for “creating needs. Table 19.2 provides a sample of this plan for three
awareness, building knowledge, managing expectations, stakeholder groups (Smaltz et al., 2005).
motivating end users, and building proficiency” (Health Communicating an EHR implementation plan to phy-
Information Management Systems Society [HIMSS], sicians, nurses, and providers is essential for EHR suc-
2011). As part of their communications plans, they cess. Unlike many other hospital initiatives, changes that
included vehicles such as a central Intranet site, leader- directly affect the responsibilities of providers may be met
ship messaging, weekly e-newsletters, regional commu- with ambivalence, passivity, or as in the west-coast medi-
nication tactics, and videos. Other health systems also cal center mentioned in the introduction, active resistance.
employ e-mail updates, end-user training, super-users Therefore, communication about such changes should
TABLE 19.2 Sample of Health IT Project Communication Plan

Stakeholder Objective Media Content
Executive Management Update on cost, benefits, service • In-person meeting and briefing Status update and
quality, and milestones impact on outcomes
Nursing Maintain awareness of progress; • Nurse educators • Project methodology
engage in design effort • Nursing leadership • Design participation
• Collateral • Educational info
• Unit meetings • Outcomes impact
• Intranet Web site
Medical Staff Maintain awareness of progress; • Medical executive committee • Project methodology
engage in design sessions • Clinical chairs • Design participation
• Targeted newsletter • Educational info
• Outcomes impact
c19.indd 300 05-02-2015 12:30:33

include the following four steps, according to Michael Patients also should be included in EHR communica-
Crossnick, HITECH Answers (Crossnick, 2012): tions. Blackstone Valley Community Healthcare, working
with a regional extension center in Rhode Island, created
1. Create process teams: Create process teams within
a patient portal named HealthKey, with which patients
the staff to define the new workflow processes. These
could schedule appointments and e-mail questions
teams get the rest of the staff involved and help edu-
(HealthIT.gov, 2011). Patients coming in for appointments
cate them as the practice prepares to adopt an EHR.
provided their e-mail addresses, which generated invita-
These teams should meet at well-defined intervals on
tions to HealthKey. While initial use of the patient portal
a regular and consistent basis.
was modest, those who did use it viewed it favorably. A
2. Communicate the logic for EHR adoption: Explain key issue has been getting patients to complete the second
all the benefits of EHR adoption, how each member step, which is completing enrollment on the portal. As a
of the staff will benefit, and how the patients will result, Blackstone is purchasing kiosk terminals for wait-
ultimately benefit by improved quality of care. Be ing rooms so patients can complete the enrollment onsite
careful to avoid “because we said so,” or “it’s a gov- and are planning a patient survey to evaluate HealthKey.
ernment mandate” statements. While this may be Communications strategies may also need some cre-
true in some instances, it does not capture the true ativity; in late 2013, patients who enrolled in the patient
spirit of EHR adoption. portal were eligible to win a mini iPad (Blackstone Valley
3. Define measurable success factors: Clearly state Community Healthcare, 2013).
what the critical success factors are surrounding
the new EHR workflows and processes and follow Communication Metrics
this with a reporting system to evaluate success and
improve the processes once the EHR has been fully The best metrics to measure communication program
deployed. effectiveness are arguably the same used to present the sto-
ries of successful health IT implementations themselves.
4. Clearly communicate results: Establish a communi- In Tenet’s case, strong governance programs supported by
cation plan to communicate the definition of success. a pervasive and adaptable communications strategy have
These communications should happen frequently at helped drive EHR/CPOE Meaningful Use go-lives in 49
pre-defined intervals on a regular basis. Be certain to hospitals across the country by the end of the first quarter of
include all successes, as well as areas for opportunity, 2014. These results were supported by weekly e-newsletters,
in these communications. Nothing aligns people hospital site–specific communications campaign, future
faster than gaining success, even if they are initially state workflow localization, change readiness assessments,
small accomplishments. at-the-elbow support for providers from super-users and
subject matter experts throughout the go-live processes,
physician partnering, post–go-live support, and 24 × 7
PROJECT PHASES AND THE command centers for 10 days post–go-live.
COMMUNICATION FUNCTIONS
Health IT projects often unfold over multi-year periods
with pre-adoption (selection), pre-implementation, imple-
KEY INDUSTRY CONSIDERATIONS
mentation (go-live), and post-implementation (outcomes) While much of the communications focus supporting the
comprising the four major phases (Rodriguez & Pozzebon, implementation of new EHR systems and related health
2011). It is important that communication plans be built IT is directed inside a health system, those responsible for
and integrated within these phases, because the informa- building communication strategies must do so in the con-
tion needs of stakeholders will vary as projects evolve and text of industry change beyond any hospital’s walls. With
mature. Furthermore, a variety of formal and informal the arrival and rapid entrenchment of the digital age over
communication media will be needed to reach different the last decade, innovations in mobile devices and social
health-system groups, a point made in a 2009 Journal media platforms have broadened, enriching communica-
of AHIMA article entitled “Planning Organizational tions options to support successful health IT integration.
Transition to ICD-10-CM/PCS” (D’Amato, et al., 2009). Furthermore, the actions of the Federal Government to
The article further states that because points of urgency ensure increasing volumes of trusted, secure health infor-
and risks to be mitigated are also critical to key stakehold- mation exchange are constantly redefining how and what
ers, they should also be considered among the key ele- the healthcare industry can expect to communicate across
ments of an effective communication strategy. the continuum of care in the coming days, months, and
c19.indd 301 05-02-2015 12:30:33

years. Therefore, communications planning in support of that have emerged in the Health 2.0/Medicine 2.0 era as
health IT initiatives must reflect the forces driving such defined by Van De Belt and colleagues in their 2010 Journal
change: an expanding world of media, the roles of Federal of Medical Internet Research article (Van De Belt, Engelen,
healthcare agencies, and the adoption of regulatory stan- Berben, & Schoonhoven, 2010). Keys to enabling produc-
dards as they are driving the evolution of health informa- tive communications with today’s new interactive tools
tion exchange itself. recognizes that “(a) health has become more participa-
tory, (b) data has become the new ‘Intel Inside’ for systems
supporting the ‘vital decisions’ in health, and (c) a sense
SOCIAL MEDIA AND eHEALTH of ‘collective intelligence’ from the network would supple-
INITIATIVES—MEETING THE ment traditional sources of knowledge in health decision-
HEALTH COMMUNICATION making” as summarized by Hesse and colleagues in their
2011 article entitled “Realizing the Promise of Web 2.0:
NEEDS OF COMMUNITIES Engaging Community Intelligence” (Hesse et al., 2011),
Physicians and clinicians across the industry are increas- Social media sites bring new opportunities to improve
ingly communicating among themselves and with their provider-to-provider communications within physician-
patients due to an explosion of mobile health device centric channels. These include sites like Sermo and
technology. A recent article entitled “Doctors’ Tablet QuantiaMD, which cater only to the physician community.
Use Almost Doubles in 2012” confirmed through a sur- Other social networking sites support patient communi-
vey of 3015 physicians that nearly 62% are using some ties that bring new opportunities for marketing of services
type of tablet platform—with the dominant choice being and disseminating best practices, as noted by David Nash,
Apple’s iPad. Such technologies are rapidly evolving, and MD, MBA, in a May 2010 article, entitled “Social network-
clinicians are increasingly depending upon them to docu- ing impact on patients, doctors, and non-profits” (Nash,
ment patient visits, manage clinical workflows, conduct 2010). As with mobile devices, the many positive effects
research on technical and clinical issues, and receive alerts to be gained from participation in social media must be
regarding patient conditions (Vecchione, 2012). considered alongside concerns for the privacy and secu-
While the upside to this rapid increase in commu- rity of protected health information. Supported by the
nication technologies is tremendous, the deployment HIPAA Privacy and Security Rules passed in 1996, health-
of such devices in the marketplace may be surpassing care organizations have become more vigilant in estab-
the pace for which security precautions can keep up, as lishing rules and policies governing participation in social
noted in a February 2012 Forbes article, aptly entitled media. Such heightened awareness was recently noted in
“How Healthcare’s Embrace of Technology has Turned the April 2012 Federation of State Medical Boards, “Model
Dangerous” (Lai, 2012). The article acknowledged the Policy Guidelines for Appropriate Use of Media and Social
“huge potential in helping medical providers diagnose Networking in Medical Practice.” Even so, as these com-
patients more quickly and accurately, improving the munication platforms evolve in the future, addressing
patient-provider relationship, and reducing extra paper- issues of privacy and security will be a key concern for
work – and the medical errors that are sometimes caused the industry, physicians, health systems, patients, and the
by them.” But it also called on hospitals to help “draft up healthcare reform movement as a whole (Lewis, 2011).
an industry-wide set of best practices governing the use of
mobile devices in hospital settings.”
To address security issues, the FDA released final ROLE OF FEDERAL
guidelines for mobile technology use in September 2013
(Food and Drug Administration, 2013). While these are
HEALTHCARE AGENCIES
non-binding guidelines that address mobile medical apps, Healthcare reform during the past decade has been
they provide a roadmap for current use and the devel- defined, spearheaded, and guided by Federal Government
opment of future medical mobile apps. They may also agencies armed with ARRA and HITECH legislation to
play a role in other eHealth initiatives as more and more providing funding, oversight, and industry-level guid-
consumers turn to their mobile devices to interface with ance on the implementation and adoption of health IT
patient portals to communicate with their providers and throughout the United States (Robert Wood Johnson
maintain their personal health records. Foundation [RWJF], 2009). Leading the government’s
Beyond devices, new digital media vehicles encom- healthcare initiatives is the U.S. Department of Health and
pass a multitude of healthcare specific social media Web Human Service (HHS) (Department of Health and Human
sites such as PatientsLikeMe, Sermo, and Diabetesmine Services, n.d.).
c19.indd 302 05-02-2015 12:30:33

Two key divisions of HHS are CMS and ONC. In addi- able to share information, including electronic copies
tion to Medicare (the federal health insurance program for and visit summaries for patients. As of October 2013,
seniors) and Medicaid (the federal needs-based program), 85% of eligible hospitals and 60% of eligible providers
CMS oversees the Children’s Health Insurance Program have received incentive payments, which means that
(CHIP), the Health Insurance Portability and Accountability they have adopted, implemented, and met the crite-
Act (HIPAA), and the Clinical Laboratory Improvement ria for EHR use (Reider & Taglicod, 2013).
Amendments (CLIA), among other services. Also, under Stage 2: To be implemented in 2014 under the current
HITECH, CMS is charged with advancing health IT through proposed rule and extend to 2016, “Stage 2 meaning-
implementing the EHR incentive programs, helping define ful use” includes new standards such as online access
meaningful use EHR technology, drafting standards for for patients to their health information and electronic
the certification of EHR technology, and updating health health information exchange between providers.
information privacy and security regulations under HIPAA
Stage 3: Expected to begin in 2017, “Stage 3 meaning-
(Centers for Medicare and Medicaid Services [CMS], n.d.).
ful use” is projected to include criteria that dem-
Much of this work is done in close conjunction with
onstrate improvement in the quality of healthcare
ONC and the two critically important federal advisory
(Reider & Taglicod, 2013).
committees that operate under its auspices. The first of
these committees is the Health IT Policy Committee, which
makes recommendations to ONC on development and
adoption of a nationwide health information infrastruc- ROLE OF REGULATORY STANDARDS
ture, including guidance on what standards for exchange of AND THE EVOLUTION OF HEALTH
patient medical information will be required (Office of the
National Coordinator for Health Information Technology
INFORMATION EXCHANGE
[ONC], n.d.-b). The Policy Committee has a number of In today’s era of healthcare reform, an increasing num-
workgroups that address specific issues, such as governance ber of standards in the area of health, health information,
for a nationwide health information exchange, consumer and communications technologies are helping guide the
involvement, and privacy and security measures for EHRs. healthcare industry toward interoperability between
The second is the Health IT Standards Committee, independent entities and systems. The goal is to support
which focuses on recommendations from CMS, ONC, and the safe, secure, and private exchange of PHI in ever-
the Health IT Policy Committee on standards, implemen- increasing volumes to improve the quality of care.
tation specifications, and certification criteria for the elec- As advised by ONC, CMS, and the Health IT Policy
tronic exchange and use of patient health information (PHI) Committee, the Health IT Standards Committee is the
(Office of the National Coordinator for Health Information primary federal advisory committee working to fulfill this
Technology [ONC], n.d.-c). Many of its workgroups aim to mandate. It is also a committee upon which this author
set specific criteria and standards to ease the implementa- is proudly serving at the appointment of HHS Secretary
tion of new programs and to measure their effectiveness. Kathleen Sebelius. Table 19.3 provides a summary of the
Understanding the roles of these agencies and duties of this committee as provided by a 2009 Robert
committees—and keeping abreast of their actions—is an Wood Johnson Foundation Report, “Health Information
important responsibility for those engaged in planning Technology in the US: On the Cusp of Change and the
and delivering communications that support health IT American Recovery and Reinvestment Act” (Robert Wood
adoption. Individually and collectively, they help drive the Johnson Foundation [RWJF], 2009).
definition of incentive payment requirements across the The Health IT Standards Committee has established
three stages of EHR Meaningful Use. Each stage not only over the course of its deliberations a number of important
creates new health IT performance requirements inside a workgroups as sub-committees to the parent committee.
given health system, but also defines the kinds of informa- These workgroups meet periodically to discuss their topics,
tion exchange—in themselves forms of communication— present their findings at Health IT Standards Committee
that will be required between healthcare entities across meetings, and make recommendations to this Committee.
the entire continuum of care, including those directly The agency’s sub-committees are formed around subjects
focused on the patient and the community. such as Clinical Operations, Clinical Quality, Privacy &
Security, Implementation, Vocabulary Task Force, Consumer
Stage 1: Beginning in 2011 as the incentives program Technology, and the Consumer/Patient Engagement Power
starting point for all providers, “Stage 1 meaningful Team (Office of the National Coordinator for Health
use” consists of transferring data to EHRs and being Information Technology [ONC], n.d.-c).
c19.indd 303 05-02-2015 12:30:33

TABLE 19.3 Duties of the HIT Standards the accelerated use of health IT. CMS, ONC, and its HIT
Committee Policy and Standards Committees are driving communi-
cations at the industry level to provide all stakeholders
Duties with a common set of rules to follow for selection, design,
implementation, and adoption of EHRs. Challenges still
Harmonize or update standards for uniform and consistent
implementation of standards and specifications.
persist, however, when effective communication plans are
not developed and followed in complex health IT projects
Conduct pilot testing of standards and specifications by the
that can affect physicians, nurses, administrators, and
National Institute of Standards and Technology.
patients alike.
Ensure consistency with existing standards. This chapter has addressed issues regarding the impor-
Provide a forum for stakeholders to engage in development tance of communications and the development of effec-
of standards and implementation specifications. tive communication strategies in strengthening initiatives
Establish an annual schedule to assess recommendations of ranging from governance efforts to physician-to-patient
HIT Policy Committee. partnerships—all as part of successful EHR implementa-
Conduct public hearings for public input. tions. Key takeaways to consider in the conclusion of this
Consider recommendations and comments from the chapter include the following:
National Committee on Vital and Health Statistics (NCVHS)
in development of standards. • Coordinated, cross-enterprise communications
strategies are critically important parts of health
IT implementations, including the development of
The Implementation Workgroup is dedicated to ensur- governance structures supporting the introduction
ing that what is being asked of the greater health-system and adoption of EHR systems.
and physician-practice communities is actually feasible • The customers and players engaged in communi-
in terms of adoption and meaningful use. A strong public cations include patients and communities, physi-
communications strategy is core to the work of this work- cians, nurses, clinical informaticists, project teams
group, which holds hearings with broad healthcare indus- and IT departments, and health system leadership.
try representation—including health systems, physicians, Remember that patient-centricity, the Meaningful
EHR and other health IT vendors and developers, among Use program, and physician and nurse engagement
others—and maintains active liaison relationships with are all critical points in the communication initia-
the sister Health IT Policy Committee. tives for these participants.
As a result, the Implementation Workgroup will con-
tinue to bring forward “real-world” implementation experi-
• Vehicles in a communications plan can include
an Intranet, print media, road shows, Town Hall
ence into the Standards Committee recommendations with meetings, and standard meetings to be used
special emphasis on strategies to accelerate the adoption of through all phases of a project and the success of
proposed standards, or mitigate barriers, if any (Office of the such projects can be the best measure of the com-
National Coordinator for Health Information Technology, munication plan’s effectiveness.
n.d.-d). Currently, the Implementation Workgroup is updat-
ing the goals and objectives for Meaningful Use Stage 3. • Some of the most powerful forces driving change
As are the meetings of the Health IT Policy and include social media, mobile devices, and contin-
Standards Committees, all workgroup meetings are held ued healthcare reforms and should be considered
in public, and notices for each meeting appear on the when developing communications plans.
ONC Web site and in the Federal Register (Office of the • The ONC’s committees, the HIT Policy and
National Coordinator for Health Information Technology, Standards Committees, and sub-committees, such
n.d-d). Public comment is always welcome. as the Implementation Workgroup, are key drivers
of national communications important to all stake-
holders involved in working toward the meaningful
CHAPTER REVIEW: FUTURE OF use of EHRs.
COMMUNICATIONS IN HEALTH IT America’s healthcare system is a complex, expensive sys-
ARRA, HITECH, and incentives programs supporting tem that needs to learn and adopt continuously to improve
the meaningful use of EHRs are helping the healthcare the quality of care and outcomes, protect patient safety, and
industry make a paradigm shift in care delivery through reduce inefficiencies (Institute of Medicine, 2013a). One of
c19.indd 304 05-02-2015 12:30:33

the major ways these goals can be accomplished is through considering new role players for your EHR implementation.
the increased use and development of health IT. Health IT The CIO’s guide to implementing EHRs in the HITECH era.
can increase providers’ abilities to share and retain patient CHIME Report. CHIME, Ann Arbor, MI. pp. 13, 31.
information and can support initiatives in patient engage- College of Healthcare Information Management Executives
(CHIME). (2010b). Chapter 9: Communication dispels
ment, care coordination, Meaningful Use, and eHealth. As
fear surrounding the EHR conversion. The CIO’s guide to
the healthcare industry grows increasingly interconnected implementing EHRs in the HITECH era. CHIME Report.
through health IT and other technologies, effective com- Retrieved from http://www.cio-chime.org/advocacy/
munication plans will remain essential parts of the process. CIOsGuideBook/CIO_Guide_Final.pdf
With a commitment to the development and execution of Crossnick, M. (2012). EHR implementation process requires
communications strategies around the implementation of communication. HITECH Answers. Retrieved from http://
emerging health IT, higher levels of ownership and com- www.hitechanswers.net/ehr-implementation-process-
mitment by professionals will help ensure the success of the requires-communication/. Accessed on March 27, 2012.
U.S. healthcare reform movement in years to come. D’Amato, C., D’Andrea, R., Bronnert, J., Cook, J., Foley, M.,
Garret, G., … Yoder, M. J. (2009). Planning organiza-
tional transition to ICD-10-CM/PCS. Journal of AHIMA/
American Health Information Management Association,
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20
Assessing the Vendors
Mark D. Sugrue
• OBJECTIVES
1. Describe an approach to evaluate the vendor marketplace for health information
technology solutions.
2. Discuss the evolution of the healthcare technology market place.
3. Distinguish the custom development or “build” approach from the purchasing of
commercially available solutions or “buy” approach.
4. Identify two or more criteria that may be used to differentiate one vendor from
another.
5. List the key Guiding Principles of a Vendor Analysis Methodology.
• KEY WORDS
Best of breed
Change management
Return-on-Investment (ROI)
Request for Information (RFI)
Request for Proposal (RFP)
Single vendor
INTRODUCTION support their own electronic health record software. The

idea of developing in-house applications, often referred
Assessing the Healthcare Information Technology market to as the “build” approach, was necessary at a time when
can be a daunting task. It is estimated that the global health commercial options were limited. The benefits of the build
IT market will reach $56.7 billion by 2017, an increase approach included the ability to program specifications to
from the 2012 market value of $40.4 billion (Pedulli, 2013). the organization’s unique requirements and the flexibility
In the United States alone, more than 1000 vendors exhibit to apply future updates or enhancements whenever they
at the Health Information Management Systems Society were needed.
(HIMSS) annual conference. Navigating the field of poten- The cost of the build approach, however, was great
tial vendors and assessing solution require a skilled and and many organizations could not compete within their
experienced leader and a team committed to a fair, unbi- market for the technical resources required to develop
ased, and thoughtful analysis. and support home grown solutions. There was also
great institutional risk associated with this approach.
Mission critical applications, for example, programmed
Build vs. Buy
by an employee could result in a single point of fail-
In the early days of Healthcare Information technology, ure should that individual no longer be available to the
many pioneering organizations elected to develop and organization.
309
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The commercial healthcare information technology 4. Use the Data; Trust your Gut
vendor market began to flourish in the middle of the 5. Make a Commitment
twentieth century with many of the early solution offer-
ings focused on financial and back office functions. As
technology continued to evolve so too did the market.
Demand for solutions increased steadily and over time VENDOR ASSESSMENT
vendors began to diversify their portfolios to include more METHODOLOGY
and more applications across different settings.
Whether large or small the introduction of new technol-
Today, there are many categories of vendors in the
ogy into an environment will have an impact on users and
market offering a wide variety of solutions. The competi-
potentially patients. Effectively managing this change at
tion has helped make purchasing or buying a solution the
both the individual and institutional levels will be a critical
more popular choice by far. This “buy” option as it is com-
success factor (Sugrue, 2010).
monly referred to has created a robust and thriving health
In many ways the selection project itself is an opportu-
IT marketplace.
nity to engage users and begin the process of introducing
change. As the team begins to assemble its plan to assess
Vendor Assessment Methodology vendors it should remember that communication with all
stakeholders is important. While it is not possible to have
Effectively assessing the vendor marketplace requires a
every stakeholder or employee of the organization actively
data-driven methodology and approach that will guide
participating in each step of the process, it is possible and
the organization through a vendor analysis process. The
highly recommended for teams to effectively communi-
graphic in Fig. 20.1 represents a Vendor Assessment
cate status and inform all of progress.
Methodology. Throughout the methodology Key Guiding
Principles are embedded to ensure that proven best prac-
tices are adhered to.
Understanding the steps of the methodology along with GUIDING PRINCIPLE #1—Manage the Change;
the Key Guiding Principles and incorporating these into a Communicate
well-developed and well-managed project plan will help
ensure that the organization is applying a fair and unbi-
ased approach to assessing potential vendor solutions. Guiding Principle #1 is “Manage the Change; Comm
unicate” and this cannot be stressed enough.
Key Guiding Principles Large-scale transformation efforts such as new technol-
ogy implementations may begin with an Organizational
The Key Guiding principles include: Change Readiness Assessment prior to a Vendor Assess
ment. In today’s rapidly changing healthcare environment
1. Manage the Change; Communicate
the pace and degree of change can be overwhelming for
2. Maintain and Document Objectivity the organization and for individuals. An Organizational
3. Think Process; Not Department Change Readiness Assessment provides a mechanism to
understand the organization’s appetite and capacity for
change and can help inform the Vendor Assessment effort.
For an example of a Readiness Assessment for a physi-
cian practice environment see http://www.HealthIT.gov
(HealthIT.gov: EHR Implementation Steps March, 2014).
It has been said that successful implementation of tech-
A. B. C. D. E. nology begins with early end-user engagement. A Change
Strategy Define Identify Evaluate Partner Management Strategy grounded in solid communication
that is incorporated throughout the project is the best
defense against resistance to change that may occur in any
organization. Examples of communication strategies used
during a vendor assessment include:
1. Newsletter publication on project goals and status
• FIGURE 20.1. Vendor Assessment Methodology. 2. E-mail or intranet communication about the project
c20.indd 310 20-02-2015 17:58:12

Chapter 20 • Assessing the Vendors 311
3. Town hall meetings led by organization leaders to 2. Future State (“What are we going to look like in the
provide status and answer questions future?”). It is important for organizations making invest-
4. Posters communicating the anticipated timeline and ments in technology solutions to consider the long-term
reasons for change outlook and impact. Most organizations will have a stra-
tegic plan which can provide some insight into the future
5. Contests to name or internally brand the project
direction of the enterprise. Leadership must fully consider
the technology implications of various business strategies.
A. Strategy Consider, for example, the potential technology impacts for
the following healthcare-related strategic initiatives:
The first major step in the Vendor Assessment Metho
dology is “Strategy.” This phase of the methodology is a. Becoming an Accountable Care Organization:
typically led by leadership and is intended to provide the Increased need to manage data on populations and
structure and strategic alignment and direction necessary predictive analytics to support transitions of care
to support the entire effort. The Strategy phase typically b. Merger and acquisitions activity: Data migration
focuses on four key strategic considerations. These are: and integration of technology platforms across an
enterprise
• Business Drivers
c. Changing payment models focused on quality: Data
• Future State Operational and IT Vision
and quality reporting needs
• Independence and Compliance
d. Clinician talent acquisition strategies: Technology
• Financial and Return-on-investment and tools to enable and support leading clinical
practice
1. Business Drivers (“Why are we doing this?”). An
e. Patient Engagement Initiatives: Technology tools such
important first step in assessing the vendor market place
as patient portals and data and information to effec-
is to ask “why?” or what are the business or clinical drivers
tively engage patients and families
behind the organization’s need to evaluate vendor solu-
tions in the first place? Establishing the need for change The operational vision helps describe what the future
and having it clearly articulated by leadership is also an operational environment of the organization may look
important element of an effective people and organiza- like. In addition to the operational vision it is important
tional change management strategy. to also understand the overall Information Technology
There may be a number of reasons why an organiza- strategy and vision during the initial phase of the Vendor
tion needs to assess the health IT vendor market. Some of Assessment Methodology. Among other things, the IT
these reasons may include: strategy will often describe the organization’s overall
approach to vendor solutions and products in the context
a. New or pending regulatory requirements unmet by of an existing or future IT portfolio.
current vendor, such as meaningful use or ICD10 In recent times, there has been an effort to minimize
b. Current solution outdated, no longer supported (e.g., the number of vendors included in an IT environment. In
Application retired) the past, organizations that embraced the best-of-breed
c. Changing business needs not met by current model found that managing communication and inte-
solution gration between multiple vendors was challenging. On
the other hand, it is well understood that there is not a
d. Merger with another institution on a different platform
single vendor who meets all of the functional and techni-
e. New enabling technology required to support cal needs of a healthcare enterprise. Today, most organiza-
improved care delivery/practice tions are attempting to minimize the number of vendors
f. Leadership decisions to change or introduce new in their portfolio in the hope of achieving better interop-
technology erability between key systems. Where an organization is
g. Current solution no longer meets business/clinical and most importantly where they want to be in the future
requirements, such as personalized healthcare along this continuum between best of breed and single
vendor is an important strategic element to understand.
h. Poor service or instability of current vendor
Both the Operational and IT strategies are impor-
Understanding the organization’s unique business dri tant inputs for the Vendor Assessment Methodology.
vers for assessing the market and documenting these as Anticipated solution benefits should be clearly defined and
part of a Vendor Assessment project charter is essential. aligned with the organization’s overall strategic direction.
c20.indd 311 20-02-2015 17:58:12

Leadership involvement is essential in order to ensure this that all project documents will come under some degree
alignment of the institutional goals and objectives with of scrutiny by those outside of the project in the future.
expected solution benefits.
3. Independence and Compliance (“Is the process fair

GUIDING PRINCIPLE #2—Maintain and Document
and defensible?”). One of the key strategic principles
Objectivity
of a well-structured vendor analysis is independence.
Merriam-Webster dictionary defines independence as
“freedom from outside control or support” (Merriam
Webster Online Dictionary: Independence, 2014). An Some of the indicators of a fair and objective system
independent vendor analysis process would be free of bias selection process are:
and would result in an objective decision for the organiza-
tion. It is important for all members of the team to abide • All vendors respond to the same RFI/RFP format.
by guidelines established to ensure strict independence. • There is a single point of contact for vendor questions.
These guidelines might include: • Vendors are asked not to interact with others in the
organization.
a. Acknowledging any real or apparent personal
conflicts of interest. Team members who have • RFI/RFP released to vendors at the same time with
relationships with representatives from one of the same deadlines.
vendors under consideration or members holding a • Any questions asked by and responded to are
financial interest in one of the companies would be shared with all vendors.
examples of a personal conflict.
• Demonstration scripts are provided at pre-deter-
b. Having a well-defined and adhered to vendors’ “no mined intervals in advance so that each vendor is
gift” policy. provided the same amount of preparation time.
c. Agreeing to no outside contact policy during the • Demonstration environment and timing is as con-
procurement such that vendors cannot circumvent sistent as possible for all vendors.
established communication channels.
• Demonstrations are managed and facilitated fairly
d. Strictly managing internal and external communi- and consistently.
cation and ensuring that information is shared with
vendors in a timely, consistent, and professional In some instances there may be local or regional
manner. requirements that must be considered from a compli-
ance perspective. A Certificate of Need (CON) process,
Oftentimes organizations pursuing large-scale vendor for example, is required in some states under certain
assessments will look to external consulting firms to assist conditions. According to the National Council of State
in guiding the organization through the process. The con- Legislatures CONs “…are aimed at restraining healthcare
sulting firm selected as well as the resources assigned to facility costs and allowing coordinated planning of new
the team should be held to the same standards relative to services and construction” (Certificate of need state health
independence and bias. laws and programs, 2013). These laws authorizing such
With healthcare organizations’ spending and investing programs are one mechanism by which state governments
tens and even hundreds of millions of dollars on technol- seek to reduce overall health and medical costs (Fig. 20.2).
ogy solutions there is an increase in oversight and scrutiny
from multiple stakeholders. Public and private boards, for 4. Financial and Return-on-investment (“What are
example, may require detailed information regarding the the costs and benefits?”). Lastly, and equally as impor-
selection of a particular vendor. It is necessary for those tant, the leadership team must provide some parameters
who lead these efforts to maintain and document objec- around anticipated solution costs and benefits. Oftentimes
tivity throughout the process. This documentation would with large-scale investments the organization’s Board of
include a project charter, a work plan, timelines, status Directors including the Finance and Investment com-
reports, correspondence, and meeting minutes to name a mittees may be involved to help provide some strategic
few. Project documents should be maintained in a secure guidance for the leadership and the Vendor Assessment
place, they should provide a detailed chronology of all project team as it relates to financial matters. This may
activity and they should be written with sufficient detail also include the need to seek funding from external
to stand alone upon review. The team should anticipate sources including capital and bond markets.
c20.indd 312 20-02-2015 17:58:12

State Certificate of Need (CON) Health Laws, 2013
WA NH
VT ME
AK MT ND
OR MN
MA
ID SD WI NY
WY MI RI
PA CT
NE IA NJ
NV OH
IL
UT IN DE
CA CO WV
KS MO VA MD
KY
NC
OK TN
AZ AR
NM SC
HI
MS GA
LA AL
TX
American
Samoa FL
Guam
U.S. Virgin
Islands
CON law; state approval may be required
PR
CON law repealed or not in effect
Compiled by NCSL November 2013; based on data from AHPA & State Agencies.
• FIGURE 20.2. State Requiring CON and those that Do Not. (Reproduced, with Permission. Copyright ©
National Conference of State Legislatures.)
The leadership team and the Board of Directors are 1. Conduct Market Research and Understand Key
often focused on the anticipated Return-on-investment Market Differentiators. Conducting a market scan of
(ROI) model of the proposed solution. To the extent that potential vendors is an important first step of the Define
they exist the Vendor Assessment project team should phase. An effective high-level market scan is as much an
fully understand any preliminary assumptions made rela- art as it is a science. While there are many resources avail-
tive to solution costs and benefits. It will be vitally impor- able within the industry, the best and most reliable way
tant for the team to secure data early in the effort that to attain an appreciation of any vendor and solution is
help support and compare the projected financial impact through networking and relationships.
analysis to an actual estimate based on data directly from Reaching out to colleagues or networking with peers
the vendors. Cost estimates will be discussed further in who have “been there; done that” is a recommended first
the Define phase. step in a successful market scan. Participating in trade
shows or industry conferences at a local or national level
B. Define can also provide an opportunity to connect with col-
leagues and to speak candidly with vendors who attend or
The Define phase of the Vendor Assessment Methodology exhibit. Lastly, there is a lot of information available on the
is intended to create the list of prospective vendors, to Internet with varying degrees of reliability. Searching tar-
document the functional and technical solution require- geted vendor Web sites and/or user groups is often helpful
ments, and to formally request information or a formal in obtaining baseline information but should be reviewed
proposal from targeted solution providers. with an eye toward bias, reliability, and credibility.
The major tasks in this phase are: It is also recommended to conduct a formal literature
review. As health information technology continues to
• Conduct market research and understand key mar-
evolve there is an ever-increasing body of knowledge in
ket differentiators.
the formal, peer reviewed literature. While the literature
• Develop functional and technical requirements. may not have vendor-specific information, it may pro-
• Develop and Submit RFI/RFP. vide some insight into solutions and anticipated benefits.
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A team considering a new acute care Electronic Health vendors, on the other hand, are focused on providing
Record (EHR), for example, may search the formal litera- management consulting, staff augmentation, or other
ture on Computerized Prescriber Order Entry (CPOE). high demand skills and expertise and do not usually
This research will provide a sound basis not only for the develop software product. Hardware vendors gener-
selection but for the identification of key benefits of the ate revenue primarily from the sale and support of the
new technology. hardware component of a solution offering and often
This review may also alert the selection team to poten- partner with other firms for software or services.
tial unintended consequences of new technology. Together It should be noted that these business differentiators
these documented benefits and unintended consequences are dynamic and can change as a vendor’s business
help inform the understanding of the market and the solu- evolves. It is also true that a single vendor may
tion being considered. differentiate across multiple dimensions. There
For a fee, industry and market research firms offer are software vendors, for example, who also offer
another way to gain information about vendors and their services and hardware. Just as there are hardware
solutions. Several examples of industry resources are pro- vendors who market, sell, and support software
vided in Table 20.1. applications. During a vendor analysis, it is impor-
As the team begins to understand the market they will tant to understand the potential vendors’ primary
find that the vendors in the health information technol- business differentiators and motivators so that an
ogy market differentiate themselves across several dimen- informed decision can be made.
sions. Among others, there are business, technical, and
Industry focus: Another important business differentia-
solution differentiators that should be considered as part
tor to consider is industry alignment. There are ven-
of the Define phase of a vendor assessment.
dors who focus 100% on the healthcare marketplace
and others who include industries outside of health-
Business Differentiators care in their portfolio. There are pros and cons for
Privately held vs. Public companies: Some health IT each. A healthcare focus offers assurance that a ven-
vendors are privately held businesses and in some dor appreciates the unique challenges the healthcare
cases wholly owned by the founders. These types of industry faces. On the other hand, the diversity of a
organizations typically make decisions about their company that serves multiple industries could offer
business and their solutions based on the company’s innovative solutions to bring forward into healthcare.
internal management and leadership. Other vendors Understanding which industries the vendors focus on
in the health IT market are publically traded orga- by asking probing questions and looking at their
nizations who ultimately report to external share- market penetration and research and development
holders. Decisions in these organizations are often investments can provide insightful information
highly focused around quarterly earnings targets. about the organization’s past as well as its long-
Software vs. Services vs. Hardware: There are vendors term commitment to providing innovative solu-
who function purely as software developers. That tions to the healthcare industry.
is, they develop software solutions but are not as
interested in generating revenue from other solution Technical Differentiators. There are multiple categories of
components such as hardware or services. Services technical differentiators to consider. Some of these include
TABLE 20.1 Health IT Market Resources

Resource Description URL
KLAS Vendor performance data based on http://www.klasresearch.com/

customer feedback
Gartner Industry research firm http://www.gartner.com
Forrester Industry research firm http://www.forrester.com
HIMSS Analytics Industry research firm http://www.himssanalytics.org
U.S. Department of Health and Human Services Certified Health IT product list http://www.healthit.gov
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those related to the development of software products, vendors, for example, may provide solutions for
product-line growth strategies, or the solution delivery the ambulatory market while others focus exclu-
mechanisms the vendor supports. sively on the needs of the acute, inpatient setting.
Further narrowing can be seen with what is typi-
Development Model: When evaluating vendors it is
cally referred to as “niche” vendors who service a
necessary to understand the underlying solution
very specific need. Peri-operative, Maternal Child
development model that is used. The develop-
Health, Behavioral Health, Radiation oncology,
ment model for software vendors, for example,
Emergency services are all examples of environ-
may involve open source software (OSS) or a
ments where niche vendors offer solutions.
proprietary, vendor-controlled approach. For
more information on OSS, please refer to Chap. 5. With the continued consolidation within the industry
While there is no right or wrong answer for one and the movement toward new models of care
development model over another it is important to delivery, it is important to consider current and
understand the vendors’ approach to development future business and clinical needs when analyz-
and to recognize how that approach is or is not ing vendors. An organization that operates as an
aligned with the organization’s current and future acute care facility today may find that its future
IT strategy. includes becoming part of an Accountable Care
Organization (ACO) model, for example, where
Product Line Growth: A vendor’s overall strategy environments such as post-acute, long term, reha-
to building its product line is another techni- bilitation, and others will need to be considered.
cal differentiator to consider. Some vendors
develop all of their solutions internally while Product evolution: Understanding the historical
other rapidly acquire technologies from others perspective of a vendor’s product is an essential
sources and essentially act as a system integrator. element of a comprehensive vendor analysis. One
Understanding the technical architecture on which Electronic Health Record vendor, for example,
the solution is built as well as the history of all solu- may have established roots by developing inpatient
tion components can provide valuable information clinical solutions while another may have started
to the team considering a vendor’s solution. out as a vendor focused on radiology systems.
Understanding this historical perspective is impor-
Solution Delivery: Today there are many options for tant in developing an appreciation of the vendor’s
the delivery of technical solutions to organiza- core competencies and a better understanding of
tions. Software solutions and electronic health how the solution has evolved over time.
records, for example, may reside on computers or
Integration: While some vendors claim to offer an
servers on the physical premises or they may be
“integrated” solution what they really provide is a
hosted remotely. In addition, many solutions are
franchise model where they purchase or acquire
now being offered by application service providers
various legacy applications and attempt to inte-
(ASP) via the Internet through such mechanisms as
grate them and sell them as a single solution
Software-as-a-service (SaaS). The team evaluating
offering. (See “Technical Differentiators” above.)
vendors will need to consider the delivery mode
It is vitally important to track each product or
that makes the most sense for the organizations. It
application back to its genesis to understand more
is not unusual for vendors to offer multiple delivery
fully whether a solution was developed as part of
options and all should be considered by the team as
a single, integrated platform or is a patchwork of
appropriate.
interfaced legacy systems.
Functionality: All solutions that enter a commercial
Solution Differentiators. Solution differentiators are those market go through a maturity cycle. In the begin-
characteristics of the vendors’ products that distinguish ning, there are wide differences in the features
them from competitors. These differentiators include the and functions and a limited number of vendors
market segments served, product evolution, integration, offering the solution. Over time, however, as the
functionality, and future product development plans. product matures and more vendors enter the mar-
Market segments served: While many vendors claim ket, competition creates a leveling of functional
to offer a “comprehensive” portfolio of solutions differentiators.
most serve relatively small market segments and An assessment of the now mature electronic health
have a narrow product line. In healthcare, some record market in the United States would show that
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the vendors who have led the market all have prod- the “How to implement EHR’s” section of the HealthIT.
ucts that are similar in their features and functions gov Web site. See Step 3: Select or upgrade to a certified
but differentiate on other elements. This Darwin- EHR (HealthIT.gov: Step 3 Select or Upgrade Certified
like survival of the fittest phenomenon is one of the EHR, March, 2014; AHRQ, n.d.).
key benefits of having a competitive, commercial Technical requirements focus less on workflow and
market for solutions. more on technical capabilities within the solution. These
Nonetheless, functionality is a key element of any might include “Ability to interface to Laboratory system,”
Vendor Assessment. Functional requirements “Supports Window Active Directory,” “Ability to send
will be explored in more detail in the “Develop and/or receive HL7 messages,” “Complies with HIPAA
Functional and Technical Requirements” section Technical Security standards,” etc.
that follows. Requirements can be very specific and detailed or they
can be high level. When the team develops requirements
Future Product Development plans: One of the most
consideration is generally given to the current state as well
important differentiators to understand about a
as the potential or desired future state workflow.
vendor is where they are headed with their product
A Key Guiding Principle that applies to requirements
line. In many cases, the partnership with vendors
development is to “Think Process; Not Department.” While
can last years or decades. As such, it is important
this principle, like all others, can be applied throughout
to develop a sense of where the vendor plans to
the Vendor Assessment Methodology, it is particularly
focus development efforts in the next 5 to 10 years.
important for requirements development.
As mentioned previously in the Strategy phase,
alignment of the vendors’ strategy with an orga-
nization’s strategic plan is an important step in
assessing a vendor’s compatibility to partner with GUIDING PRINCIPLE #3—Think Process; Not
an organization over the long term. This is espe- Department
cially true with understanding the vendors’ short-
and long-term product development plans.
As such, functional requirements should be developed
2. Develop Functional and Technical Requirements. from a process perspective and not a departmental or silo
Requirements definition is a very important step in the perspective. It is important, for example, when developing
Vendor Assessment methodology. Requirements can requirements for medication administration to consider
serve multiple purposes. First of all, they help define cur- the implications from the patients’ perspective as well as
rent state workflows requirements. They also help orga- the physicians’ (ordering), pharmacists’ (verification and
nize the desired future state features and functions. Often dispense), and nurses’ (administration and evaluation)
referred to as the “wish list,” future state requirements perspectives. Approaching requirements from a single
provide an opportunity for the Vendor Assessment team discipline, a single department or one step of the workflow
to see if a vendor’s solution can support the desired future would only partially define what is needed.
state environment. Nursing represents the largest segment of the health-
Requirements may also serve a purpose during the con- care workforce. In the United States, it is estimated that
tract negotiations phase. Gaps in functionality, for exam- there are 3.1 million Registered Nurses (Nursing by the
ple, may inform any custom modifications that may be numbers fact sheet, 2013). Table 20.2 highlights some
contractually obligated. In addition, some institutions may sample requirements organized around the Nursing
contractually bind the vendor’s response to requirements. Process. Again, it is important to consider the process and
As discussed, solution requirements can be divided not the department or in this case the nursing perspective
into functional and technical capabilities. Functional alone. Assessment requirements, for example, may lead to
requirements refer to those features and functions that an impact for nutrition, respiratory, or rehabilitation ser-
support workflow of end users. Examples of functional vices. Keeping this broader, process-focused perspective
requirements in a healthcare software application might will ensure that functional requirements are comprehen-
include: “Ability to log onto the system,” “Ability to register sive (see Table 20.2).
a patient,” “Ability to enter an order,” “Ability to generate Technical requirements can be complex. Requirements
a claim,” etc. The U.S. federal government offers a host of in this section generally pertain to the technical aspects
templates, best practices, and examples of functional and that your system must fulfill, such as performance-related
technical requirements and many other great resources in issues, system reliability, and availability issues. This
c20.indd 316 20-02-2015 17:58:13

TABLE 20.2 Sample Functional Requirements TABLE 20.3 Sample Technical Requirements
Nursing Hardware Describe the hardware support model
Process Sample Functional Requirement Implementation Will the system be available 99.99% of
the time for any 24-hour period?
Assessment Ability to capture admission assessment data
Regulatory Is the system Meaningful Use
Supports Braden Skin Scale Assessment
Compliance certified?
Diagnosis User can enter and modify Nursing
Report Writing Is the report writer native to the core
Diagnoses
application?
System supports multiple Nursing
Interfaces Do you support HL7?
terminologies
Technical System supports alphanumeric
Plan Supports Nursing and inter-professional
Security passwords?
plans of care
Backups and Can a single record be recovered?
Capture user-defined outcomes
Downtime
Implement Nursing work lists generated by system
Support Do you offer 24 × 7 × 365 technical
System displays status of all tasks support?
Evaluate Supports analytics related to nursing
sensitive quality
Ad hoc reporting capabilities
It may be helpful to start with a pre-defined list of
requirements and validate those against your existing
workflows. Colleagues who have been through similar efforts
may be able to provide sample requirements. An orga-
section may include multiple categories of questions that nization may also gather requirements from an external
may or may not be able to fit into the structured response source. The Health Resources and Services Administration
(see above) requirement. It is important to develop these (HRSA), for example, offers a number of resources to con-
requirements in collaboration with subject matter experts sider including Electronic Health Record system require-
from the organization who understand the requirements ments (HRSA, n.d.). In large-scale efforts it is not unusual
(Agile Modeling, n.d.). to seek out the services of a consulting partner to help
manage some of the key steps of a Vendor Assessment.
Sample Technical Requirements (Table 20.3) Consultants often have libraries of requirements that they
Structured Responses. It is important to structure the can leverage as part of their work. Regardless of the source
response to functional and technical requirements where of the requirements, it is always recommended to validate
possible to alleviate ambiguity and facilitate requirements these with the operational areas. This not only ensures the
analysis. Best practice is to phrase requirements such that
they can be answered in a Yes/No response format. This
can be difficult for some requirements but will provide for TABLE 20.4 Sample Structured Response
a more effective response analysis. Definitions
Soliciting a Yes/No response is not as simple as it may
Response Description
seem. Recognizing that they are being scored and competi-
tion exists, vendors will want to respond to requirements YC Yes, Current release fulfills
with a “Yes” response. This may introduce some ambiguity, YF Yes, Future release fulfills (note version # and
however, and responses should be structured to add clarity. release mm/yy)
To help alleviate concerns about this ambiguity, ven- NM Not standard, custom Modification available if
dors should be instructed to respond more accurately agreed upon by vendor
through a structured response approach. This may look
ND Not standard, requires further Discussion
like those described in Table 20.4.
The scope of the Vendor Assessment project will deter- NN Not standard, custom modification Not available
mine the work effort involved in developing requirements. OI Other third-party software, supports via
A focused assessment of a Laboratory solution, for exam- Interface
ple, would involve a narrower set of requirement than a full ON Other third-party software, No interface
Electronic Health Record and Revenue Cycle evaluation.
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requirements are correct but it can be an important step in b. Requires the organization to specify what it proposes
the user engagement process as well. to purchase. If the Requirements Analysis has been
prepared properly, it can be incorporated quite easily
3. Develop and Submit RFI/RFP. A Request for Information into the Request document (see below).
(RFI) is generally used to gather initial information about
c. Alerts vendors that the selection process is
a vendor and solution offerings and may be used to qualify
competitive
certain vendors to participate in further analysis. The RFI is
often used as a precursor or in conjunction with more for- d. Allows for wide distribution and response
mal requests such as a Request for Proposal (RFP), Request e. Ensures that suppliers respond factually to the
for Tender (RFT), or Request for Quotation (RFQ). RFQ is identified requirements
used oftentimes by the government when the product is f. Follows a structured evaluation and selection
approved for purchase, but the local authority must spend procedure, so that an organization can demonstrate
the money to purchase and install the software. An RFT, impartiality—a crucial factor in public and private
on the other hand, is usually an open invitation for suppli- sector procurements
ers to respond to a defined need as opposed to a request
g. May be used as part of future contract negotiations
being sent to selected potential suppliers.
An RFP is a generally considered a more formal docu- Table 20.5 shows a sample RFI/RFP outline.
ment of solicitation made, often through a formal and struc-
tured bidding process. An RFP may be issued by an agency
or company interested in procurement of a product, ser- C. Identify
vice, or other valuable asset. In the case of a federal or state During the Identify stage each vendor’s eligibility for fur-
agency the RFP may be posted to a procurement Web site. ther participation is determined and the vendor finalists are
The use of an RFI or an RFP offers several benefits. An identified. While the RFI/RFP may have been sent to a large
RFI/RFP: number of vendors the goal is to limit the field to three to
a. Informs vendors that an organization is looking to five qualified vendors for the upcoming and more resource
purchase products and/or services and encourages intense Evaluation phase. A review of the RFI/RFP responses
them to participate is conducted and inclusion criteria are established.
TABLE 20.5 Sample RFI/RFP Outline

Section Description
1 Executive Overview A high level summary of the request

2 Organizational Background Vital statistics and rationale for selection
3 Response Instructions for the vendors to follow
4 Evaluation Criteria Describes what the vendors will be evaluated on
5 Vendor Response This section explains to the vendor how to respond
Executive Summary Response to executive-level questions
General Information Response to background information on the vendor

Application Functions/ Response to functional requirements (one for each functional area in scope with structured
Features responses)
Technical Requirements Response to technical requirements (may be several pages and may not be in Yes/No or free
text format)

System Provide timelines and resources for deployment
Implementation
System Documentation Provide supporting documentation
Other Additional information the vendor would like to provide
Costs Response to detailed system cost information (usually provided in a structured format)
6. Attachments Templates for the vendor to use or additional information
c20.indd 318 20-02-2015 17:58:14

Quantitative and qualitative analyses are conducted on Rather high-level scripts can be developed that guide the
the RFI/RFP responses, including the functional and tech- vendor, allow for some flexibility, and provide a mechanism
nical requirements. to capture quantitative and qualitative data. The U.S. govern-
Eliminating vendors from the process can be difficult ment’s HealthIT.gov Web site offers sample demonstra-
but should be conducted with transparency and open tion scripts (Health IT.gov: EHR Demonstration Scenario,
communication. Once the decision to eliminate a vendor Evaluation and Vendor Questions, January, 2013).
has been made, the vendor should be notified verbally
and through a formal written response. Vendors may be 2. Site Visits. Site visits are generally conducted with a
holding resources in preparation for demonstrations and limited number of organizations due to the commitment
should have the opportunity to re-deploy those resources of time and expense for both the host facility and the orga-
should they not be invited to demonstrate their solution. nization considering the solution. It is important for site
visits to be planned in advance with specific goals and
objectives identified. Site visits are time limited and vary
D. Evaluate
in duration based on the extent of the solution being con-
During the Evaluation phase, the remaining field of ven- sidered. Vendor participation in site visits varies as does
dors and solutions are looked at more closely. During this the number of participants. In general, it is better to keep
phase vendor demonstrations, site visits, and reference the group small but also important to be inclusive with
calls may occur to further inform the team and identify good representation from key stakeholders. The primary
the vendor of choice. objective is to see the solution deployed in an operational
environment and to hear direct and candid feedback from
1. Demonstrations. Conducting demonstrations is a sig- the host facility.
nificant investment in time and resources for the organi- Typically, a site visit agenda will include the following:
zations and vendors. When conducting demonstrations, it
a. Introduction and Overview
is important to strike a balance between the organizations’
need to objectively evaluate each vendor and the vendors’ b. Solution Discussion
desire to show the best features of their product. All of this c. Facility Tour
needs to be considered in the context of time and resource d. Questions and Answers
availability as well as competing priorities for both the
organization and the vendor. The introduction and overview is intended to intro-
It is recommended to establish demonstration dates duce the host site and visitors to each other and to reiterate
very early in the process; even before final vendors are the goals and objectives of the visit. A solution discussion
known. Depending on the size of the effort and resources typically follows which describes the host organization’s
demonstration dates should be set, rooms reserved, and experience with the solution from the beginning. This
communication to hold the dates delivered to vendors in discussion should include the issues the organization was
the RFI/RFP. looking to resolve, the decision process used to identify the
It is important that the demonstrations are fair for all selected vendor, the implementation of the solution,
participants. Where possible the same or similar facility the relationship with the vendor, and whether or not
should be used at the same time of day for the same dura- expected benefits have been achieved. The mix and num-
tion and with a consistent list of participants. This level of ber of participants is governed in a large part by the scope
rigor is required to provide an “apples to apples” compari- of the solution being considered. Key stakeholders should
son of demonstration results. be well represented. It is recommended for the partici-
Scripts or scenarios developed by the organization are pants to debrief immediately following the site visit and
often used to help guide the demonstration and to capture not wait for the return home. Debriefing together and doc-
quantitative and qualitative data for evaluation. Having umenting observations immediately ensure that the team
process-oriented scripts that highlight key system require- accurately captures their thoughts. Observations related
ments provides an opportunity to see how the system is to the workflow integration as well as general observations
used to achieve organizational goals. Scripts for clinical about the host facility are important to document. When
systems should be oriented around the patient experience multiple site visits occur and time passes it can be difficult
and care delivery. It is a common mistake to overengineer to remember details from facility to facility.
the script which makes it challenging for the vendor to
demonstrate to an overly prescriptive process and hard for 3. Reference Calls. Reference calls should be conducted
participants to evaluate. in order to appreciate the perspective of customers who
c20.indd 319 20-02-2015 17:58:14

have successfully implemented the vendor solution. When between the organization and its potential future busi-
requesting references, it is important to find organizations ness partner.
that are as similar as possible so that a comparison can
be completed. It is recommended that at least three (3)
reference calls are conducted. References are completed GUIDING PRINCIPLE #5—Make a Commitment
with those organizations that the vendor has provided as a
qualified reference. A reference call questionnaire should
be developed so that the same questions are captured for
As in any relationship, once a partner is identified it
each reference.
is important for both parties to make a commitment to
each other’s success. Contract negotiations may begin as
4. Due Diligence. Due diligence refers to a process of
soon as the preferred vendor is identified. At this stage, it
further and deeper investigation of a company prior to
is common for organizations to include legal representa-
contract signing. Much of the information required
tives who are familiar with health information technology
to support due diligence should have been requested in
contracts as part of the team.
the RFI/RFP. In some instances, it may be necessary to
In some cases, early planning activities will occur
engage a third party to conduct due diligence and to more
in parallel with contract negotiations. Data gathered
thoroughly investigate the financial status of a potential
throughout the analysis may be used to inform planning
vendor partner.
and contract discussions. Some organizations, for exam-
The quantitative and qualitative data collected
ple, may include the vendor’s response in the require-
throughout the process are used to support and inform
ments as part of the contract in order to hold the vendor
the vendor of choice decision. As with most major deci-
accountable for their answers.
sions, however, there is a need to do a “gut check.” If
Stakeholder communication is vital throughout the life
despite the data collected the vendor does not “feel” like
cycle of a vendor selection. Oftentimes the team will be
the right partner during the selection and pass the teams
expected to provide a summary of the analysis and current
gut check it is unlikely that they will meet the organiza-
status. The audience for these presentations can range all
tions’ needs once a contract is signed. While the data are
the way from front-line staff to the organization’s board of
helpful in the end, the instincts of the team and leaders
directors or creditors. Effective communication and pre-
involved in the process are the most valid indicator of
sentation skills are essential. The team should anticipate
future success.
questions and be prepared to respond with short notice to
any and all stakeholders. A well-thought-out communica-
tion plan during the selection effort will set the stage for
GUIDING PRINCIPLE #4—Use the Data; Trust ongoing communication during the planning and imple-
your Gut mentation phases.
A major deliverable of the Evaluation phase is the

Summary Analysis. The Summary Analysis brings SUMMARY AND BEST PRACTICES
together data from all parts of the methodology in a clear In conclusion, it is immense responsibility to lead or par-
and concise format that is ready for executive review. A ticipate in the selection of a new vendor partner for an
sample Summary Analysis appears in Fig. 20.3. organization. Following a data-driven and evidence-based
Vendor Assessment Methodology provides the opportu-
E. Partner nity for a thoughtful and objective analysis of the vendor
marketplace.
In a well-structured vendor selection process, the win- The Key Steps of the Vendor Assessment Methodo
ner or “Vendor of Choice” often emerges as the clear logy are:
answer.
In the past, some organizations elected to enter into A. Strategy
contract negotiations with multiple potential solution B. Define
providers in order to increase leverage and provide for
C. Identify
a more competitive bidding environment. In practice,
however, this strategy seldom achieves the intended D. Evaluate
results and more often creates unnecessary tension E. Partner
c20.indd 320 20-02-2015 17:58:14

Overall Weighted Scores Per Vendor
100.00%
90.74% 89.00% 88.70% 88.14% 88.07% 87.68%
90.00%
84.43% 83.25%
80.00%
70.00%
63.54%
60.00%
50.00%
40.00%
30.00%
20.00%
Vendor A Vendor B Vendor C Vendor D Vendor E Vendor F Vendor G Vendor H Vendor I
Vendors
Vendor A Vendor B Vendor C Vendor D Vendor E Vendor F Vendor G Vendor H Vendor I

1) Live POE solution β β β β
2) Live Pharmacy solution β NP
3) a. POE Software License Cost $15,172,299 $23,866,807 $19,780,000 $16,025,000 $4,424,000 $9,229,000 $5,850,000 $9,503,000 $10,658,000
b. Pharmacy Software License Cost I I N/A $1,433,900 $980,000 $3,902,250 $1,604,000 I NP
c. Total Proposed Start-up Cost $18,449,745 $25,054,748 $34,439,268 $25,771,424 $10,600,000 $44,973,980 $24,117,936 $110,568,870 $72,000,000
4) POE Key Functional Requirements
iv.a.1.f Ability to enter orders via PDA F F N F N F N N
Dose Calculator based on
v.a.2.f documented patient weight F N
Supports Adult TPN ordering with
v.a.2.r templates F F N N
v1.1.n Flag orders entered remotely N N N N
Require countersignature based on
N N
vii.1.d intervention
vii.5.l Escalation Rule F N N N N
ix.a.l Ability to modify drug database N N
5) Largest Relative Bedsize >500
6) Pharmacy system is stand-alone β
Legend
Operational
β Beta
NP No Product/System
I Included in POE cost
F Future: Available prior to Q4 2003
Not Available or Future without
N date
• FIGURE 20.3. Sample Summary Analysis.
Remember to consider and apply the Key Guiding 4. Use the Data; Trust your Gut
Principles throughout the lifecycle of the Vendor 5. Make a Commitment
Assessment:
REFERENCES
1. Manage the Change; Communicate
Agile Modeling (n.d.). Technical (non-functional) require-
2. Maintain and Document Objectivity ments: An agile introduction. Retrieved from http://www.
3. Think Process; Not Department agilemodeling.com/artifacts/technicalRequirement.htm
c20.indd 321 20-02-2015 17:58:14

AHRQ (n.d.). Application and system development require- HRSA (n.d.). What are the specific functionalities that are
ments. Retrieved from http://www.ahrq.gov/research/ needed in an EHR? Retrieved from http://www.hrsa
publications/pubcomguide/pcguide2apa.html .gov/healthit/toolbox/ruralhealthittoolbox/getting
Certificate of need: State health laws and programs. (2013). started/ehr.html. Accessed November 22, 2014.
Retrieved from http://www.ncsl.org/research/health/ Health Resources and Services Administration. (September
con-certificate-of-need-state-laws.aspx 2010). The Registered Nurse Population: Findings From
HealthIT.gov (January, 2013). EHR demonstration scenario, evalu- the 2008 National Sample Survey of Registered Nurses.
ation and vendor questions. Retrieved from http://www.heal- Washington, DC: U.S. Department of Health and Human
thit.gov/providers-professionals/implementation-resources/ Services.
ehr-demonstration-scenario-evaluation-and-vendor Merriam Webster Online Dictionary. (2014) Independence.
HealthIT.gov (March, 2014). Step 3: Select or upgrade Retrieved from http://www.merriam-webster.com/
certified EHR. Retrieved from http://www.healthit.gov/ dictionary/independence
providers-professionals/ehr-implementation-steps/ Pedulli, L. (2013). Report global health IT market to hit
step-3-select-or-upgrade-certified-ehr $56.7 billion by 2017. Retrieved from http://www
HealthIT.gov (March 20, 2014). EHR implementation steps. .clinical-innovation.com/topics/clinical-practice/
Retrieved from http://www.healthit.gov/providers- report-global-health-it-market-hit-567-billion-2017
professionals/ehr-implementation-steps/step-1-assess- Sugrue, M. (2010). Clinical leaders and the adoption of
your-practice-readiness. Accessed November 22, 2014. health IT. Nursing Management, 2010 Sep, 18–21.
c20.indd 322 20-02-2015 17:58:14

32
Public Health Practice Applications
Judy D. Gibson / Janise Richards / Arunkumar Srinivasan / Derryl E. Block
• OBJECTIVES
. Define public health informatics and the public health nurse informatician.
1
2. Describe the National Electronic Disease Surveillance System.
3. Describe two public health electronic information systems with implications for
the public health nurse.
4. Discuss the public health informatician role and the emerging role of the public
health nurse informatician in case studies.
• KEY WORDS
Public health informatics
Electronic public health surveillance
Electronic public health information systems
Interoperability standards
Office of National Coordinator for Health Information Technology
National Electronic Disease Surveillance System
Health departments are collecting and analyzing

OVERVIEW data on a scale that was inconceivable even 10 years ago
For many years, public health practitioners stated the (Fig. 32.1) (Centers for Disease Control and Prevention
belief that if nobody thought about public health, then [CDC], 2013a). To be able to manage this overwhelming
public health must be doing its job. The battles that health deluge of data and information, public health practitio-
practitioners waged against infectious diseases (such as ners have tapped into information technology. During
malaria, tuberculosis [TB], and leprosy), chronic diseases, 2000–2010, information systems have become widely
and environmental health hazards were often not high- adapted to fit the special needs within public health.
lighted in the media. In recent years, after recent outbreaks Recognizing the importance of linkages among clinical
of SARS and Influenza A virus (H1N1), dramatic large- care (also known as direct care), clinical care information
scale foodborne disease outbreaks, and the explosion of systems, laboratory information systems, and other data
chronic illnesses that are linked to multiple vectors such as sources to better understand and improve the state of the
obesity, public health is frequently in the media limelight. nation’s health, public health has helped establish data
The continuing need to be alert to emerging public health and information exchange standards to support system
problems, responsive in emergencies, and accountable to interoperability.
the public has intensified health departments’ efforts to This chapter provides an overview of the application
collect data and information from multiple sources. of informatics to public health, describes legislation that
457
c32.indd 457 2/5/2015 3:22:33 PM

458 P art 5 • A dvanced N ursing I nformatics in P ractice
Schools Civic Groups
Nursing
Homes
EMS Neighborhood
Organizations
Non-profit Community
Organizations Centers
Home
Hospitals Health
Drug Public Health Laboratories

Treatment Agency
Primary Mental
Providers Health
Law Faith Institutions

Pharmacy Enforcement
Fire
CHCs Tribal Health Transit
Employers Elected
Officials
Corrections
• FIGURE 32.1. Local public health information and data Exchange Entities.
(Reproduced from OSTLTS (2009). National Public Health Standards Program. Centers for
Disease Control and Prevention. http://www.cdc.gov/ostlts/.)
has affected public health information systems, and pro- The roots of public health were established in the United
vides examples of electronic data exchange between clini- States when the Public Health Service (PHS) was estab-
cal care and public health. The chapter also introduces the lished in 1798 by the Marine Hospital Service Act. In
emerging role of the Public Health Nurse Informatician 1944, with the passage of the Public Health Service Act
(PHNI) and gives examples of differentiating the public [Title 42 U.S. Code], the PHS mission was broadened
health nurse (PHN) and the PHNI. to protect and advance the nation’s physical and mental
health. To accomplish this mission, public health had to
define the activities clearly that would lead to this desired
outcome.
PUBLIC HEALTH, PUBLIC HEALTH In a seminal study by the Institute of Medicine, The
INFORMATICS, PUBLIC HEALTH Future of Public Health, the functions of public health
NURSING, AND THE PUBLIC were described as assessment, policy development, and
assurance (Institute of Medicine, 1988). Assessment
HEALTH NURSE INFORMATICIAN includes activities of surveillance, case finding, and moni-
In 1920, C.-E. A. Winslow defined public health as “the toring trends, and is the basis for the decision-making and
science and art of preventing disease, prolonging life policy development by public agencies. Policy develop-
and promoting health through the organized efforts and ment is the broad community involvement in formulating
informed choices of society, organizations, public and plans, setting priorities, mobilizing resources, convening
private, communities and individuals” (Winslow, 1920). constituents, and developing comprehensive public health
c32.indd 458 2/5/2015 3:22:36 PM

Chapter 32 • Public Health Practice Applications 459
policies. Assurance covers activities that verify the imple- health information widely, in the sharing of epidemiologi-
mentation of mandates or policies, and guarantees that cal and statistical data, reports, guidelines, training mod-
the provision of necessary resources is provided to reach ules and periodicals” (World Health Organization, 1997).
the public health goals. To enhance further the core public Although there are numerous sources of public health data
health functions, a committee of public health agencies and information, the sources lack standardization in data
and organizations convened by the U.S. Public Health organization, nomenclature, and electronic transmission.
Service described the 10 essential services of public health Innovative methods for storing, organizing, exchanging,
(Public Health Functions Steering Committee, 1994). and disseminating the millions of pieces of data gathered
Figure 32.2 (Centers for Disease Control and Prevention during public health activities have provided the founda-
[CDC], 2013a) describes the relationship between the core tion for the field of public health informatics.
functions and essential services of public health. Public health informatics has been defined as “the
The essential governmental role in public health is systematic application of information and computer sci-
guided and implemented by a variety of federal, state/ ence and technology to public health practice, research,
territorial, and local regulations and laws as well as federal, and learning” (Friede, Blum, & McDonald, 1995). Public
state/territorial, and local governmental public health agen- health informatics, like public health, focuses on popula-
cies. At the local level, tens of thousands of governmental tions. In public health informatics, population-level data
units at the county, municipality, township, school district, and information are collected, analyzed, and dissemi-
and other special jurisdiction levels must interact to provide nated with the ultimate goal of supporting preventive, as
public health services. This complex array of public health opposed to curative, interventions.
functions, services, responsibilities, and interactions is not The demarcation between public health and clinical
a static environment, but one that is constantly changing. healthcare systems is frequently blurred, especially given
Information forms the basis of public health. To make legislation that has provided the funding and legal plat-
informed decisions and policies, public health practitio- forms to build the information systems needed to protect
ners require timely, quality information. The 1996 World and advance the nation’s physical and mental health. The
Health Report cites the continuing need to “disseminate provision in the 2004 Health Insurance Portability and
Accountability Act (HIPAA) that generally prohibits disclo-
sure of an individual’s medical record and payment history
without expressed authorization of the individual is known
AS as the Privacy Rule. For public health purposes, the law
SE
SS provides for the disclosure of patient information to public
M
Evaluate Monitor health without authorization from the patient, for the pur-
EN
Health pose of preventing or controlling disease, injury, or disability,

T
Assure and for conducting public health surveillance, public health

Diagnose investigations, and public health interventions (Health
Competent managem & Investigate
em
ASSURANCE
Workforce Insurance Portability and Accountability Act [HIPAA],

t
en
Sys
2002). The 2010 Patient Protection and Affordable Care Act

t
Link Research Inform, (PPACA) established policies and technically interoperable

to/Provide Educate, and secure standards for federal and state health and human
Care Empower services programs (DHHS, 2010). As public health, clinical
Mobilize care, information science, computer science, and infor-
Enforce Community mation technology continue to come together, the field of
Laws Partnerships public health informatics will continue to expand to support
PO
Develop
LIC
the public health functions of assessment, policy develop-

Policies
Y
DE
VE
LO ment, and assurance to promote a healthy nation.
PM
ENT
Public Health Nursing
• FIGURE 32.2. Three core functions and 10 essential Public health nursing practice “focuses on population
services of public health. (See ASTDN, 2000. Reproduced health through continuous surveillance and assessment
from Public Health Functions Steering Committee (1994). of the multiple determinants of health with the intent to
Public Health in America. DHHS. http://www.health.gov/ promote health and wellness; prevent disease, disability,
phfunctions/public.htm.) and premature death; and improve neighborhood quality
c32.indd 459 2/5/2015 3:22:37 PM

of life. These population health priorities are addressed health. Public health professionals use these data to inform
through identification, implementation, and evalua decisions about the most effective mechanisms for interven-
tion of universal and targeted evidence-based p rograms tions. Information from multiple, sometimes incompatible,
and services that provide primary, secondary, and tertiary systems or sources must be combined for an accurate depic-
preventive interventions. Public health nursing practice tion of problems (Fig. 32.1) (Centers for Disease Control
emphasizes primary prevention with the goal of achieving and Prevention [CDC], 2013a). There is a need for rapid
health equity” (American Nurses Association, 2013). and comprehensive access to data across system boundar-
The Public Health Informatician (PHI) is a “public ies, that is, the system at all levels as well as the healthcare
health professional who works either in practice, research, industry systems (Koo, Morgan, & Broome, 2003).
or academia and whose primary work function is to Data collection and sharing in public health occur at
use informatics to improve population health. The role three levels: local, state/territorial, and federal (e.g., Centers
requires more expertise than the multi-highly functional for Disease Control and Prevention [CDC]). Programs
public health professional that assists with informatics- at each level have similar organization and management
related challenges or supports personal productivity with structures. Since most funding is based on programmatic
information technology” (U.S. Department of Health and need, many information systems have been built to support
Human Services, CDC, 2013). specific programs, thereby creating “silo”-like systems. To
Nursing informatics (NI) “is a specialty that integrates be productive, the program-oriented funding streams and
nursing science, computer science, and information sci- information systems need to flow together.
ence to manage and communicate data, information, Efforts are underway to assist healthcare providers
knowledge, and wisdom in nursing practice. NI supports in overcoming barriers to data collection and sharing
consumers, patients, nurses, and other providers in their through the implementation of regional, state/territorial,
decision-making in all roles and settings. This support is and local health information exchanges (HIEs) (Wild,
accomplished through the use of information structures, Hastings, Gubernick, Ross, & Fehrenbach, 2004) and the
information processes, and information technology” National Electronic Disease Surveillance System (NEDSS)
(American Nurses Association, 2008). (CDC, 2013c) initiative. This comprehensive rather than
The proposed role of the Public Health Nurse disease-specific approach to data collection and sharing is
Informatician (PHNI) combines the competencies of PHI the foundation of public health informatics and warrants
and nursing informatics. A PHNI is a PHN who has spe- further inspection.
cialized in nursing informatics and has skills in support-
ing the establishment of systems to improve public health
surveillance through access to clinical care information. Infectious Disease Electronic Surveillance
Further, the PHNI has advanced skills in using nurs-
The three levels of the organizational structure of public
ing taxonomies and nomenclatures as a tool for nursing
health have distinct data collection and sharing roles in
informatics in public health practice. PHNIs ensure that
support of the electronic surveillance system (Fig. 32.3)
data needs are adequate to measure performance for mul-
(Birkhead & Maylahn, 2000). Each year, the Council of
tiple determinants of health. These are examples of the
State and Territorial Epidemiologists (CSTE) and the CDC
differences between the PHN and the PHNI that will be
jointly update a list of reportable diseases and conditions.
described in this chapter.
The CSTE recommends that all states and territories enact
laws (statue or rule/regulation as appropriate) to make
nationally reportable conditions reportable in their juris-
The Public Health Surveillance Landscape
diction (Council of State and Territorial Epidemiologists
The public health mission is to promote the health of the [CSTE], 2010). The local (city or county) health
population rather than to treat individuals. In support of department—the frontline of public health—interacts
this mission, public health workers collect data on the most closely with clinicians and agencies in the commu-
determinants of health and health risks from factors in nity, gathers reports of communicable diseases, tracks
the pre-exposure environment, the presence of hazard- and monitors cases, conducts investigations, and often
ous agents, behaviors, and exposures (Centers for Disease provides direct services (STD testing, vaccines, contact
Control and Prevention [CDC], 2013b; World Health tracing, directly observed therapy, case management). The
Organization, 2010). Public health workers monitor the state health department uses legislation as well as regula-
occurrence of health events, conditions, deaths, and the tions to require reporting by healthcare entities: to report
activities of the healthcare systems and their effects on certain illnesses, to require vaccinations for school entry,
c32.indd 460 2/5/2015 3:22:37 PM

Other Providers Laboratory was determined that no further modification to NETSS
Required would be made. NETSS differs from NEDSS in several
by state
ways. NETSS was case based; NEDSS is person based. In
statutes
(includes Local Health addition, NETSS used proprietary codes, but NEDSS is
patient Department based on standards so it can capture data already in elec-
identifiers) tronic healthcare data streams. These differences precipi-
tated the need to transition to NEDSS.
State Health
Voluntarily shared per Department
CDC/CSTE agreement National Electronic Disease Surveillance
(without identifiers) System (NEDSS)
CDC
In 1999, the CDC, the CSTE, and state and local pub-
lic health department staff began work on information
• FIGURE 32.3. Notifiable disease surveillance data flow system standards for the NEDSS initiative (National
to public health. (Data from Birkhead & Maylahn, 2000.) Electronic Disease Surveillance System Working Group,
2001). The NEDSS initiative uses standards to advance
the development of efficient, integrated, and interoper-
to coordinate statewide disease surveillance, and to moni-
able surveillance systems at the state and local levels. This
tor incoming reports from counties, and then submit
initiative facilitates the electronic transfer of information
those reports, voluntarily and minus names, to the CDC.
from clinical information systems in healthcare, reduces
The state prioritizes problems and develops programs,
the provider’s burden of providing data, and enhances the
runs the state public health laboratory, and serves as liai-
timeliness and quality of information provided.
son between the CDC and local level. The CDC publishes
Implementation of the NEDSS initiative was supported
national surveillance summaries and conducts research
by the CDC. States were funded to assess their current sys-
and program evaluations to produce public health recom-
tems and develop plans to implement criteria compatible
mendations. The CDC provides grants to states for spe-
with the NEDSS initiative. The criteria included browser-
cific programs, technical assistance, and, by invitation,
based system data entry, an Electronic Laboratory Results
outbreak response for state and local partners (Birkhead
(ELR) system for laboratory staff to report results to health
& Maylahn, 2000).
departments as authorized, and a single repository for
integrated databases from multiple health information
National Electronic Telecommunications systems. Also supported were system-wide electronic
System for Surveillance (NETSS) messaging upgrades for sharing the data. Finally, the CDC
developed a platform called the NEDSS-Base System
In 1984, the CDC, in cooperation with the CSTE and epi-
(NBS) for public health surveillance functions, processes,
demiologists in six states, began testing the Epidemiologic
and data integration in a secure environment. States then
Surveillance Project. The project’s goal was to demon-
had the option to choose this platform or another NEDSS-
strate the effectiveness of computer transmission of public
compatible system.
health surveillance case-based data between state health
Some states developed systems using specified NEDSS
departments and the CDC. By 1989, all 50 states were
standards, while other states used a CDC-developed
participating in the reporting system. The Epidemiologic
system. To understand better how the NEDSS initiative
Surveillance Project was renamed the National Electronic
meets its mission, we will examine the NBS role in sup-
Telecommunications System for Surveillance (NETSS) to
porting public health surveillance.
reflect its national scope (CDC, 2013d). The NETSS sys-
tem includes 22 core data elements for reportable disease
conditions. The CDC analyzes these data and dissemi-
Healthcare Providers Role and the NBS
nates them in the Morbidity and Mortality Weekly Report
(MMWR). This overwhelming volume of data to be man- Healthcare providers are responsible for providing clini-
aged by health departments led to the National Electronic cal care and reporting state-designated reportable condi-
Disease Surveillance System (NEDSS) initiative, which tions to public health departments. As a registered user
provides guidance for the technical architecture and stan- of the NBS, a healthcare provider can directly enter data
dards for nationally reportable condition reporting. When from case and laboratory reports into the state’s electronic
the CDC decided to transition from NETSS to NEDSS, it surveillance system at the point of care. In addition to the
c32.indd 461 2/5/2015 3:22:37 PM

direct entry of data, healthcare providers can securely and standardized manner and in near real time for analysis
query the database, verify completeness of reporting by CDC program areas. This supports effective policy for-
using analysis tools, and ensure compliance with state mation at the national level when events of public health
public health laws. Healthcare providers can send elec- significance happen. The data are disseminated through
tronic case reports using the Health Level Seven Clinical the Morbidity and Mortality Weekly Reports (MMWR).
Document Architecture (HL7 CDA) format when their
electronic health record (EHR) is equipped to report in the
Privacy Protection and the NBS
standard format.
In order to protect personally identifiable information,
the NBS requires user authentication, authorization, and
Clinical Laboratories and the NBS
auditing protocols. To verify the identity of the user, the
Staff members in public and private laboratories are NBS supports custom authentication. Once authenti-
required by law to notify public health departments of cated, the NBS application authorizes access to data based
state reportable conditions. Timely reports are critical on user role, geographical area(s), disease(s), public health
to public health surveillance because they prompt inves- event(s), and action(s). For example, a local public health
tigations of cases of reportable diseases or outbreaks. practitioner may be assigned access to Foodborne and
Registered laboratory users of the NBS system enter Diarrheal (FDD) investigations and laboratory reports
reports directly using the Web-based laboratory reporting for a public health jurisdiction. The supervisor can be
function of the NBS. This report is then readily available to assigned access to multiple public health jurisdictions
the public health NBS users to conduct the investigation across multiple families of diseases (e.g., FDD and hepati-
(Levi, Vinter, & Segal, 2009). tis). The NBS creates an audit file containing a fingerprint
trail with a timestamp of the user’s activities.
Public Health Practitioner Role and the NBS
Value of Information Solutions to
The local or state public health practitioner responds to
Surveillance Practice
incoming data on reportable conditions and implements
appropriate public health case finding, tracking, and mon- NEDSS-compatible infectious disease electronic surveil-
itoring. Public health practitioners, who are registered lance systems change how public health departments at
users of the NBS, may review reports from laboratories all levels communicate to perform their mission. Access to
and healthcare providers for patients residing within their data repositories is no longer limited to a central location.
jurisdictional boundaries. The public health practitioner Rather, epidemiologists, registered as the NBS users, may
may create an “alert” function for new data received in have data access at all public health levels. These systems
the NBS (such as for reports of meningococcal disease). enhance the capacity of local and state public health agen-
Upon receipt of a new report, the public health practitio- cies to react quickly to disease occurrences.
ner may order a public health field investigation. Clinical,
laboratory, epidemiologic, and follow-up data are entered
Future Directions for Infectious
at point of care and stored in the NBS. Stored data can be
Disease Surveillance
read, analyzed, and shared. The public health practitioner
classifies the case, based on stored data and standard case State public health programs face major funding and
definitions, and forwards the notification to CDC using infrastructure challenges in adopting the standards-driven
the NEDSS messaging format, HL7, or NETSS (if no mes- information systems for electronic disease surveillance.
saging guide exists). A data transfer function in the NBS The CDC encourages adequate and sustained funding
allows users to notify another jurisdiction when a patient by public health programs for the NEDSS initiative and
moves and to transfer records for follow-up. encourages partners and clinical providers at the point of
care to adopt standards and create a uniform, interoper-
able, and bi-directional process for electronic disease
Federal (CDC) Role and the NBS
surveillance. Initiatives such as the CDC’s Public Health
A key part of the public health surveillance process is Informatics Fellowship Program train professionals to
assessment of population health in the United States. The apply information science and technology to the practice
capabilities of the NBS support public health investiga- of public health (CDC, 2013e).
tions and interventions at the state level and allow report- Because public health informatics requires the inte-
ing of nationally notifiable diseases in a more complete gration of computer science, information science, and
c32.indd 462 2/5/2015 3:22:37 PM

information technology into the public health system and Benefits of the implementation of an IIS for the pub-
with clinical care, one method to better understand how lic include having a private and secure place to safeguard
public health information systems work is to examine their important immunization information from multiple pro-
application in collecting, organizing, exchanging, and dis- viders that will be used throughout a person’s life; receiving
seminating data and information. The following two cases timely immunization reminders; and eliminating duplicate
illustrate public health information systems applied in the immunizations. Benefits for healthcare providers include
context of an immunization information system and a TB consolidating immunization records from different sources;
electronic surveillance system. automatically calculating the immunizations needed; easily
providing official copies of immunization records; reduc-
ing chart pulls for coverage assessments and Healthcare
Using Informatics in an Immunization
Effectiveness Data and Information Set (HEDIS) reviews
Information System
(National Committee for Quality Assurance [NCQA],
Public health has been an advocate for immunization to 2013); automating vaccine inventory and ordering proce-
prevent disease for decades. Currently, vaccine-prevent- dures; allowing for vaccine tracking during vaccine short-
able diseases are at, or near, record lows (Roush, Murphy, & ages or manufacturer recalls; flagging high-risk patients for
Vaccine-Preventable Disease Table Working Group, 2007). timely vaccination recalls; and assisting with vaccine safety
The Every Child By Two organization provides some basic and adverse event reporting. To accomplish these activi-
facts regarding the need for immunization registries. In the ties, the IIS must be able to exchange data and information.
United States, there are around 4 million births each year Data, vocabulary, and transmission standards are criti-
(11,000/day); by age 2, a child will need to have up to 20 cal to IIS success. A core IIS dataset has been defined,
vaccinations; 2.1 million children are under-immunized; current procedural terminology (CPT) codes have been
and 22% of American children see two immunization pro- mapped to CVX (vaccine codes), and MVX (manufacturers
viders in their first 2 years (Every Child By Two, 2010). of vaccines) codes have been developed to facilitate immu-
Immunization records and registries began as paper nization data exchange between IIS, billing and adminis-
forms that were completed by hand at the point of service. trative systems, inventory management systems, and other
The immunization record was kept with the patient’s file, support systems. In addition, HL7 standards are used for
and an official copy was given to the patient or patient’s codes as well as patient demographics, appointment sched-
guardian. On a periodic basis, usually once a month, all the uling, file synchronization, and other data management
immunizations records were aggregated by hand (or calcu- transactions produced and received by the systems.
lator) with patient demographics and vaccine information The IIS has been successfully implemented in many states.
written into a registry that was shared with the local health Examples include the Michigan Care Improvement Registry
agency. This time-consuming process contained many vul- (Michigan Care Improvement Registry [MCIR], 2013), the
nerable points where the data could be wrongly entered, Oregon Immunization ALERT system (Oregon DHHS, 2013),
incorrectly calculated, or not included in the overall tally. the Wisconsin Immunization Registry (WIR) (Wisconsin
Newer immunization registries are based on elec- Immunization Program, 2013), the Iowa Immunization
tronic Immunization Information Systems (IIS). These IIS Registry Information System (Iowa Department of Public
are confidential, computerized information systems that Health, 2013), and the Louisiana Immunization Network for
allow for the collection of vaccination histories and pro- Kids Statewide (LINKS) (Louisiana Immunization Network
vide immediate access by authorized users to a child’s cur- for Kids Statewide [LINKS], 2013).
rent immunization status. One impetus for IIS arose from Challenges to moving IIS forward include funding
the Healthy People 2010 objective (14.26), which stated and human capacity to build and manage the system. The
that 95% of children younger than 6 years of age would HITECH Act (American Recovery and Reinvestment Act
be registered in a fully operational IIS (U.S. Department [ARRA], 2009) that provides funding and educational pro-
of Health and Human Services, 2010). “Nationally, 19.2 grams focusing on informatics will help nurses and oth-
million U.S. children aged <6 years (84%) participated ers develop skills refine and effectively use this important
in an IIS in 2011. Child participation in IIS has increased public health information system.
steadily, from 63% in 2006 to 84% in 2011. Of the 54 grant-
ees with available data in 2011, 24 (44%) reported that
Using Informatics in a Tuberculosis Electronic
>95% of children aged <6 years in their geographic area
Information System
participated in their IIS. An additional 13 (24%) grantees
reported child participation rates ranging from 80% to Tuberculosis is a chronic bacterial infection caused by
94%” (CDC, 2013f ). Mycobacterium tuberculosis. The most common site of
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infection is the lung, but other organs may be involved. programs receiving federal funding for TB prevention and
Healthcare providers are required by laws in all 50 states control. The national reports are used by state programs
to report patients with TB and other conditions on the to set performance targets, measure performance, and
state’s list of notifiable conditions. Confirmed TB cases evaluate the program’s capacity to control and prevent TB
are reported by clinicians and laboratory staff to local (Division of TB Elimination, 2012).
health departments and then to statewide disease surveil- Work continues on managing data quality to improve
lance programs connected to state health departments. A accuracy, completeness, consistency in collecting data,
confirmed case of TB is one that meets the clinical case and timeliness of reporting in the National TB Surveillance
definition or is laboratory confirmed. Reporting is also System. Additionally, future applications are needed to
recommended for patients who have suspected respira- automate data exchange between the TB reporting sys-
tory TB prior to laboratory confirmation, to expedite con- tems and to standardize laboratory data for direct report-
tact tracing and TB transmission control. ing to the National TB Surveillance System.
Multiple systems are involved in electronic TB report-
ing. Data reporting systems include the National TB The Public Health Informatician and
Surveillance System (Division of TB Elimination, 2013a), the Emerging Roles for Public Health
the TB Genotyping Information Management System Nurse Informatician
(Division of TB Elimination, 2013b), and the Electronic
Disease Notification System (CDC: Division of Global The emerging role of the PHNI is illustrated in case
Migration and Quarantine, 2013). studies to demonstrate the core public health functions
The National TB Surveillance System is an electronic of assessment and assurance performed by the PHNI
incidence surveillance system that collects 49 data items and the PHI. In the first case study, the PHI ensured the
on newly diagnosed verified cases of TB in the United retrieval of destroyed health records (immunization data)
States. The appropriate authority transmits the data from for displaced Hurricane Katrina communities by linking
the state or designated health jurisdiction to CDC at three people with their records through informatics. By retriev-
intervals: initially at the time of case verification, at receipt ing health records, the PHI enforced the rules regarding
of initial test results for drug susceptibility, and at treat- immunization record requirements while ensuring provi-
ment closure. Formats for reporting TB cases have evolved sion of needed immunizations. In the second case study,
over decades from paper-based reporting beginning in the PHI, while participating in assessment activities to
1952, to electronic reporting introduced in the mid-1980s, monitor health status and health problems in displaced
to an NEDSS-compatible, electronic surveillance system, Hurricane Katrina communities, identified a norovirus
using HL7 messaging, operational in 2010 for verified TB outbreak. The PHI developed and used a simple data
cases reported in 2009. checklist of symptoms, and compiled daily information
The TB Genotyping Information Management System reports and environmental risk information to evaluate
(TB GIMS) builds upon the established infrastructure of the ongoing effectiveness and quality of emergency public
the CDC’s National TB Surveillance System and incorpo- health services. In the third case study, the PHNI designed
rates genotype data to create a centralized database and an assessment activity for barriers to adherence behaviors
reporting system. State public health laboratories submit with TB treatment. The PHNI described a clinical nurs-
isolates from culture-confirmed cases to one of two desig- ing information system (CNIS) for a behavioral adherence
nated genotyping laboratories for molecular characteriza- model adapted to TB program literature. The resulting
tion, which helps with identifying recent transmission and dataset can be used to manage data, monitor the perfor-
potential outbreaks. mance plan, and evaluate the effectiveness and quality of
The Electronic Disease Notification System alerts state personal health services.
and local health department programs of refugees and
immigrant arrivals to their jurisdictions and provides
overseas medical screening results and treatment follow- CASE STUDY 32.1. IMMUNIZATION
up information. Each refugee or immigrant with a TB REGISTRIES AND EMERGENCY
classification is referred to the TB program for medical RESPONSE AFTER
screening and treatment follow-up.
CDC uses data from these reporting systems to dis-
HURRICANE KATRINA
seminate performance measurement reports for national Hurricane Katrina made landfall in Louisiana on August
TB-related performance indicators (NTIP). CDC shares 29, 2005. To escape the storm, more than 200,000 resi-
these reports electronically with health department dents of New Orleans and the surrounding area evacuated
c32.indd 464 2/5/2015 3:22:38 PM

to shelters in Houston, Texas. In their hurry, they left on an intake form in medical facilities setup to provide
behind most personal belongings, including immuni- care on an outpatient basis. This information was gathered
zation records or medical records. Since the hurricane and entered into a database, and results were distributed
landed as the fall school session was about to begin, state each morning.
and local school boards in Texas agreed to accept the dis- On September 2, staff observed an increase in adults and
placed children into schools without proof of immuni- children with symptoms of acute gastroenteritis. On some
zation, but stated that proof of immunizations would be days, nearly 21% of adults and 40% of children visiting one
necessary to remain in school. clinic had acute gastroenteritis. They conducted enhanced
To assist families in finding their children’s records, the surveillance to improve identification of acute gastroen-
Houston-Harris County (Texas) Immunization Registry teritis, investigated the apparent outbreak, identified the
(HHCIR) staff contacted their vendor, who was also the infectious agent, and implemented control measures.
vendor for the Louisiana Immunization Network for Kids The reported epidemiologic and laboratory findings
Statewide (LINKS), to investigate the possibility of link- suggested that an outbreak of norovirus gastroenteri-
ing the two IIS. In less than 24 hours, the HHCIR, ven- tis had affected individuals in numerous facilities. These
dor, and LINKS personnel had developed a technological outbreaks are not associated with contaminated food or
bridge built on HL7 standards connecting the two systems. water, but spread through person-to-person contact or
Ten days later, they had created a mechanism that allowed from fomites in crowded settings. This information was
health authorities to acquire child and adolescent immu- used to provide a health alert for epidemiologic features
nization histories from LINKS. This merged Web-based and clinical presentation, and to promote rehydration
immunization registry was made available to public health treatment and measures to prevent secondary transmis-
officials and selected healthcare providers in temporary sion (CDC, 2005).
clinics in the Astrodome and George R. Brown Convention
Center. Originally, the new IIS was a “search and view” only
system; the HL7 data exchanges capability was added to CASE STUDY 32.3. USING
allow the LINKS-HHCIR connection to exchange patient INFORMATICS FOR PUBLIC
data and information from one system to the other.
Over the next month, more than 20,000 records were
HEALTH PROGRAM EVALUATION
searched and approximately 10,000 were successfully A diagnosis of TB disease or latent TB infection in a child
matched for displaced children in the greater Houston area. represents recent transmission of M. tuberculosis; there-
By September 2006, one year later, nearly 19,000 records fore, trends in TB disease and latent TB infection in young
had been successfully matched. The estimated cost savings children are important indicators to assess the effective-
of this on-the-fly, hybrid IIS, just in vaccines for these chil- ness of TB prevention and control efforts. Investigations
dren, is slightly over $1.6 million. These costs do not factor of persons having infectious pulmonary TB can avert TB
in the savings in time, pain, and lost work time or missed in children who have been infected with M. tuberculosis by
school that would have occurred if the children had finding and treating these children before they progress to
needed to be re-immunized. Nor do the costs reflect the TB disease (Lobato et al., 2008).
societal costs that may have occurred if the children had Monitoring standardized nursing activities (investiga-
not been allowed to attend school (Boom, Dragsbaek, & tion and adherence) can help identify missed opportuni-
Nelson, 2007). The use of the IIS immunization registry ties for preventing TB in young children. For example,
post-Katrina empowered patients, parents, and healthcare when a child develops TB disease or latent TB infection,
providers to know immunization history. how timely was the exposed child identified or screened
for TB (case interview/investigation adequacy)? Was the
child recommended for TB treatment but did not start or
CASE STUDY 32.2. NOROVIRUS did not complete treatment (caregiver adherence issues)?
OUTBREAK IN PERSONS DISPLACED Was the person having infectious pulmonary TB and
exposing the child recommended for treatment, but did
BY HURRICANE KATRINA not start or did not complete treatment (adherence issues)?
Collecting and sharing data and information is essen- PHNs use a clinical nursing information system (CNIS)
tial for public health practice. In September 2005, nearly dataset, constructed with standardized nursing terminol-
1000 evacuees from Hurricane Katrina and relief workers ogy recognized by the American Nurses Association, to
in numerous facilities had symptoms of acute gastroen- account for nursing activities, to manage program out-
teritis. A checklist of symptoms was used to collect data comes, and to describe a planned approach to nursing
c32.indd 465 2/5/2015 3:22:38 PM

care. Although PHNs use the CNIS dataset to generate identify, describe, and label interventions that affect those
data on patient assessments and to characterize health- outcomes. The Patient-Centered Care (PCC) Model for
care provider interactions with patients, authors looked Perceived Barriers to Adherence with TB Treatment helps
for a CNIS dataset specifically adapted for identifying bar- the nurse identify and document multiple determinants of
riers to investigation and adherence to treatment. adherence behavior and useful interventions (Table 32.1)
PHNs can select from various CNIS datasets. They (Gibson, Boutotte, Wilce, & Field, 2011).
selected a vendor application of CNIS for the public health
programs in Maine and Minnesota. The CNIS in Maine is
a statewide PHN initiative within the public health system. FUTURE DIRECTIONS IN PUBLIC
It is used to document clinical care and to inform program
evaluation. Common tools are used for nursing care and
HEALTH INFORMATION SYSTEMS
education plans, flow sheets, and encounter forms for indi- Although public health information systems have matured
vidual client services (TB, MCH, childhood lead poison- over the past decade, many challenges remain. In general,
ing) (Correll & Martin, 2009). In Minnesota, the Omaha public health practitioners have not taken an active role
system contributes to the outcomes management program in the development of health information systems within
in local public health departments by providing quantita- their jurisdictions. Since the bulk of public health activi-
tive data and graphs for program planning, evaluation, and ties occur within state/territorial level and local health
communication with administrators and local government departments, public health practitioners must provide
officials (Monsen, Martin, Christensen, & Westra, 2009). support and leadership to local healthcare systems in
PHNs in the TB program described components of a the emerging concept of multiagency responsibility for
planned approach to overcome adherence barriers and health. Local agencies and institutions such as managed
support completion of long-term TB treatment. PHNIs care organizations, hospitals, laboratories, environmental
are in an excellent position to identify, describe, and label health agencies, nursing homes, police staff, community
the issues associated with health outcomes as well as to centers, pharmacies, civic groups, corrections staff, drug
TABLE 32.1 Patient-Centered Care Model (PCC Model) for Barriers to Patient Adherence With Taking Medication
and Keeping Appointments for Tuberculosis Treatment (Gibson, Boutotte, Wilce, & Field, 2011)
Patient Diagnosis (NANDA-I) Nursing Interventions (NIC) Patient Outcomes (NOC)
Ineffective health maintenance Sustenance support Social support

Ineffective protection Infection control Immune status
Adjustment impaired/Risk-prone health behavior Decision-making support Well-being
Decisional conflict: whether to participate in Mutual goal setting Participation in healthcare decisions
treatment
Defensive coping Patient contracting Coping
Fear (stigma) Emotional support Fear self-control
Powerlessness: perceived threat Patient’s rights protection Health beliefs: perceived ability to perform
Ineffective therapeutic regimen management Medication management Medication response
Ineffective family therapeutic regimen management Discharge planning Family participation in professional care
Noncompliance Health policy monitoring Compliance
Knowledge deficit Teaching Knowledge of
•• Disease process •• disease process •• disease process
•• Treatment regimen •• treatment regimen •• treatment regimen
Communication impairment Culture brokerage Communication ability
NANDA-I, Nanda International; NIC, Nursing Interventions Classifications; NOC, Nursing Outcomes Classification.
Reproduced, with permission, from Gibson, J.D., Boutotte, J., Wilce, M., & Field, K. (2010). A patient-centered care model for perceived barriers to
adherence with tuberculosis treatment. (Unpublished Work.)
c32.indd 466 2/5/2015 3:22:38 PM

treatment centers, EMS staff, and home health agencies and population health can be planned. Health reform and
are partners in maintaining the public’s health. Figure related funding is driving the HIT platform. In response,
32.1 (Centers for Disease Control and Prevention [CDC], fellowship programs and internships in surveillance and
2013a) illustrates entities involved in local data/informa- public health informatics are addressing those needs
tion exchange. Additionally, public health practitioners (Drehobl, Roush, & Stover, 2012; CDC; ASPH partner fel-
have the expertise needed to inform developers of the lowship programs; ASPPH Graduate Training Program
health information system about specific data and infor- fellowships and internships; MELDI-Public Health
mation needs for population-based analyses to recognize Informatics Fellowship Program; NIH Nursing Informatics
emergent issues in the community, to assist in diagnostic Internship; Informatics university programs; American
and treatment decisions, and to understand better meth- College of Medical Informatics [ACMI] fellowship).
ods to improve the health of the community. Federal agen- Health reform promises the eliciting of evidence-
cies involved in public health can provide the leadership based practice to improve health (Agency for Healthcare
and expertise in developing consensus on data and health Research and Quality [AHRQ], 2013). Therefore, HIT
information technology (HIT) standards that will allow must capture interventions by multiple providers includ-
for the exchange of public health data and information ing nurses. Many promising practice-based interventions
across public health jurisdictions creating a “network of are addressed by nursing practice (Spencer, Schooley, &
networks” that function as a national public health infor- Anderson, 2013).
mation system. PHN leaders, working in partnership with other stake-
Using data in innovative ways through the use of data holders, monitor and evaluate program performance.
visualization and decision support systems will increase They clarify and describe practice-based interventions
public health’s ability to understand disease trends, make linked with achieving partnership goals and objectives.
decisions, and apply the appropriate resources where For example, The COPE Healthy Lifestyles Teen inter-
needed. The use of decision support based on clinical and vention for the national priority of Nutrition, Physical
prevention guidelines can integrate prevention messages Activity, Obesity (CDC, 2013g) links the nursing role
into primary care. and responsibilities with program goals and objectives by
As some HIT stabilizes and other technology innova- tracking nurse-sensitive indicators for BMI and pedom-
tions occur, public health can be the beneficiary of the focus eter step (Melnick, Jacobson, & Kelly, 2013). As healthcare
and funding that are driving healthcare reform. As clinical reform continues to evolve, PHN leadership will need to
care and public health continue to integrate and support take an active role in the development of the scope and
each other’s goal of keeping people healthy, HIT will pro- standards of public health nursing informatics practice
vide the platform to improve the health of the nation. and informatician competencies associated with these
accountabilities.
The Future of the Public Health Nurse
Informatician Role
“The PHN practice specialty needs a deeper understand-
SUMMARY
ing of informatics theories and methods to practice more In summary, public health, public health informatics, pub-
effectively” (American Nurses Association, 2013). While lic health information systems, and the ever-increasing
the Scope & Standards of Nursing Practice for Nursing integration of public health and healthcare present many
Informatics (American Nurses Association, 2008) and opportunities to improve the Nation’s health. Recent leg-
the Competencies for Public Health Informaticians islation has provided the guidance and funding platforms
(Association of Schools of Public Health, University of to create a seamless integration of health information sys-
Washington Center for Public Health Informatics, 2013) tems to assist with better decision-making in patient care
have been published, literature review did not identify and in policy development. The development of individual
scope and standards of public health nursing informatics data and information system standards is occurring less
(PHNI) or competencies for public health nursing infor- frequently as nationally recognized HIT and data exchange
maticians. It is necessary to describe the nursing profes- standards are stabilizing. Efforts supporting the certifica-
sion’s contributions to addressing national public health tion of the information technology used in health have an
priorities and initiatives. impact on the adoption and integration of these standards
The workforce capacity for public health surveillance by information system vendors. Successful implementa-
is limited but necessary to identify public health needs tions of standards-based information systems have dem-
so that interventions to improve individual, community, onstrated enormous cost savings in time and money.
c32.indd 467 2/5/2015 3:22:38 PM

PHNs contribute data to the standards-based data CDC. (2013d). National Electronic Telecommunications
exchange systems; use information to target care for indi- System for surveillance (NETSS). Atlanta, GA. Retrieved
viduals, families, groups, and populations; and then evalu- from http://www.cdc.gov/ncphi/disss/nndss/netss.htm
ate programs by means of the information systems. The CDC. (2013e). Public health informatics fellowship program.
Atlanta, GA. Retrieved from http://www.cdc.gov/phifp/
PHNI seeks partners to understand variables of concern
CDC. (2013f ). Progress in Immunization Information
to nurses in clinical care, such as barriers to adherence Systems—United States, 2011. Morbidity and Mortality
behaviors, in the development of the standards-based Weekly Report. 62(03), 48. Retrieved from http://www.
data exchange systems. The PHNI provides leadership to cdc.gov/mmwr/preview/mmwrhtml/mm6203a2.htm
the PHNs in the use of health information technology to CDC. (2013g). Winnable battles. Retrieved from http://www.
improve the health of the nation. cdc.gov/winnablebattles/
CDC: Division of Global Migration and Quarantine. (2013).
Disease surveillance among newly arriving refugees and
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33
Informatics Solutions for Emergency
Planning and Response
Elizabeth (Betsy) Weiner / Capt. Lynn A. Slepski
• OBJECTIVES
1. Describe the contributions that informatics can provide to emergency planning
and response.
2. Illustrate various ways that informatics tools can be designed and used to
support decision-making and knowledge base building in emergency planning
and response efforts.
3. Utilize the 2009 H1N1 example as a case study in how informatics was used to
plan and respond to this pandemic event.
4. Project areas of emergency management and response that would benefit from
informatics assistance.
• KEY WORDS
Emergencies
Disasters
Public health informatics
Bioterrorism
Biosurveillance
2014) reported that during 2013 they responded to three

INTRODUCTION major crises: Syria, where 9.3 million people were in need
Unfortunately, both natural and manmade disasters have of urgent humanitarian assistance; the Philippines, where
catapulted us into a world that has resulted in making Typhoon Haiyan/Yolanda killed nearly 6000 people, dev-
emergency planning and response a high priority need. astated the lives of millions, and destroyed over a million
There has been a documented rise in terrorism incidents, homes, and the Central African Republic where rising
as well as natural disasters worldwide. Natural events have tensions between Muslim and Christian communities and
ranged from earthquakes, tsunamis, floods, hurricanes, the collapse of the state have left the entire population of
typhoons, to pandemic disease events affecting billions. the country in fear and affected by the crisis. These emer-
Conflicts and nuclear disasters have added to the complex- gencies can have extensive political, economic, social,
ities. In addition to natural disasters, political and social and public health impacts, with potential long-term
upheavals massively disrupt the lives and livelihoods of consequences sometimes persisting for years after the
populations and result in the forced displacement of mil- emergency (WHO, 2013). As a result, both planning and
lions of people. The World Health Organization (WHO, response efforts have taken on new importance in relation
471
c33.indd 471 2/5/2015 5:03:56 PM

to emergencies and disasters. The purpose of this chap- and enhance informatics support at both the scene of the
ter is to explore the intersection between informatics and disaster and at the community resource levels.
emergency planning and response in order to determine The 2004 earthquake and tsunami that devastated parts
current and future informatics contributions. of Southeast Asia illustrated the uncoordinated invasion of
The United States is not immune from this increased people and organizations that resulted in unnecessary dupli-
emphasis on emergency preparedness. The events of cation, competition, and failure to assist many of the victims
September 11, 2001, forced the United States into the real- in need (Birnbaum, 2010). Subsequently, the Interagency
ization that the country was not adequately protected from Standing Committee (IASC) of the United Nations Office
terrorism. Then, within a short window of time, the anthrax for the Coordination of Humanitarian Affairs (UN-OCHA)
outbreaks stressed the public health infrastructure to the initiated changes called the “humanitarian reform.” This
point that bioterrorism arose as an additional deadly threat. reform effort organized clusters whose principal mission
As a result of these two experiences, the government of the was to assist the impacted government with coordination
United States responded at an unprecedented pace to bet- of all responses and with evaluations of the impact of inter-
ter prepare and manage terrorist events. Furthermore, the ventions. The World Health Organization was appointed as
pandemic H1N1 incident in 2009 created data collection the lead agency for health, which includes coordination and
challenges that caused public health officials to creatively production of health information (WHO, 2009, p. 8). Three
provide solutions for meaningful data acquisition in order of the eight strategic areas of their five-year programme
to be able to effectively manage the event. Events such as the required informatics: (3) improve health information and
mass shooting in Newtown, Connecticut, Hurricane Sandy operational intelligence; (4) provide baseline information on
on the eastern coast of the United States, and the horrific health risks, health risk reduction, and emergency prepared-
tornado in Moore, Oklahoma, serve as recent illustrations ness; and (7) build emergency preparedness knowledge and
of how response efforts have had to be altered to meet var- skills through training, guidance, research, and information
ied situations. Hemingway and Ferguson (2014) reflected services. This organization at the global level was aimed at
on lessons learned during the Boston Marathon bombing discouraging individual and organizational response efforts
and concluded that emergency preparedness plan updates that were not part of this coordinated response. The United
must reflect the changing types of disasters, changing com- States has also organized their planning and response
munication technologies, and the changing workforce. efforts for the same reasons, and informatics is increasingly
Early contributions by the informatics community taking on more important roles in these efforts.
focused on surveillance of threat detection. However,
as informaticists became more familiar with emergency
planning and response, it became clear that contributions THE FEDERAL SYSTEM FOR
toward efficiency, analysis, remote monitoring, telemedi- EMERGENCY PLANNING
cine, and advanced communications would be valued.
The most consistent challenge for emergency and disaster
AND RESPONSE
response continues to be communication and information Most disasters and emergencies are handled by local and
management. Effective response requires high situational state responders. The federal government provides sup-
awareness analyzing real-time information to assess needs plemental assistance when the consequences of a disaster
and available resources that can change suddenly and exceed local and state capabilities.
unexpectedly. There is a critical interdependence between Under the Homeland Security Presidential Directive 5
data collected in the field about a disaster incident, casu- (HSPD5) (White House, 2003), the Secretary of Homeland
alties, healthcare needs, triage, and treatment and the Security, as the principal Federal official for domestic inci-
needed community resources such as ambulances, emer- dent management, coordinates Federal actions within the
gency departments, hospitals, and intensive care units. United States to prepare for, respond to, and recover from
Concurrently, information from the various inpatient terrorist attacks, major disasters, and other emergencies.
facilities and ambulance resources alters the manage- Coordination occurs if and when any one of the following
ment and disposition of victims at the scene of a disaster. four conditions applies: (1) a Federal department or agency
Opportunities abound for new telecommunication tech- acting under its own authority has requested the assistance
nologies. Smart devices, wireless connectivity, and posi- of the Secretary; (2) the resources of State and local author-
tioning technologies are all advances that have application ities are overwhelmed and Federal assistance has been
during disaster events. These technologies are being used requested by the appropriate State and local authorities;
and evaluated to improve patient care and tracking, foster (3) more than one Federal department or agency has become
greater safety for patients and providers, enhance incident substantially involved in responding to the incident; or
management at the scene, coordinate response efforts, (4) the Secretary has been directed to assume responsibility
c33.indd 472 2/5/2015 5:03:56 PM

Chapter 33 • Informatics Solutions for Emergency Planning and Response 473
for managing the domestic incident by the President. and private sector partners, including the healthcare sector,
Further, HSPD5 directs Federal department heads to prepare for and provide a unified domestic response,
provide their full and prompt cooperation, support, improving coordination and integration. The Framework
and resources to the Secretary in protecting national emphasizes preparedness activities that include planning,
security. organizing, training, equipping, exercising, and applying
The National Response Framework, enacted in January lessons learned and assigns lead federal agencies to each
2008, established a comprehensive, national, and all-haz- of 15 Emergency Support Functions (ESF) (Department of
ards approach to respond to disasters and emergencies Homeland Security, 2008b).
(Department of Homeland Security, 2008a). Built on its The ESF group functions are used to provide Federal
predecessor, the National Response Plan, it includes guid- support during a response (Table 33.1), and assigns leads
ing principles that detail how federal, state, local, tribal, for each functional area. The Department of Health
TABLE 33.1 Emergency Support Functions by Lead Department and Scope

Lead Department/
Function Agency Scope
ESF #1— Transportation Aviation/airspace management and control

Transportation Transportation safety
Restoration/recovery of transportation infrastructure
Movement restrictions
Damage and impact assessment
ESF #2— Homeland Coordination with telecommunications and information technology
Communications Security/Federal infrastructures
Emergency Restoration and repair of telecommunications infrastructure
Management Agency Protection, restoration, and sustainment of national cyber and information
technology resources
Oversight of communications within the Federal incident management and
response structures
ESF #3—Public Defense/U.S. Army Infrastructure protection and emergency repair
Works and Corps of Engineers Infrastructure restoration
Engineering Engineering services and construction management
Emergency contracting support for life-saving and life-sustaining services
ESF #4— Agriculture/ Fire Coordination of federal firefighting activities
Firefighting Service Support to wildland, rural, and urban firefighting activities
ESF Scope ESF #5— Homeland Coordination of incident management and response efforts
Emergency Security/Federal Issuance of mission assignments
Management Emergency Resource and human capital
Management Agency Incident action planning
Financial management
ESF #6—Mass Homeland Mass care
Care, Emergency Security/Federal Emergency assistance
Assistance, Emergency Disaster housing
Housing, and
Management Agency Human services
Human Services
ESF #7—Logistics Homeland Comprehensive, national incident logistics planning, management, and
Management and Security/Federal sustainment capability
Resource Support Emergency Resource support (facility space, office equipment and supplies, contracting
Management Agency services, etc.)
(continued)
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TABLE 33.1 Emergency Support Functions by Lead Department and Scope (continued)
Lead Department/
Function Agency Scope
ESF #8—Public Health and Human Public health

Health and Services Medical
Medical Services Mental health services
Mass fatality management
ESF #9—Search and Defense Life-saving assistance

Rescue Homeland Search and rescue operations
Security/Federal
Emergency
Management Agency
ESF #10—Oil and Homeland Security/ Oil and hazardous materials (chemical, biological, radiological, etc.)
Hazardous U.S. Coast Guard response
Materials Environmental short- and long-term cleanup
Response
ESF #11— Agriculture Nutrition assistance

Agriculture and Interior Animal and plant disease and pest response
Natural Resources
Food safety and security
Natural and cultural resources and historic properties protection and
restoration
Safety and well-being of household pets
ESF #12—Energy Energy Energy infrastructure assessment, repair, and restoration

Energy industry utilities coordination
Energy forecast
ESF #13—Public Justice Facility and resource security

Safety and Security planning and technical resource assistance
Security
Public safety and security support
Support to access, traffic, and crowd control
ESF #14—Long- Homeland Social and economic community impact assessment

Term Community Security/ Long-term community recovery assistance to states, local governments, and the
Recovery Federal private sector
Emergency Analysis and review of mitigation program implementation
Management Agency
Urban Development
Small Business
Administration
ESF #15—External Homeland Emergency public information and protective action guidance
Affairs Security/Federal Media and community relations
Emergency Congressional and international affairs
Management Agency Tribal and insular affairs
Reproduced from Department of Homeland Security (2008b).
c33.indd 474 2/5/2015 5:03:57 PM

and Human Services leads public health and medical Many governments believed that if a pandemic-capa-
responses, including biosurveillance. ble virus emerged, there would be rapid worldwide spread
The Federal Emergency Management Agency (FEMA) as the 1918 Pandemic had spread across countries and
received critical public feedback following their poor continents in less than one year in a time without com-
response efforts during the 2005 Hurricane Katrina. Since mercial air travel to facilitate the spread of disease (DHHS,
that time, the agency has creatively added new social 2005). It was understood that a worldwide influenza pan-
media sites, ways to crowdsource disasters, and central- demic occurring in this century could have major effects
ized places to get information. Examples include an inter- on the global economy, especially travel, trade, tourism,
active emergency kit checklist with information about food, consumption, and eventually, investment and finan-
what to do during specific hazards; a disaster reporter fea- cial markets and could lead to widespread economic and
ture where users upload disaster photos with GPS features social disruptions. As a result, many countries engaged in
for posting on a public map; and a new social hub (FEMA, detailed pandemic planning and prepared to adopt draco-
2013). In addition, they have recently added the FEMA nian-like measures to delay but not stop the arrival of the
LinkedIn page and the U.S. Fire Administration Facebook virus, such as border closures and travel restrictions.
page where there are job listings, stories about what a “day Here in the United States, modelers predicted cata-
in the life” looks like at FEMA, other training resources, strophic death estimates (Table 33.3). The 1918–1919 flu
and tips for assisting fire departments or firefighters. pandemic, to date the most severe, had caused the deaths
of at least 675,000 Americans and affected about one-fifth
CASE STUDY 33.1. INFORMATICS of the world’s population. Researchers believed that if a
pandemic of similar severity occurred today, 90 million
AND 2009 H1N1 Americans could become ill, quickly exceeding available
Although there have been other viruses that have surfaced healthcare capacity and result in approximately 2 million
with the potential to become pandemic, the 2009 H1N1 Americans deaths (DHHS, 2005).
influenza pandemic continues to be the most recent pan- Preparedness planners assumed that all populations
demic and illustrates how informatics can contribute to an were at risk. They believed that disease would be wide-
emergency response. Initially concerned that a circulating spread, affecting multiple areas of the United States and
H5N1 virus (Avian Influenza A) was mutating and could other countries at the same time preventing the redistri-
cause a human pandemic, global experts had focused bution of resources. The world would experience multiple
efforts over the last several years on rapidly developing waves of outbreaks potentially occurring for an extended
catastrophic plans even though a pandemic virus had period of time (over 18 months), affecting the entire
not emerged. There were significant concerns, given that United States for a period of 12 to 16 weeks with commu-
during the twentieth century three flu pandemics were nity waves each lasting 6 to 8 weeks (DHHS, 2005). One to
responsible for more than 50 million deaths worldwide and three pandemic waves would occur (Occupational Safety
almost a million deaths in the United States (Department and Health Administration [OSHA], 2007). Further, plan-
of Health and Human Services [DHHS], 2005) (Table 33.2). ners believed that a pandemic could affect as many as 40%
The CDC estimates that 43 million to 89 million people of the workforce during periods of peak flu illness, pre-
had H1N1 between April 2009 and April 2010, and they dicting that employees could be absent because of their
estimate between 8870 and 18,300 H1N1 related deaths own illness, or would be caring for sick family members or
(DHHS, 2014a). On August 10, 2010 the WHO declared for children if schools or daycare centers are closed. They
an end to the global H1N1 flu pandemic (WHO, 2010). also recognized that workers would be absent if public
TABLE 33.2 History of Pandemics by Deaths, Causative Strain, and At-Risk Population
Populations at
Pandemic Estimated U.S. Deaths Estimated Worldwide Deaths Influenza A Strain Greatest Risk
1918–1919 500,000 40 million H1N1 Young, healthy adults

1957–1958 70,000 1–2 million H2N2 Infants, elderly
1968–1969 34,000 700,000 H3N2 Infants, elderly
Reproduced from Department of Health and Human Services Pandemic Influenza Plan (2005), p. B-7.
c33.indd 475 2/5/2015 5:03:57 PM

TABLE 33.3 Estimates of Numbers of Episodes The Centers for Disease Control and Prevention, part
of Illness, Healthcare Utilization, and of HHS, monitors influenza activity and trends and virus
Death Associated With Moderate and characteristics through a nationwide surveillance system
Severe Pandemic Influenza Scenarios* as well as estimates the burden of flu illness using sta-
in the United States tistical modelling (CDC, 2010). On April, 29, 2009, the
CDC began reporting cases of respiratory infection with
Moderate swine-origin influenza A (H1N1) viruses transmitted
Characteristic (1958/68-like) Severe (1918-like) through human-to-human contact (CDC, 2009a, 2009b).
Illness 90,000,000 90,000,000 It established the case definition for 2009 H1N1 as an
(30%) (30%) acute febrile respiratory illness in a person and laboratory-
confirmed swine-origin influenza A (H1N1) virus infec-
Outpatient 45,000,000 45,000,000
Medical Care (50%) (50%)
tion at CDC by either of the following tests: real-time
reverse transcription-polymerase chain reaction (rRT-
Hospitalization 865,000 9,900,000
PCR), or viral culture (CDC, 2009a). The CDC began
ICU Care 128,750 1,485,000 tracking and reporting the number of cases, hospitaliza-
Mechanical 64,875 742,500 tions, and deaths at state, local, and national levels using
Ventilation standard state reporting mechanisms. It was soon appar-
Deaths 209,000 1,903,000 ent that using actual case counts resulted in dramatically
underreported disease.
Reproduced from Department of Health and Human Services
Pandemic Influenza Plan (2005), p. 18.
On July 24, 2009, CDC abandoned initial case counts,
*Estimates based on extrapolation from past pandemics in the United when it recognized that those numbers represented a sig-
States. Note that these estimates do not include the potential nificant undercount of the actual number of 2009 H1N1
impact of interventions not available during the twentieth-century cases. They found that 2009 H1N1 was less severe and
pandemics.
caused fewer deaths than expected when compared to
the pandemic planning assumptions. As a result, existing
plans, which used case fatality numbers as the trigger for
transportation was disrupted or if they were afraid to leave initiating response actions, were not effective.
home (Department of Homeland Security, 2007). Scientists turned to other means to begin to under-
Adopting a “worst case scenario,” government experts stand the effects of disease and predict its future course.
rapidly developed a number of strategies to help local gov- For example, because trending indicated that children
ernments plan, stating that the Federal government would and young adults were at higher risk, the Department
not likely be able to provide any assistance during the of Education began looking at school closures and
actual pandemic. For example, DHHS (2007) developed a school absenteeism, examining both teacher and student
Pandemic Severity Index (PSI) to characterize the sever- absences. Each of the critical infrastructure key resource
ity of a pandemic. It was designed to predict the impact sectors held weekly calls with private sector partners to
of a pandemic and provide local decision-makers with elicit whether there were trends beginning to indicate
standardized triggers that were matched to the severity business interruption problems, which might forecast
of illness impacting a specific community (Table 33.4). social disruptions. The National Retail Data monitor-
The severity index was based on a case-fatality ratio to ing system tracked the real-time purchase of over-the-
measure the proportion of deaths among clinically ill per- counter (OTC) medications, such as fever reducers and
sons. Recommended actions were identified in advance, influenza treatments, in over 29,000 retail pharmacies,
and communicated to the public in hopes of increasing groceries, and mass merchandise stores. This University
their understanding and compliance. Using the PSI, a of Pittsburgh system (2014a) is used to provide early
severe pandemic influenza, similar to the 1918 Pandemic, detection of naturally occurring disease outbreaks as well
was defined as a category 4 or 5, with 20% to 40% of the as bioterrorism.
population infected. For a severe pandemic, HHS recom- The CDC moved to using estimates. Using the influ-
mended that localities be prepared to dismiss children enza module from BioSense, CDC tracked flu with data
from schools and close daycares for up to 12 weeks, as from over 500 local and state health departments, hospital
well as initiate adult social distancing, which included emergency rooms, Laboratory Response Network labs,
suspension of large public gatherings and modification of Health Information Exchanges, as well as the Departments
the work place schedules and practices (e.g., telework and of Defense and Veterans Affairs. The Real-Time Outbreak
staggered shifts). Disease Surveillance (RODS) was designed in 1999 to
c33.indd 476 2/5/2015 5:03:57 PM

TABLE 33.4 Matrix of Community Mitigation Strategies by Pandemic Severity Index
Interventions by Setting 1 Pandemic Severity Index 2 and 3 4 and 5
Home
Voluntary isolation of ill at home Recommendb, c Recommendb, c Recommendb, c
(adults and children); combine with
use of antiviral treatment as available
and indicated
Voluntary quarantine of household Generally not recommended Considere Recommende
members in homes with ill personsd
(adults and children); consider combin-
ing with antiviral prophylaxis if effec-
tive, feasible, and quantities sufficient
School
Child social distancing
• Dismissal of students from schools and Generally not recommended Consider: ≤ 4 weeksf Recommend:
school-based activities, and closure of ≤ 12 weeksg
childcare programs
• Reduce out-of-school social contacts Generally not recommended Consider: ≤ 4 weeksf Recommend:
and community mixing ≤ 12 weeksg
Workplace / Community
Adult social distancing
• Decrease number of social contacts Generally not recommended Consider Recommend
(e.g., encourage teleconferences, alter-
natives to face-to-face meetings)
• Increase distance between persons Generally not recommended Consider Recommend
(e.g., reduce density in public transit)
• Modify or cancel selected public gath- Generally not recommended Consider Recommend
erings to promote social distance (e.g.,
postpone indoor stadium events)
• Modify work place schedules and prac- Generally not recommended Consider Recommend
tices (e.g., telework, staggered shifts)
Reproduced from Department of Health and Human Services (2007), p. 12.

Generally Not Recommended = Unless there is a compelling rationale for specific populations or jurisdictions, measures are generally not
recommended for entire populations as the consequences may outweigh the benefits.
Consider = Important to consider these alternatives as part of a prudent planning strategy, considering characteristics of the pandemic such as age-
specific attack rate, geographic distribution, and the magnitude of adverse consequences. These factors may vary globally, nationally, and locally.
Recommended = generally recommended as an important component of planning strategy.
a
All these interventions should be used in combination with other infection control measures including hand hygiene, cough etiquette, and
personal protection equipment such as face masks. Additional information on infection control measures is available at www.pandemicflu.gov
(DHHS, 2007).
b
This intervention may be combined with treatment of sick individuals using antiviral medications and vaccine campaigns, if supplies are available.
c
Many sick individuals who are not critically ill may be managed safely at home.
d
The contribution made by contact with asymptomatically infected individuals to disease transmission is unclear. Household members in homes with
ill persons may be at higher risk and have asymptomatic illness promoting community disease transmission. Therefore, household members of
homes with sick individuals would be advised to stay home.
e
To facilitate compliance and decrease risk of household transmission, this intervention may be combined with provision of antiviral medications to
household contacts depending on drug availability, feasibility, and effectiveness; policy recommendations for antiviral prophylaxis are addressed in a
separate guidance document.
f
Consider short-term suspension of classes, that is, less than four weeks.
g
Plan for prolonged suspension of classes, that is, one to three months; actual duration may vary depending on transmission in the community as the
pandemic wave is expected to last six to eight weeks.
c33.indd 477 2/5/2015 5:03:57 PM

collect and analyze disease surveillance data in real time Middle East Respiratory Syndrome (MERS-CoV), which
(University of Pittsburgh, 2014b). Interpreting these esti- arose in 2013 in Saudi Arabia (Todd, 2014). Todd con-
mates, one study hypothesized that for every reported cludes that since all viral mutations are unpredictable,
lab-confirmed case of H1N1 between April and July 2009, it is impossible to predict whether any of these viruses
there were an estimated 79 total cases. The same study or yet another emerging virus will be the cause of a new
found that for every identified hospitalized case there were pandemic. We must, therefore, continue our diligence in
more likely 2.7 hospitalized people (Reed et al., 2009). surveillance activities.
Concerned that the limited capacity of the healthcare
system would be overwhelmed and finite resources such
Healthcare Consumers Contribute to
as H1N1 test kits would be consumed, CDC published
Surveillance Activities
updated self-treatment guidance and told the public
that H1N1 testing was no longer necessary. Instead, In the H1N1 case study described above, healthcare con-
persons with minor flu-like illnesses were assumed to be sumer data became an important aspect of the disease
infected and encouraged to utilize advice lines staffed surveillance model that augmented data collected by
by nurses to obtain answers to questions rather than to the CDC. Why was that the case? Now more than ever
seek appointments with healthcare providers. For the before consumers have the opportunity to contribute to
first time, the U.S. government established a one-stop surveillance activities. In some cases, the participation
federal Web site (www.flu.gov) that housed informa- is a conscious decision, but in others consumers may be
tion such as frequently asked questions as well as mes- unknowingly contributing to this informatics process.
saging aimed at individuals and families, businesses, Part of the advantage of externally generated CDC
and healthcare professionals from across the federal surveillance mechanisms is that they shorten the typi-
interagency. The Web site contained tailored planning cal lag time to publication for CDC’s publicly reported
documents for schools and communities, and included data which is currently estimated to be from 10 to 14 days
targeted information for special populations. One par- (Ginsberg et al., 2009). Telephone triage data are now
ticularly helpful site was a Flu Vaccine Locator, which being used to help track influenza in a specified geo-
contained a database that provided the general public graphic location with the added advantage that the data
with the locations of clinics that had vaccine supplies are real time in nature. In addition, patient demograph-
utilizing zip codes (DHHS, 2014b). ics and disease symptoms can also be captured in a stan-
For the first time, HHS used social media to commu- dard format. Another new mechanism for data capture
nicate with young people. Recognizing that large numbers about influenza is through physician group proprietary
of young adults were affected, they launched a Facebook systems. In these systems, the healthcare providers enter
application “I’m a Flu Fighter!” that allowed and encour- the data for suspected or confirmed influenza patients. By
aged users to spread information about H1N1, such as far, the most talked about trend in influenza surveillance
where they received the H1N1 vaccine, to their Facebook for the 2009 H1N1 outbreak was Google’s Flu Trends.
friends (Mitchell, 2010). The assumption made with this system was that there
Other recent viruses have arisen but cannot be cat- was a relationship between how many people search the
egorized as pandemic because they have not caused Internet for flu-related topics and how many people have
sustained and efficient human-to-human transmis- flu-like symptoms. In studies conducted by Google.org
sion. Informatics has been important in this report- comparing Google Flu Trends to CDC published data,
ing and analysis. H5N1, commonly known as avian they found that the search-based flu estimates had a con-
influenza (“bird flu”), is such an example. In July 2013, sistently strong correlation with real CDC surveillance
WHO announced a total of 630 confirmed human cases data (Ginsberg et al., 2009).
which resulted in the deaths of 375 people since 2003,
but did not meet pandemic criteria (WHO, 2013). Also
in 2013, the American Academy of Family Physicians COMPETENCY-BASED LEARNING
(2013) reported that the case numbers of H7N9 stalled in
China, but that the pandemic potential remains. H7N9
AND INFORMATICS NEEDS
is an unusually dangerous virus for humans with cases In order to provide a successful nursing response effort,
resulting in severe respiratory illness, with a mortality nurses must be appropriately and consistently educated
rate of roughly 30% (Li et al., 2014). H7N9 does not kill to provide the right response. Competency-based educa-
poultry, which makes surveillance much more difficult. tion provides an international infrastructure for nurses to
Other recent threats include a new respiratory virus learn about emergency preparedness and response. Yet,
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currently there are no accepted, standardized require- related to their systems, but find themselves in a new
ments for disaster nursing training or continuing educa- role as part of a more comprehensive team approach to
tion (Slepski & Littleton-Kearney, 2010). disasters and emergencies. The incident management
There have been, however, a number of competency system (IMS) was first used by firefighters to control
development efforts geared to different nursing audi- disaster scenes in a multijurisdictional and interdepart-
ences. In collaboration with the CDC, researchers from mental manner. The IMS calls for a hierarchical chain of
the Columbia University School of Nursing identified nine command led by the incident manager or commander.
objectively measurable skills for public health workers Each job assignment is consistently followed by assigned
and seven competencies for leaders, followed by an addi- personnel who refer to a specific job action sheet. This
tional three competencies for public health professionals system improves communication through a common
(Columbia University School of Nursing Center for Health language, allows staff to move between management
Policy, 2001). There were also two competencies identi- locations, and facilitates all responders to understand
fied for public health technical and support staff relating the established chain of command. The IMS has been
to (1) demonstration of equipment and skills associated adapted for hospital use and is called the Hospital Incident
with his/her functional role in emergency preparedness Command System (HICS).
during regular drills and (2) description of at least one The Emergency Operations Center (EOC) is the physi-
resource for backup support in key areas of responsi- cal location where the Incident Management Team con-
bility. In 2003, the International Nursing Coalition for venes to make decisions, communicate, and coordinate
Mass Casualty Education (later renamed the Nursing the various activities in response to an incident. Accurate,
Emergency Preparedness Coalition, or NEPEC) gener- real-time data acquisition regarding patient needs, rescue
ated a list of 104 competency statements for all nurses personnel, and resources available is critical to overall
responding to disasters using domains developed by the coordination. Table 33.5 presents functions where tech-
American Association of Colleges of Nursing (Stanley, nology can be used to capture and represent data for pur-
2005). Additional competencies were developed by the poses of increasing situational awareness in the EOC for
University of Hyogo and the International Council of the purposes of making the most informed and efficient
Nurses. All of the competency efforts were considered by decisions. In addition, the informatics processing efforts
a WHO group of nursing experts as they developed com- that contribute to the incident management system are
petency domains during the first consultation on nursing also described.
and midwifery in emergencies (WHO, 2007, p. 10).
Efforts to identify content to match competencies have
Informatics and Volunteerism
also proven successful. An additional group of experts met
following WHO’s first consultation on nursing and mid- Healthcare volunteers are a necessary component of mass
wifery contributions in emergencies to identify possible casualty events but also create challenges. How do you
content that matched the identified competencies at the count volunteers so that they are only entered once? How
undergraduate nursing level (WHO, 2008). Online mod- do you educate them so that they can perform effectively
ules produced by NEPEC (http://www.nursing.vanderbilt. when needed? How are liability issues dealt with? Are there
edu/incmce/modules.html) and the National Nursing certain tasks that lend themselves to volunteer efforts?
Emergency Preparedness Initiative (NNEPI) (www.nnepi. Some states offer their nurses the opportunity to volunteer
org) both received international awards from Sigma Theta when they renew their nursing licensure. It is then possible
Tau International for quality computer-based education for state-wide volunteer databases to be built, but these are
programs. only shared within the state system. Some states require a
The CDC currently sponsors a public health informat- set number of hours of continuing education in emergency
ics fellowship program that is a two-year paid fellowship in preparedness in order to renew licensure.
public health informatics (CDC, 2014). The competency- The federal government does have a system for orga-
based and hands-on training allows students to apply nizing teams that are willing to travel to other regions of
information and computer science and technology to solv- the country in the event of an emergency. These teams are
ing real public health problems. called disaster medical assistance teams (DMATs). When
DMATs are activated, members of the teams are federal-
ized or made temporary workers of the federal govern-
Informatics and Incident Management
ment, which then assumes the liability for their services.
Information technology staff members have long been Their licensure and certifications are then recognized by
familiar with emergency planning for disaster recovery all states.
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c33.indd 480
480 P art 5 • A dvanced N ursing I nformatics

TABLE 33.5 Technology and Informatics Contributions to Incident Management
Functions Possible Technologies Informatics Processing
Data for Incident Smart White Board Organize and detect patterns and trends in data
Command Center Electronic Dashboards Predict resource needs and safety zones
Resource Modeling Access additional data and information
Internet Access to Information Resources Record and process decisions for legal and financial purposes
Staffing and Scheduling Records Analyze data to determine statistical significance
Electronic Logs to Capture Data and Decisions Report and analyze Internet surveillance systems
Resource Inventories Promote standardization of data collection and vocabulary
Resource Distributor Database
Online Disaster Manual with Job Action Sheets
Communications Landlines Standardized vocabulary and roles
Radio Communications Communication standards set in order to prioritize and determine accuracy of
Cell Phones data transmission
in
Satellite phones Data collection from the field is sent back to EOC
P ractice
Amateur Radios Data collection and analysis contributes to situational awareness
Third and Fourth Generation Wireless Devices
Electronic Mail
Internet, Twitter, Facebook, YouTube
Television and Radio announcements E-commerce
Patient Tracking Global Positioning systems (GPS) Data and Information processed for purposes of triage and transport
Bar code tracking Data collected to determine magnitude of disaster
Radio frequency identification
Provider Safety Radiation monitors and badges Data collection and Monitoring to determine safe radiation levels
Radio communications Cellular triangulation to determine location
GPS devices
Cell phones
Ambulance Tracking GPS Monitor for triage and admission purposes
Cell phones
Radio communication
Patient data acquisition Electronic record Collect and analyze to determine trends across geographic area
and monitoring ED status system
Wireless monitoring
Pharmacy electronic records
2/5/2015 5:03:57 PM
The Medical Reserve Corps (MRC) and the Emergency a standardized registry allows for more informed deci-
System for Advance Registration of Volunteer Health sions and increased efficiency of services during times of
Professionals (ESAR-VHP) both represent initiatives of response and relief efforts.
the Department of Health and Human Services to improve
the nation’s ability to prepare for and respond to public
Disaster Electronic Medical Records and Tracking
health emergencies. The MRC is a national network of
community-based volunteer units that focus on improving Expanding the use of the electronic health record should
the health, safety, and resiliency of their local communi- help both patients and their healthcare providers during
ties. MRC volunteers include medical and public health times of emergencies and disasters. Accessing clinical data
professionals such as physicians, nurses, pharmacists, den- for displaced patients should also improve tremendously
tists, veterinarians, and epidemiologists. Many community with interoperable data and the sharing of clinical informa-
members—interpreters, chaplains, office workers, legal tion, all recent initiatives from the Office of the National
advisors, and others—can fill key support positions. For Coordinator for Health Information Technology (ONC).
example, nurses trained in informatics are often used by One project that emerged from that office during Hurricane
MRC units to compile needed databases depending on the Katrina was called KatrinaHealth and illustrated such
response effort at hand. At the time of this writing, there potential with the pooling of information resources across
are 991 units composed of 206,770 volunteers, covering federal and private sectors. KatrinaHealth.org was a free
73.69% of the United States (Medical Reserve Corps, 2014). and secure online service that provided Katrina evacuees
The national ESAR-VHP program provides guidance their authorized healthcare providers and pharmacists with
and assistance for the development of standardized state- a list of the prescription medications evacuees were tak-
based programs for registering and verifying the credentials ing before they were forced to leave their homes, lost their
of volunteer health professionals in advance of an emer- medications, and the medical records (Markle Foundation,
gency or disaster (ESAR-VHP, 2014). Each state program American Medical Association, Gold Standard, RxHub,
collects and verifies information on the identity, licensure & SureScripts, 2006).
status, privileges, and credentials of volunteers. These pro- Another situation served to illustrate the importance of
grams are built to a common set of national standards and the electronic health record when an EF5 tornado struck
give each state the ability to quickly identify and assist in Joplin, Missouri, on May 22, 2011 (Abir, Mostashari,
the coordination of volunteer health professionals in an Atwal, & Lurie, 2012). Significant damage was inflicted on
emergency. These registration systems include information St. John’s Regional Medical Center, claiming the lives of five
about volunteers involved in organized efforts at the local of its 188 patients and one visitor. The EHR system had been
level (such as MRC units) and the state level (DMAT and implemented only three weeks earlier, and fortunately had
state medical response teams). In addition, individuals who a regional backup in Springfield, Missouri. Besides being
prefer not to be part of an organized unit structure can also able to access patient records, the informatics staff were
be entered into the registry in order to allow for a ready able to modify the names and beds in the units to reflect the
pool of volunteers. State ESAR-VHP programs provide a temporary facilities that were needed due to damage in the
single, centralized source of information to facilitate the main facility. A number of regional physician practices were
intrastate, interstate, and state-to-federal deployment or also able to resume caring for patients in alternate sites.
transfer of volunteer health professionals. Several collabo- DeMers et al. (2013) describe a secure, scalable disas-
ration suggestions have been generated in an effort to inte- ter electronic medical record and tracking system called
grate both the MRC and ESAR-VHP initiatives, including the Wireless Internet Information System for medi-
having state coordinators for both initiatives (MRC, 2014). cal Response in Disasters (WIISARD). This system is a
Most volunteer opportunities require education prior handheld, linked, wireless EMR system utilizing current
to responding to the event. MRC units have competency- technology platforms. Smart phones connected to radio
based education requirements. The American Red Cross frequency identification readers can be used to efficiently
has a long history of volunteerism during disasters, and track casualties resulting from the incident. Medical
has education requirements for nurses depending on information can be transmitted on an encrypted network
what roles they will play in disaster relief. Regardless of to fellow team members, medical dispatch, and receiv-
the group, nurses are urged to be a part of an organized ing medical centers. The authors report that the system
group rather than simply showing up on the scene of a has been field tested in a number of exercises with excel-
disaster and contributing to the confusion. All of these lent results. This pre-hospital EMR merges data with the
initiatives require informatics solutions in order to func- receiving hospital EMR using HIPAA-compliant meth-
tion effectively. Organizing the results of these efforts into ods. Fayaz-Bakhsh and Sharifi-Sedeh (2013) are critical
c33.indd 481 2/5/2015 5:03:57 PM

in noting that one of the most typical consequences of Future Advances
disasters is the near or complete collapse of terrestrial
telecommunications infrastructures, resulting in disaster While the 2009 pandemic fortunately was far less severe
managers having difficulty getting Internet connectivity than the “Armageddon-like” event that planners fore-
or cell phone coverage. The WIISARD team recognized casted, it served to highlight many opportunities for the
those concerns and used an ad hoc field network that use of informatics to assist in emergency preparedness
could circumvent challenges around damaged or over- and response. Health information technology invest-
whelmed traditional communication network systems ments are a necessary foundation in healthcare reform,
(Chan, Griswold, & Killeen, 2013). linking potentially valuable information such as vaccina-
Tracking of patient victims is another important tion records and subsequent use of healthcare services to
function needed during disaster and emergency events. provide information about adverse events as well as vac-
The allocation of various resources over multiple geo- cine effectiveness (Lurie, 2009). Already, the CDC works
graphical locations makes for a complex decision- closely with WHO to make certain that many of the
making process, thus allocation of patients to hospitals databases link to one another, but over time this will
and adequate patient tracking and tracing are major improve as well. Continuing to pay attention to social
issues. Accurate and current information is critical for sit- media for crowdsourcing, for trending, and for analysis
uational awareness—the ability to make timely and effec- of text messages will remain an important contribution to
tive decisions during rapidly evolving events. In order disaster care.
to overcome such challenges, these authors developed a Using “grids” to connect multiple computers across
Victim Tracking and Tracing System (ViTTS) (Marres, the country will allow data sources to share and view large
Taal, Bemelman, Bouman, & Leenen, 2013). Their system amounts of health information. Grid participants will be
design allowed for early, unique registration of victims able to analyze data in other jurisdictions without mov-
close to the impact site that was able to later connect to ing the actual data, which is an important step forward in
the receiving systems. overcoming policy barriers to moving data out of a juris-
Mobile health (mHealth) technology can also play a diction to protect individual privacy.
critical role in improving disaster victim tracking, tri- Having interoperable patient data is a current goal
age, patient care, facility management, and theater-wide of the Office of the National Coordinator for Health
decision-making. Callaway et al. (2012) thought that the Information Technology, but it will also serve to improve
delivery of care after disasters like the earthquake in Haiti the data available as victims become dispersed from their
could be better integrated using mHealth. They chose to typical healthcare environments. Pulling that data closer
develop, deploy, and evaluate a novel electronic patient to the point of care with mobile devices will only enhance
medical record and tracking system in the immediate the quality of data available for healthcare providers to
post-event setting. An iPhone-based mobile technol- make critical decisions with limited time and resources.
ogy platform called iChart was selected. During their Allowing these data to be transmitted across international
implementation, there were 617 unique patient entries lines will most certainly assist in our quest to provide
into the patient tracker, resulting in an adequate ability healthcare to victims regardless of where they seek shelter.
to triage patients as they arrived as new transfers. Users International communication standards will also become
rated that the iChart improved provider handoffs and an important factor in improving communication across
continuity of care, and standardized the information into borders.
one language. Given the chaotic nature of volunteer phy-
sicians’ arrivals and departures, the mobile application
also accommodated fluctuating provider schedules by
SUMMARY
keeping a centralized repository of basic patient informa- In conclusion, the 2009 H1N1 outbreak was a recent
tion. The online database was also used to generate daily example of emergency preparedness and response. It rein-
census figures. forced the fact that estimating the number of actual flu
Case, Morrison, and Vuylsteke (2012) reviewed the lit- cases is very challenging as current case counting relies on
erature to determine ways that mobile technology could encounter information, which is prone to underreporting.
help disaster medicine. They classified applications into Informatics is an emerging field that has the potential to
five types: (1) disaster scene management; (2) remote immediately support the early identification of a commu-
monitoring of casualties; (3) medical image transmission; nicable disease such as pandemic influenza, reducing loss
(4) decision support applications; and (5) field hospital of life and the consumption of limited resources. Use of
information technology systems. automated case-specific disease monitoring applications
c33.indd 482 2/5/2015 5:03:58 PM

such as BioSense, ESSENCE, and RODS and tracking retail Centers for Disease Control and Prevention. (2010). CDC
data such as OTC medication purchases allow researchers estimates of 2009 H1N1 influenza cases, hospitaliza-
to collect, analyze, and present real-time disease informa- tions and deaths in the United States. Retrieved from
tion which allows users to have immediate access to infor- http://www.cdc.gov/h1n1flu/estimates_2009_h1n1.htm.
Accessed on April 2009–April 10, 2010.
mation that previously would have taken days to assemble.
Centers for Disease Control and Prevention. (2014). Public
Technological developments will further enhance the abil-
health informatics fellowship program. Retrieved from
ity to use informatics to detect the first warning signs dur- http://www.cdc.gov/PHIFP/About.html
ing an emergency. Chan, T. C., Griswold, W. G., & Killeen, J. P. (2013). Author
Consumers themselves have assumed surveillance reply. Prehospital and Disaster Medicine, 28(6), 647.
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The increase use of social media provides a new mecha- Columbia University School of Nursing Center for Health
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emergencypreparednesscorecompetencies_Columbia_
can contribute to this agenda, particularly in an era when
University.pdf
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structure contributes continuous monitoring of data, Griswold, W., & Chan, T. (2013). Secure scalable disas-
standards for combining data, technology-enhanced pro- ter electronic medical record and tracking system.
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51
Nursing Informatics in Canada
Lynn M. Nagle / Kathryn J. Hannah / Margaret Ann Kennedy
• OBJECTIVES
1. Describe key drivers advancing Canadian nurses’ use of information and commu-
nications technology.
2. Describe key organizations supporting the advancement of health and nursing
information management in Canada.
3. Describe key nursing informatics initiatives currently underway in Canada.
• KEY WORDS
Health information
Nursing data standards
Nursing outcomes
Information and knowledge management
INTRODUCTION profession with evidence to demonstrate the essential

contribution of nurses.
Registered nurses should advocate for and lead efforts Substantial investments in information and commu-
toward the collection, storage, retrieval and use of nication technology (ICT) have been made in all sectors
nursing care data to generate information on nurs- of Canadian healthcare. Acute care, long-term care, pri-
ing outcomes…. These data are essential to expand mary care, public health, and community-based nursing
knowledge, to evaluate the quality and impact of nurs- settings have all begun to realize the benefits of using
ing care, to promote patient safety and to support inte- ICT to support clinical care and administrative activities.
grated health human resources planning. Nonetheless, in a majority of Canadian care environments,
–Canadian Nurses Association (CNA), 2006a information management activities continue to require
clinicians to use a combination of electronic and paper
Nursing’s role in the management of information has records. Much work remains to be done to achieve a fully
long been considered to include the information neces- functional Electronic Health Record (EHR) in many set-
sary to manage client care and the information neces- tings. In this regard, nurses’ documentation of care plans,
sary for managing clinical operations. Over the years, interventions, and outcomes is to a large extent still lack-
client care and nursing management decision-making ing standardization of data capture methodology and stan-
has become increasingly underpinned by the use of evi- dardized clinical terminology that can be readily coded for
dence. Like nurses in many other developed countries, use in information systems. In many organizations nursing
Canadian nurses integrate information from a variety of documentation is not yet part of the EHR. Additionally,
sources to inform practice and improve the quality and while likely not a unique situation, Canada’s existing health
safety of care delivery. Moreover, having ready access information repositories do not include comprehensive
to information about practice outcomes equips the information about the impacts of nursing practice.
741
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742 P art 10 • I nternational P erspectives
The Canadian Nurses Association (CNA) has taken future sustainability, it has been identified as needing sub-
the position that registered nurses and other stakehold- stantial reform (Kirby, 2002; Romanow, 2002). A common
ers in healthcare delivery require information on nursing outcome of health system reviews conducted throughout
practice and its relationship to client outcomes (CNA, the first decade of the twenty-first century was the recogni-
2006a). The creation of a coordinated system to collect, tion of information systems being key enablers (and lack of
store, and retrieve nursing data in Canada is essential for quality information as a key barrier) to health sector reform.
health human resource planning, and to expand knowl- Specifically, Kirby’s (2002) report cited the significance of
edge and research on determinants of quality nursing care. improving health information management in Canada:
Across Canada, the engagement of nurses to effectively
achieve this vision is being supported by a variety of initia- EHR solutions will enable the creation, analysis and
tives. Several professional nursing organizations includ- dissemination of the best possible evidence from across
ing the CNA and its provincial and territorial affiliates, Canada and around the world as a basis for more
the Academy of Canadian Executive Nurses (ACEN), the informed decisions by patients, citizens and caregivers;
Canadian Association of Schools of Nursing (CASN), the by health professionals and providers; and by health
Canadian Nursing Informatics Association (CNIA), and managers and policymakers. They will also help maxi-
other nursing informatics interest groups across Canada mize the return on ICT investments through alignment,
have been instrumental in advancing and supporting and drive the development of common standards and
nurses’ involvement in health informatics. Their collective interoperability (p. 176).
efforts have included the (a) active dissemination of rele-
vant information, (b) provision of opportunities for infor- As a consequence of such recommendations, federal
matics education, (c) development of entry to practice and jurisdictional investments in ICT were accelerated
competencies, (d) promotion and deployment of nursing across Canada during the last decade, resulting in infor-
data standards, and (e) development of a national nursing mation management and supporting technologies being
report. In this chapter, we describe these activities in fur- central to the delivery of health services.
ther detail and highlight some of the ongoing challenges In addition, an aging demographic and ever-escalating
faced by the nursing informatics community in Canada. costs associated with chronic disease management have
driven an increase in the use of ICT such as telemedicine
and telehomecare. These cost-effective approaches used
KEY FACTORS DRIVING NURSES’ to remotely diagnose, manage, and monitor disease have
USE OF INFORMATION AND been successful in keeping Canadians in their homes and
local communities as well as supporting nursing practice.
COMMUNICATION TECHNOLOGY Indeed the essential coordination role of nurses in tele-
Canadians have a healthcare system that is the envy of homecare is unfolding at a rapid pace in some regions of
many countries. One of the things that make the Canadian the country (Ontario Telemedicine Network, 2014). With
healthcare system unique is the belief in health as a right a greater emphasis on primary care and the local deliv-
rather than a privilege or an economic commodity. This ery of health services, care is being increasingly dein-
philosophy is reflected in the principles upon which the stitutionalized. Furthermore, in response to increasing
provincial and territorial health systems in Canada are demands for care, changes are occurring in the scope of
based, and it is legislated through the Canada Health Act medical and nursing practice including a greater role for
(Government of Canada, Minister of Justice, 1985) by nurse practitioners. Based upon the growth reported in
which all Canadian jurisdictions abide. These principles 2011, the number of nurse practitioners has more than
include universality, portability, accessibility, comprehen- tripled over the last decade (Canadian Institute for Health
siveness, and public administration. In addition, health is Information, 2011). In summary, nursing remains a central
a provincial and territorial responsibility in Canada, not a player in evolving mechanisms of care delivery, impacting
federal one. Conformity on health matters between prov- the health of Canadians more than ever before.
inces, territories, and the federal government is by mutual There is also an increasing trend toward consumerism
consent and agreement, not legislation. The publicly funded in which self-help groups, disease-specific groups, and
health system in Canada provides about 70% of healthcare, other special interest groups expect to be involved in their
the other 30% is paid for out of pocket or by health insur- own care and the management of their health information.
ance companies. Despite the philosophical and financial The power differential between caregivers and patients is
underpinnings of Canadian healthcare, in the interest of equilibrating such that with the advent of the Internet
c51.indd 742 19-02-2015 09:39:54

Chapter 51 • Nursing Informatics in Canada 743
consumers now have ubiquitous access to information reliable, and timely aggregated health information for use
about disease management, treatment options, and pro- in understanding and improving the management of the
vider performance. Citizens are now utilizing ICT to com- Canadian health systems and the health of Canadians.
municate with clinicians and exchange information about
their health. The face of healthcare delivery will be forever Canada Health Infoway. As CIHI and its various aggre-
transformed through these changes and the Canadian gated databases evolved and matured, the focus was on
nursing community is recognizing the need to respond. health indicators and population health as well as infor-
These are but a few of the factors influencing the drive mation to manage the healthcare system. The healthcare
toward identifying the essential data needs of nurses. In community came to realize that there was still limited
Canada, initiatives by healthcare organizations to develop information available to caregivers for use in supporting
or acquire automated information systems have histori- decision-making related to the clinical care of individuals
cally focused on the utilization of data for the purposes and groups of patients or clients of the health systems. In
of resource allocation, patient-specific costing, and health October 2000, the federal government committed initial
outcomes monitoring. In this regard, nurses have been funding to support the development and coordination
using tools like workload measurement systems for many of pan-Canadian health information systems necessary
years without a substantive impact on practice or care. to achieve an electronic health record (EHR). This fund-
However, with the implementation of EHRs Canadian ing was recognition, by federal, provincial, and territo-
nursing has an unprecedented opportunity to advance the rial governments, of the potential of ICT to improve the
adoption of standardized clinical terminology and begin efficiency, cost-effectiveness, access, quality, and safety
the realization of data repositories that include a represen- of health services in Canada. The Federal/Provincial/
tation of nursing practice. Nurses’ use of information sys- Territorial Advisory Committee on Health Infostructure
tems in practice, administration, education, and research (Advisory Committee on Health Infostructure, 2001) set
has become pervasive and this is reason enough to ensure its top priority as the development of EHR and telehealth.
that these systems optimally serve the profession. The committee identified an immediate need to begin put-
ting building blocks in place for the next stages of EHR
SUPPORT FOR THE ADVANCEMENT development.
Incorporated in January 2001, Canada Health Infoway
OF EFFECTIVE NURSING (Infoway) is an independent, not-for-profit organization
INFORMATION MANAGEMENT funded by the federal government. Infoway jointly invests
with every province and territory to accelerate the devel-
Key National Organizations
opment and adoption of EHR projects in Canada. Strategic
Canadian Institute for Health Information. Created investments have been directed to each of the provinces
in 1992, the Canadian Institute for Health Information and territories in support of initiatives that provide the
(CIHI) is an independent, pan-Canadian, not-for-profit foundation for an interoperable pan-Canadian EHR.
organization, established jointly by federal, provincial, Most Canadian jurisdictions have the beginnings of a
and territorial ministers of health that provides essen- basic infrastructure in place to support an interoperable
tial data and analysis on Canada’s health system and the EHR including (1) client registries, (2) provider registries,
health of Canadians. Information is derived from many (3) drug information systems, (4) laboratory information
sources including hospitals, regional health authorities, systems, (5) diagnostic imaging information systems,
medical practitioners, and governments. This information (6) telehealth systems, and (7) public health surveillance
is further supplemented from other sources to support systems. These foundational systems are providing the
CIHI’s analysis and the generation of reports that focus on basis for provincial and territorial EHRs. However, there
(Canadian Institute for Health Information, 2012): continues to be considerable regional/local variation in
terms of adoption between organization and clinical pro-
• Healthcare services
fessions, e.g., some institutions are still using paper and
• Health spending some health professionals lag behind in terms of adopt-
• Health human resources ing technology. Beyond the data from the foundational
systems, other key data elements to be included in the
• Population health
national and jurisdictional EHRs have yet to be confirmed.
In existence for more than two decades, CIHI has Canadian nurses have been working to ensure that juris-
become an acknowledged and trusted source of quality, dictional EHRs include patient-centered information and
c51.indd 743 19-02-2015 09:39:54

clinical outcomes data. Presently, there is also substantial with CNA to review and influence relevant national nurs-
investment being directed to the deployment of primary ing policy and strategic planning related to informatics.
care electronic medical records (EMR) to support physi- The CNIA also has a formal alliance with Canada’s
cian practice and a growing nurse practitioner practice Health Informatics Organization, COACH, which has
across the country (Canada Health Infoway, 2008). facilitated the appointment of the Canadian nurse nomi-
Through Infoway’s leadership, Canada became a nee to the International Medical Informatics Association
charter member of the International Health Information Special Interest Group Nursing Informatics (IMIA
Standards Development Organization (IHTSDO) in 2006. SIG-NI). The IMIA SIG-NI provides an opportunity to
The development and deployment of health data and tech- engage with international nursing informatics colleagues
nical standards are germane to the evolution of an interop- and share our knowledge beyond national borders.
erable EHR, and Infoway recognizes the centrality of this Opportunities to further leverage respective expertise
work in the achievement of their mission. The emerging and experiences are under discussion with colleagues in
EHR will ultimately incorporate data related to patient the United States, Europe, South America, and Australia.
assessment and interventions contributing to patient out- CNIA also maintains close relationships with several
comes and providers’ patterns of practice. As the single international colleagues who are trying to generate com-
largest group of healthcare providers, it is imperative that munities of interest in their own countries or to launch
nurses’ contributions to care are captured in the EHR. NI groups. Several international director roles have been
established on the CNIA Board to enable mentoring and
Canadian Nurses Association. The Canadian Nurses to share lessons learned from the Canadian experience.
Association first established its eNursing Strategy in The need to harness existing nursing informatics
2006. The eNursing Strategy was based on three princi- expertise, address the required informatics competencies
ples: nurses’ access, competence, and participation in the of all nurses, and extend the profession’s understanding of
use of ICT in healthcare (CNA, 2006b). These principles the significance of health informatics are key priorities for
have served CNA well in guiding its activities related to the CNIA. The overall objectives include the following:
informatics. CNA has actively led, participated in, and/
or provided a nursing perspective on numerous national • To provide nursing leadership for the development
health informatics initiatives such as the EHR and data of nursing and health informatics in Canada
standards, NurseONE, The Canadian Health Outcomes • To establish national networking opportunities for
for Better Information and Care (C-HOBIC), NNQR, nurse informaticists
CASN’s Competency Development activities, and Canada
Health Infoway’s National Nursing Reference Group. Each
• To facilitate informatics educational opportunities
for all nurses in Canada
of these efforts will be further elaborated in the sections
that follow. • To engage in international nursing informatics
initiatives
Canadian Nursing Informatics Association. Although • To act as a nursing advisory group in matters of
the cadre of Canadian nurses working in informatics roles nursing and health informatics
continues to grow, it is clear that efforts are needed to • To expand awareness of nursing informatics to all
increase awareness among all nurses about the relevance nurses and the healthcare community
of informatics to the profession. In particular, nurse lead-
ers in practice and education need to embrace and actively These objectives are being operationalized through
advance the health informatics agenda and assure that a number of initiatives including biannual national con-
nurses are engaged. Across Canada, provincial nursing ferences, a Web site, and a newly emerging informatics
informatics interest groups emerged during the 1990s in journal.
various parts of the country; some have continued to grow
and expand while others languished. National Nursing Reference Group. In 2009, in partner-
In 2002, the Canadian Nursing Informatics Association ship with the CNA, the Canada Health Infoway Clinical
(CNIA) was established with the goal of engaging nurses Adoption group established a nursing reference group
in all sectors and in all roles. In 2004, the scope and growth (NRG) that includes practicing nurses, national nursing
of the CNIA’s national membership and compliance with associations, and other provincial nursing leaders and
the CNA criteria, afforded the CNIA “Associate Group” informatics experts. The purpose of the NRG is to pro-
status within the CNA. This status brings further acknowl- vide national nursing leadership, engagement, expertise,
edgment and recognition to the CNIA, as they collaborate and input to inform Infoway’s nursing strategy and plans
c51.indd 744 19-02-2015 09:39:54

to accelerate nursing’s adoption and realization of the ben- competent, and connected” (CNA, 2014). Through this
efits of EHRs. The objectives of the NRG are to: Web-based health information service, nurses and nurs-
ing students across the county can connect with each
• Provide strategic-level advice and input on poli-
other through communities of practice and to credible,
cies, priorities, and strategic plans aligned with
up-to-date electronic resources that support patient care
Infoway’s Clinical Adoption business strategy and
and tools for lifelong learning such as, e-books, e-learning
clinical engagement
courses, specialty libraries, databases, Webliographies,
• Review and provide feedback on products, ser- continuing education Webinars.
vices, and projects under consideration, or being
implemented where appropriate Entry to Practice Informatics Competencies for Nurses.
• Provide strategic input on the needs and engage- Among the issues related to the realization of effective
ment of nurses in practice, education, policy, information management among nurses in Canada is
administration, and research need for the inclusion of nursing informatics competen-
cies in basic nursing education programs. At the time of
• Provide ongoing oversight and input into the estab-
writing, there is still a limited number of nursing educa-
lished six key nursing strategic directions and tacti-
cal plans and associated working groups tion programs in Canada offering an informatics course
or content about the use of ICT, and information man-
• Act as liaisons and promote a coordinated agement techniques and strategies related to nursing.
approach of activities and strategies within their Ideally such courses would also introduce concepts and
organizations and across partners provide hands-on experience related to the use of ICT
In May 2009, six strategic goals were developed and in practice.
preliminary action plans were established to accelerate In 2011, the Canadian Association of Schools of
nursing engagement and EHR adoption: Nursing (CASN) secured funding from Canada Health
Infoway to develop entry-to-practice nursing informat-
1. Identification of nursing key business and functional ics competencies and a toolkit to support faculty deliver-
requirements ing the essential content. The competencies were created
2. Development of a structure and strategy for using consensus-based, iterative process, involving key
collaboration stakeholders from across Canada. When the process con-
3. Development of an education strategy cluded one over-arching competency statement reflective
of the three competency domains and their associated
4. Development of a communications strategy indicators were identified as inclusive of the requisite
5. Advancing and leveraging the C-HOBIC knowledge and skills for nurses (see Table 51.1) (CASN,
implementation 2012). The published competency document also includes
6. Advancing and leveraging the NurseONE portal an articulation of the expectation that prior to admis-
sion, students will likely have already acquired a number
In March 2010, the NRG met to review the previously of basic computer literacy competencies related to device
identified nursing components of health information and and application use.
to validate that these were still relevant and appropriate for The informatics teaching toolkit was developed as a
inclusion in EHRs. The group overwhelmingly endorsed the companion document to the competencies. The toolkit
elements as being relevant and worthy of continued devel- provides strategies and methods (e.g., relevant content,
opment for capture within EHRs. Furthermore, the NRG examples of integration within existing courses, down-
supported the continued deployment and development loadable slide presentations) to support faculty with the
of C-HOBIC and the need to secure additional funding to assimilation of informatics content into undergraduate
support this work. The NRG continues to meet annually. curricula (CASN, 2013).
As nursing practice is increasingly enabled by technol-
ogy, it is essential that basic nursing programs embrace
Key National Initiatives Advancing
nursing informatics. The national development of entry-
Informatics in Nursing
level nursing informatics competencies has been a key
NurseONE (www.nurseone.ca). NurseOne is an inno- step to ensuring that this occurs. In conjunction with
vative, Web-based portal created and maintained by the nursing faculty members’ use of the supporting resource
Canadian Nurses Association (CNA) as a service for its toolkit, there is an expectation that these competencies
members to assist them in “keeping current, credible, will have an impact on nursing curricula across Canada.
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TABLE 51.1 Nursing Informatics Entry-to-Practice Competencies for Registered Nurses (2012)
Over-arching competency: Uses information and communication technologies to support information synthesis in
accordance with professional and regulatory standards in the delivery of patient/client care.
Information and Knowledge Management
Competency: Uses relevant information and knowledge to support the delivery of evidence-informed patient/client care.
Indicators:
• Performs search and critical appraisal of online literature and resources (e.g., scholarly articles, Web sites, and other appropriate
resources) to support clinical judgment, and evidence-informed decision-making.
• Analyzes, interprets, and documents pertinent nursing data and patient data using standardized nursing and other clinical termi-
nologies (e.g., ICNP, C-HOBIC, and SNOMED-CT, etc.) to support clinical decision-making and nursing practice improvements.
• Assists patients and their families to access, review, and evaluate information they retrieve using ICTs (i.e., current, credible, and rele-
vant) and with leveraging ICTs to manage their health (e.g., social media sites, smart phone applications, online support groups, etc.).
• Describes the processes of data gathering, recording, and retrieval, in hybrid or homogenous health records (electronic or paper),
and identifies informational risks, gaps, and inconsistencies across the healthcare system.
• Articulates the significance of information standards (i.e., messaging standards and standardized clinical terminologies)
necessary for interoperable electronic health records across the healthcare system.
• Articulates the importance of standardized nursing data to reflect nursing practice, to advance nursing knowledge, and to
contribute to the value and understanding of nursing.
• Critically evaluates data and information from a variety of sources (including experts, clinical applications, databases, practice
guidelines, relevant Web sites, etc.) to inform the delivery of nursing care.
Professional and Regulatory Accountability
Competency: Uses ICTs in accordance with professional and regulatory standards and workplace policies.
Indicators:
• Complies with legal and regulatory requirements, ethical standards, and organizational policies and procedures (e.g., protection
of health information, privacy, and security).
• Advocates for the use of current and innovative information and communication technologies that support the delivery of safe,
quality care.
• Identifies and reports system process and functional issues (e.g., error messages, misdirections, device malfunctions, etc.) accord-
ing to organizational policies and procedures.
• Maintains effective nursing practice and patient safety during any period of system unavailability by following organizational
downtime and recovery policies and procedures.
• Demonstrates that professional judgment must prevail in the presence of technologies designed to support clinical assessments,
interventions, and evaluation (e.g., monitoring devices, decision support tools, etc.).
• Recognizes the importance of nurses’ involvement in the design, selection, implementation, and evaluation of applications and
systems in healthcare.
Information and Communication Technologies
Competency: Uses information and communication technologies in the delivery of patient/client care.
Indicators:
• Identifies and demonstrates appropriate use of a variety of information and communication technologies (e.g., point-of-care sys-
tems, EHR, EMR, capillary blood glucose, hemodynamic monitoring, telehomecare, fetal heart monitoring devices, etc.) to deliver
safe nursing care to diverse populations in a variety of settings.
• Uses decision support tools (e.g., clinical alerts and reminders, critical pathways, Web-based clinical practice guidelines, etc.) to
assist clinical judgment and safe patient care.
• Uses ICTs in a manner that supports (i.e., does not interfere with) the nurse–patient relationship.
• Describes the various components of health information systems (e.g., results reporting, computerized provider order entry, clini-
cal documentation, electronic Medication Administration Records, etc.).
• Describes the various types of electronic records used across the continuum of care (e.g., EHR, EMR, PHR, etc.) and their clinical
and administrative uses.
• Describes the benefits of informatics to improve health systems, and the quality of inter-professional patient care.
Reproduced, with permission, from Nursing Informatics Entry-to-Practice Competencies for Registered Nurses. © 2012 Canadian Association of Schools
of Nursing.
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DEVELOPING THE NURSING • Primary nurse identifier is a single unique lifetime
identification number for each individual nurse.
COMPONENTS OF HEALTH This identifier is independent of geographic location
INFORMATION FOR USE IN CANADA (province or territory), practice sector (e.g., acute care,
In Canada, nurses are in the fortunate position of rec- community care, and public health), or employer.
ognizing the need for nursing data elements at a time Identifying those data elements that represent the most
when the status of national health information was under important aspects of nursing clinical documentation for
review. The challenge for nurses continues to be how to patient care is only the first step. Beyond their definition,
capitalize on this timing and define those data elements there is the ongoing work of promoting and further devel-
required by nurses in Canada. To prevent losing control oping the data elements and ensuring that they become
of nursing data, Canadian nurses are taking a proactive integrated into an inter-professional, client-centred, pan-
stance and mobilizing resources to ensure the develop- Canadian EHR. With every new government agency or
ment and implementation of a national health database initiative it is important to advocate for nursing data to be
that is congruent with the needs of nurses in all practice part of the inter-professional clinical data set.
settings in Canada. Some initiatives intended to promote In 2009, a nursing informatics think tank was hosted
the vision of a national health database becoming a reality by the CNA and Infoway. It resulted in a renewed part-
in Canada are in progress. nership with national nursing organizations representing
nursing education, unions, nurse administrators, as well
Health Information: Nursing Components as professional colleges and associations that identified
key strategies to advance nursing informatics in Canada
During the 1990s, the work of individual nurse leaders (see National Nursing Reference Group previously in this
and the Canadian Nurses Association led to the 1997 con- chapter). The first strategy area is the identification of
sensus on five data elements: client status, nursing inter- nursing requirements for the pan-Canadian EHR, includ-
ventions, client outcome, nursing intensity, and primary ing both required functionality for nursing and the nursing
nurse identifier. core data. Just over a year later, another forum attended
by an even larger group of nursing leaders had moved the
• Client status is broadly defined as a label for the set
issue of nursing data forward to a renewed 2010 consensus
of indicators that reflect the phenomena for which
that nurses in Canada require data on client assessment,
nurses provide care, relative to the health status
nursing interventions, client outcomes, nursing intensity,
of clients (McGee, 1993). Although client status is
and a unique nurse identifier. The forum also supported
similar to nursing diagnosis, the term client status
the position of the CNA, in advocating the International
was preferred because it represents a broader spec-
trum of health and illness. The common label client ®
Classification of Nursing Practice (ICNP ): ®
status is inclusive of input from all disciplines. The
The adoption of a single clinical terminology that…
summative statements referring to the phenomena
facilitates communication across all health settings,
for which nurses provide care (i.e., nursing diagno-
spoken languages and geographic regions, that has the
sis) are merely one aspect of client status at a point
capacity to represent client health data and the clinical
in time, in the same way as medical diagnosis.
practice of all healthcare providers…For a clinical ter-
• Nursing interventions refer to purposeful and minology to adequately represent the practice of reg-
deliberate health-affecting interventions (direct istered nurses across all regions and settings it, must
and indirect) based on assessment of client status, be developed in collaboration with the International
which are designed to bring about results that ben- Council of Nurses…. The International Classification
efit clients (AARN, 1994).
®
of Nursing Practice (ICNP ) which is compliant with
• Client outcome is defined as a “clients’ status at a international standards in a manner consistent with
defined point(s) following healthcare [–affecting] other disciplines. (CNA, 2006a)
intervention” (Marek & Lang, 1993). It is influ-
enced to varying degrees by the interventions of all
care providers. The Canadian Health Outcomes for Better
Information and Care (C-HOBIC) Project
• Nursing intensity “refers to the amount and type of
nursing resource used to [provide] care” (O’Brien- Infoway has made an investment to support the early efforts
Pallas & Giovannetti, 1993). to capture the “outcomes” dimension of patient care using
c51.indd 747 19-02-2015 09:39:55

nursing data. In the fall of 2006, the CNA partnered with the ®
the CNA has endorsed the ICNP for use in Canada. It is
Ministries of Health in three Canadian provinces to under- also important to define the scope of the compiled data
take the inclusion of 32 nursing-sensitive patient outcomes set to ensure that only those essential data elements are
measures in four categories in EHRs. Infoway provided collected and to avoid proliferation of data, i.e., C-HOBIC
funding for this work, launched as the Canadian Health data. In addition, it is essential to promote the concept to
Outcomes for Better Information and Care (C-HOBIC) ensure widespread use and educate the nurses to ensure
project. This project supports the advancement and use of the quality of the data that are collected.
standardized patient assessments and related documen-
tation. Further, these assessments enable the provision of
National Nursing Quality Report-Canadian
feedback to nurses about patient outcomes and the abil-
ity to compare outcomes over time. Of additional value is Conceived in 2010 under the leadership of the Academy
that C-HOBIC provides an EHR adoption lever, providing of Canadian Executive Nurses (ACEN) and the Canadian
information of use to nursing practice. Nurses Association (CNA), the National Nursing Quality
The C-HOBIC project builds upon work originating in Report-Canadian (NNQR-C) is a pilot project to determine
the province of Ontario. A detailed history of this work the feasibility of using outcomes and productivity indicators
is chronicled elsewhere (Nagle, White, & Pringle, 2007; to establish a monitoring system for health professionals,
Nagle, White, & Pringle, 2010; White & Pringle, 2005). utilizing existing databases (HOBIC/C-HOBIC, Resident
The 32 C-HOBIC measures were derived from evidence Assessment Instrument— interRAI, Discharge Abstract
in the nursing literature and are in four categories: func- Database-DAD, Management Information Systems-MIS)
tional status, symptoms, safety, and readiness for dis- (VanDeVelde-Coke et al., 2012) The goals are to:
charge. The measures are constituted by 32 data elements
that are being collected in four sectors of the healthcare • Implement a national nursing quality report
(NNQR-C)
system: (1) acute care, (2) long-term care, (3) home care,
and (4) complex continuing care. Each of the measures • Evaluate the feasibility and costs associated
has a concept definition and an associated valid and reli- with producing the indicators for healthcare
able measurement instrument. As part of the C-HOBIC organizations
project, the concepts originally identified in Ontario were • Evaluate the potential of these indicators to impact
mapped to the International Classification of Nursing organizational quality improvement and quality
®
Practice . The specific details of this mapping are reported outcomes
elsewhere (Kennedy, 2008). Hannah, White, Nagle, and
Pringle (2009) have provided more details about the The NNQR is envisioned as a minimum set of input, pro-
C-HOBIC initiative in another publication. Experience cess, and outcome indicators that can be collected nation-
with C-HOBIC to date indicates that these outcome mea- ally across the continuum of care; can be readily available
sures can be collected using standardized tools across the through dashboard applications in healthcare institutions;
healthcare system. Moreover, the nurses using the mea- and can be used as benchmarks to influence policy directions
sures are deriving value in addressing clinical care issues for nursing to improve client outcomes in all care settings.
and quality improvement for their patients and clients. There are 15 indicators in the three categories of structure,
In Canada, nurses have come to recognize the need to process, and outcome. There are 10 pilot sites from acute
incorporate nursing data into the national health informa- care, long-term care, and inpatient mental health, represent-
tion infostructure (i.e., national databases and EHR) as ing the provinces of Manitoba, Ontario, New Brunswick,
federal, provincial, and territorial health information sys- and Nova Scotia. The initiative has received a funding con-
tems are being restructured. To ensure that nursing data tribution from Canada Health Infoway as well as support
are incorporated into the national health infostructure, from the sponsoring and participating organizations.
nurses must participate in the design, standards develop-
ment, and pilot studies to ensure the capture of data that
are essential to reflect nursing’s contribution to healthcare INFLUENCING NURSING
in Canada. INFORMATICS GLOBALLY: C-HOBIC,
As nurses in Canada pursue the development of core
nursing data for inter-professional clinical information
ICNP®, AND SNOMED-CT
systems, several issues are germane. The first need is to In keeping with the progression toward systematically
ensure that data are available, reliable, valid, and com- representing nursing data, CNA formally endorsed the
parable (i.e., data standards are established). To this end, International Classification for Nursing Practice (ICNP ) ®
c51.indd 748 19-02-2015 09:39:55

in 2001 for use in Canada “as a foundational classifica- nursing leaders are actively pursuing the vision to include
tion system for nursing practice in Canada” (CNA, 2001). these as core elements in a national health information
This endorsement was renewed in 2006 as CNA contin- database. There is no question that progress has been
ued to promote accurate and timely capture of nursing made during the last decade, but nursing leaders must
data (CNA, 2006a). The International Council of Nurses continue to respond to the challenge to further advance
(ICN) goals of increasing the visibility of nursing contri- this agenda. Early experience with the collection and
butions in healthcare, standardization of nursing data to use of the C-HOBIC measures demonstrates the great
support inter-sectoral comparability and analysis, as well potential of a common clinical data set utilized across
as supporting evidence-based practice were highly aligned care settings. Establishing a standardized set of nursing
to the nursing goals in Canada, and Canada has actively components for health information has the potential to
®
contributed to the progression of ICNP through research provide nurses with the data required to transform nurs-
(Lowen, 1999; Kennedy, 2005; Kennedy & Hannah, 2007; ing into a profession prepared to respond to the health
Imam, 2009) and other professional contributions (Frisch, needs of Canadians in the twenty-first century; however,
2009; Stanton, 2006). the window of opportunity to have nursing data elements
As the C-HOBIC work progressed, extensive collabo- included in a national data set is narrowing. We must
ration led to the development and approval of the ICNP ® continue our efforts to ensure that the vision of nursing
Catalogue, Nursing Outcomes Indicators (available: http:// components in our national health information system
www.icn.ch/pillarsprograms/icnpr-catalogues/). This was becomes a reality for nursing in Canada.
the first formally approved and accepted Canadian cata-
®
logue or subset of ICNP available for international use.
Although Canada Health Infoway, in consultation with
various stakeholder groups, adopted the Systematized
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Nomenclature of Medicine—Clinical Terms (SNOMED Advisory Committee on Health Infostructure. (2001).
®
CT ) as the terminology for the pan-Canadian electronic Tactical plan for a pan-canadian health infostructure:
2001 update. Ottawa, Canada: Office of Health and the
®
health record, ICNP remained the preferred terminology
Information Highway, Health Canada.
for nursing.
Alberta Association of Registered Nurses (AARN). (1994).
In March 2010, ICN and the International Health Client status, nursing intervention and client outcome tax-
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(IHTSDO) agreed to collaborate to harmonize terms Government of Canada, Minister of Justice (1985). Canada
in their two resources, further supporting interoper- Health Act. Retrieved from: http://laws-lois.justice.gc.ca,
ability (IHTSDO, 2010). Through this process, extensive December 12, 2014.
efforts to cross-map and harmonize terms have improved Canada Health Infoway. (2008). Infoway’s investment pro-
® ®
both ICNP and SNOMED CT , resulting in numerous grams. Retrieved from http://www.infoway-inforoute.ca/
lang-en/about-infoway/approach/investment-programs.
change requests for refinement of terms and new terms.
The Nursing Outcome Indicators catalogue has been Accessed on March 18, 2014.
Canadian Association of Schools of Nursing (CASN).
used as a demonstration project for this purpose and
(2012). Nursing informatics entry to practice
has been cross-mapped to SNOMED CT. On January competencies for registered nurses. Retrieved from
20, 2014, the International Council of Nurses (ICN) http://casn.ca/vm/newvisual/attachments/856/
and the International Health Terminology Standards Media/NursingInformaticsEntryToPractice
Development Organisation (IHTSDO) announced an CompetenciesFINALENG.pdf. Accessed on March 18,
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®
for Nursing Practice (ICNP ) concepts and SNOMED CT Canadian Association of Schools of Nursing (CASN). (2013).
®
concepts (ICN, 2014). The table contains ICNP Diagnosis Nursing informatics teaching toolkit. Retrieved from
http://casn.ca/vm/newvisual/attachments/856/Media/
and Outcomes Statements that have semantic equivalen-
cies with SNOMED CT concepts. 2013ENNursingInformaticsTeachingToolkit.pdf.
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Canadian Institute for Health Information. (2011). Canada’s
health care providers – 2011 provincial profiles: A look at
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ca/estore/productFamily.htm?locale=en&pf=PFC2160.
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Series.htm?pc=PCC287. Accessed on March 18, 2014. Research, 39(7), 58–79.
Canadian Nurses Association. (2001, November). Position Kirby, M. J. L. (2002). The health of Canadians – The federal
statement: Collecting data to reflect the impact of nursing role. Final report on the state of the health care system in
practice. Ottawa, Canada: Author. Canada. Retrieved from http://www.parl.gc.ca/
Canadian Nurses Association. (2006a). Nursing information content/sen/committee/372/soci/rep/repoct02vol6-
and knowledge management. Ottawa, Canada: Author. e.htm. Accessed on March 18, 2014.
Canadian Nurses Association. (2006b). E-nursing strategy for Lowen, E. (1999). The use of the International Classification
Canada. Ottawa, Canada: Author. Retrieved from http://
www.cna-aiic.ca. Accessed on March 18, 2014.
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for Nursing Practice for capturing community-based
nursing practice. Unpublished Master’s Thesis. University
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Victoria in BC, Canada. University of Victoria, British
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Columbia, Canada. Retrieved from http://www.icn.ch/ McGee, M. (1993). Response to V. Saba’s paper on Nursing
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Standardizing nursing information for inclusion in elec- Canadian Nurses Association.
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Medical Informatics Association, 16, 524–530. outcomes in spite of our systems. Canadian Journal of
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University of South Australia, Adelaide, Australia. Boal, A.S., Velji, K., ... Hannah, K. (2012). Measuring
Kennedy, M. A. (2008). Mapping Canadian clinical outcomes outcomes of nursing care, improving the health of
in ICNP. Retrieved from http://c-hobic.cna-aiic.ca/ Canadians: NNQR (C), C-HOBIC and NQuiRE. Nursing
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NI LE (Chaps 19,20,32,33,51)

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19

for eligible physicians and healthcare providers who suc-

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Global VP of Clinical Informatics EXECUTIVE

HOSPITAL STEERING OPERATIONS

• FIGURE 19.1. EHR Implementation and Oversight Governance.

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Healthcare System Leadership • Fact Sheets, newsletters, and posters: collateral

TABLE 19.2 Sample of Health IT Project Communication Plan

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INTRODUCTION support their own electronic health record software. The

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3. Independence and Compliance (“Is the process fair

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TABLE 20.1 Health IT Market Resources

KLAS Vendor performance data based on http://www.klasresearch.com/

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TABLE 20.5 Sample RFI/RFP Outline

1 Executive Overview A high level summary of the request

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A major deliverable of the Evaluation phase is the

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Vendor A Vendor B Vendor C Vendor D Vendor E Vendor F Vendor G Vendor H Vendor I

5) Largest Relative Bedsize >500

6) Pharmacy system is stand-alone β

• FIGURE 20.3. Sample Summary Analysis.

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Health departments are collecting and analyzing

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Drug Public Health Laboratories

Law Faith Institutions

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Health pose of preventing or controlling disease, injury, or disability,

Assure and for conducting public health surveillance, public health

Workforce Insurance Portability and Accountability Act [HIPAA],

2002). The 2010 Patient Protection and Affordable Care Act

Link Research Inform, (PPACA) established policies and technically interoperable

the public health functions of assessment, policy develop-

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