TOPIC 1: SYSTEM LIFE CYCLE TOOLS

System life cycle (SLC) is a continuous series of system changes, or evolutions. Even
after the system is installed, there is continuous analysis, design, and implementation of
new modules, upgrades, and improvements.

American Nurses Credentialing Center defines the System Life Cycle as having
five phases:
● System Planning
● System Analysis
● System Design, Development, and Customization
● System Functional Testing
● System Implementation, Evaluation, Maintenance, and Support

ANALYSIS AND DOCUMENTATION OF THE CURRENT PROCESS AND

WORKFLOW
Karsh & Alper (2005) describe system analysis and workflow analysis as a way to
understand how a system works, and how the different elements in the system interact.

WAYS TO DEPICT A WORKFLOW

● Documentation - may be done by walking through the steps via an intensive
interview with those intimately familiar with the process by observation or by a
combination of the two.
● Analysis - provides the data with which you will base decisions that must be
made in the design, development, implementation, and evaluation stages of the
training project according to Kulhanek (2011, p. 5)

WORKFLOW DIAGRAM
Is generally prepared to document the current state when planning for a system
implementation and to identify problems or areas that need improvement. A workflow
diagram documents the processes of the users; the data workflow diagram documents
the interaction and flow of the information system(s). There are several types of
diagrams that can be utilized to document a process, including swim lanes, data flow
diagrams (DFDs).

Types of diagrams that can be utilized to document a process:

● Swim lane diagram - represents a process and is usually grouped in lanes
(either columns or rows) to help visualize the users or departments involved.
Basically, it is used to show the processes and individual/ departmental
responsibilities. The horizontal rows indicate individuals/ departments and both
horizontal and vertical lines and arrows are used to show the workflow separating
tasks, which are named in rectangles on the horizontal planes. The diagram
clearly indicates steps to the processes and responsible individuals. Before
 creating the swimlanes diagram, it is necessary to determine the purpose and the
process or processes to focus on.

Example:

Figure 1: A Swim Lane Presentation of a Simplified Diet Order Process.

● Data flow diagrams (DFDs) - are intended for graphical representation of data
flows in the information system and for analysis of data processing during the
structural projection. Data flow diagrams are often used in connection with
human processes and can be displayed as workflow diagrams.
Example:

Figure 2
SYSTEM SELECTION AND IMPLEMENTATION
The TIGER Usability and Clinical Application design team came up with the
following attributes of successful implementations (The TIGER Initiative, n.d., p.
20).
● User and key stakeholder involvement began early in the project with
system requirements development and system selection.
● Clinicians worked with developers to create definitions, wording, and
graphics that represented workflow processes.

SYSTEM IMPLEMENTATIONS
System implementation requires system design and building, and testing. System
design should involve key stakeholders, especially end users throughout. Like
Lab, each order needs to be tested from the time it is ordered through the time it
is performed and the final report is posted.
Example:

Figure 3: An example of the unit testing required for a lab interface

Figure 4: An example of a tool that can be used when testing Radiology orders
 Integrated testing - is done after unit testing has been accomplished and is the last
phase of testing, ensuring that all systems that share data are working correctly in
real-life scenarios (National Learning Consortium, 2012).

Example of a tool to verify that the fields related to patient information are correct
being converted from one system to another, or when being interfaced from one
system to another.

● Backloading - or manually entering information into the new system (Ohio KePRO,
n.d.), is often done in between two and five days before a new system is live so that
important patient information is available.
Example:
 Figure 6: An example of a report from the legacy system with the
information on it

● Reporting the status of the project from implementation through optimization is

critical. Stakeholders, according to Hanson, Stephens, Pangaro, and Gimbel
(2012), include clinicians, nurse/ancillary, patients, and administrators.
Example:

Figure 7: Example of Columnar Report

SYSTEM OPTIMIZATION AND METRICS

Surveys can be done post-implementation to evaluate staff satisfaction with the
system, the education, and/or the support.
Examples of pre- and post-implementation metrics include the accuracy and
completeness of charting, charging, and time studies.

MEASURING SUCCESS, CONTINUING TO IMPROVE

Continuous Quality Improvement (CQI) - is based on the principle that there is
an opportunity for improvement in every process (Wallin, Bostrom, Wikblad, &
Ewald, 2003).
● Philosophies that can be utilized to implement a CQI program; some
can be used in combination
Six Sigma - is a “data-driven quality improvement methodology
that uses statistical analysis to reduce process variation.
● Six Sigma utilizes five steps to evaluate metrics, known
as DMAIC:
❖ Define
❖ Measure
❖ Analyze
❖ Improve
❖ Control.
Lean Six Sigma - has a strong focus on eliminating waste by
removing non-value activities including defects, unnecessary, or
redundant steps using value stream mapping (VSM).
Plan Do Study Act (PDSA) - is a process for enacting and
evaluating change; according to Nakayama et al. (2010) it has
 been recommended by the Joint Commission and the Institute of
Medicine as an effective tool for complex processes.
Failure Mode and Effects Analysis (FMEA) - can be used
throughout the system life cycle to evaluate processes for real or
potential failure points.

TOPIC 2: HEALTH CARE PROJECT MANAGEMENT

What is a Project?

A project is temporary, has a defined beginning and end, and is managed to time,
budget, and scope. The Project Management Institute (PMI) defines a project as “a
temporary endeavor undertaken to create a unique product or service with a definite
beginning and a definite end.

Distinguishing features of a project:

-          Specific objectives

-          Defined start and end dates

-          Defined funding limitations

-          Consumption of resources

-          Multifunctional or cross organizational structure

What is Project Management?

Project management is facilitation of the planning, scheduling, monitoring, and

controlling of all work that must be done to meet the project objectives. PMI states that
“project management is the application of knowledge, skills, tools and techniques to
project activities to meet project requirements”. It is a systematic process for
implementing systems on time, within budget, and in line with customer expectations of
quality.  

Project Management Knowledge Areas

Describe the key competencies that project managers must develop and use during
each of the Process Groups
 Initiating Process Group (IPG)
defined by the PMI as follows: “those processes performed to authorize and define the
scope of a new phase or project or that can result in the continuation of halted project
work. Purpose: is to formally define a project, including the business need, key
stakeholders, and the project goals.

Examples of tools and techniques that facilitate completing the information gathering,
research, and related analysis required during the IPG include the SWOT (Strengths,
Weaknesses, Opportunities, and Threats) analysis, stakeholder analysis, and the value
risk assessment. The outputs from the IPG are used to inform project planning and
reused during project closure to facilitate evaluation of the project deliverables.

Planning Process Group (PPG)

● Is often the most difficult and unappreciated process in project management, yet it is one
of the most important and should not be rushed.
● The phase where decisions are made on how to complete the project and accomplish
the goals and objectives defined in the Initiating Process Group.
● The project plan is created, whose main purpose is to guide the project execution phase.
It also provides structure for the project monitoring and controlling process, as it creates
the baseline to which the work is measured against as it is completed.

Work Breakdown Structure (WBS) Projects are organized and understood by breaking
them into a hierarchy, with progressively smaller pieces until they are a collection of
defined “work packages” that include tasks and are used as the outline to provide a
framework for organizing and managing the work.

Executing Process Group (EPG)

 The processes performed to complete the work defined in the project management plan
to accomplish the project’s objectives defined in the project scope statement. –
PMI,2003

● Integration management: Coordination of project resources and activities to complete the

project on time. 
● Quality management: Monitoring of project performance. 
● Human resource management: Enhancing and motivating performance of project team
members. 
● Communication management: Distribution of information in a complete and timely
fashion. 
● Procurement management: Obtaining goods and services from outside an organization.

Executing Process Group Tools and Techniques

● Project meetings
● Gantt chart
● Request for proposal
● Issue log
● Progress reports 

Monitoring and Controlling Process Group (MCPG)

The purpose of the Monitoring and Controlling Process Group (MCPG) is to observe
project execution so that issues and potential problems can be identified in a timely
manner and corrective action can be taken when necessary to control the execution of
the project.

The Triple Constraint

Every project is constrained in some way by scope, cost, and time.

● Scope refers to the work that needs to be done to accomplish the project goals.
● Cost is the resources required to complete the project.
● Time is the duration of the project.  

Monitoring and Controlling Process Group Tools and Techniques

● Project management methodology

● Project management information systems
● Time reporting tools
● Progress reports

The Closing Process Group (CPG)

The processes performed to formally terminate all activities of a project or phase and
transfer the completed product to others or close a canceled project (PMI, 2013).

● Integration management: Coordination of project closure activities 

● Procurement management: Coordination of formal contract closure procedures

Closing Process Group Tools and Techniques

● Post-implementation survey
● Post-mortem review document
● Project closeout checklist 

OTHER CONSIDERATIONS

Project Governance
Successful projects are owned and sponsored by the leaders and staff that will be
making the practice change and will be benefiting from the change. 

Project managers are responsible for planning, executing, and closing projects, as well
as ensuring they are completed on time, within budget, and to the satisfaction of
stakeholders. To be a successful project manager, a combination of technical,
interpersonal, and leadership skills is necessary.

Here are some of the essential skills required for project managers:

1. Project Planning: The ability to create and manage project plans, including defining
project scope, setting timelines and milestones, identifying resources needed, and
determining project budget.
2. Communication: Effective communication skills, including listening, speaking, and
writing, are critical for project managers. They must be able to communicate project
objectives, status updates, and potential risks to stakeholders and team members.
3. Leadership: The ability to motivate and lead a team towards a common goal is essential
for project managers. They must be able to delegate tasks, provide direction, and make
decisions that benefit the project and the team.
4. Risk Management: Identifying and managing potential risks and issues that could
impact the project's success is a crucial skill for project managers. They must be able to
develop contingency plans and work with team members to mitigate risks.
5. Budget Management: Project managers must have a solid understanding of project
budgets and be able to manage project costs effectively. This includes tracking
expenses, forecasting future costs, and managing project resources efficiently.
6. Time Management: The ability to manage time effectively, set priorities, and meet
deadlines is essential for project managers. They must be able to manage their time and
the time of the team members to ensure project deadlines are met.
7. Conflict Resolution: The ability to resolve conflicts that arise during the project is an
important skill for project managers. They must be able to identify conflicts, address
them promptly, and work with team members to find a resolution that benefits the project
and the team.
8. Technical Skills: Project managers must have a basic understanding of the technical
aspects of the project. They should have knowledge of relevant technology, tools, and
processes used in the project.
9. Adaptability: Project managers must be adaptable and able to adjust to changing
project requirements, stakeholder needs, and team dynamics.
10. Critical Thinking: Project managers must be able to think critically, solve problems, and
make decisions that benefit the project and the team. They must be able to analyze
data, identify trends, and make informed decisions based on the information available.

The Project Management Office (PMO) is a department or function within an

organization that is responsible for defining and maintaining project management
 standards, practices, processes, and tools. The PMO provides support and guidance to
project managers and teams to help them deliver projects successfully.

The primary objective of a PMO is to ensure that projects are aligned with the
organization's strategic goals, delivered on time, within budget, and with the desired
quality. The PMO achieves this by providing a framework for project management, which
includes the following:

1. Standardization: The PMO defines standards, templates, and best practices for project
management. This ensures consistency across all projects in the organization and
enables efficient and effective project management.
2. Governance: The PMO establishes governance policies and procedures to ensure that
projects adhere to the organization's standards and policies. The PMO ensures that
projects are aligned with the organization's strategic objectives and have the necessary
resources and support.
3. Resource Management: The PMO is responsible for resource allocation, which
includes managing the availability of resources required for project execution. This
ensures that the projects have the necessary resources and that resources are utilized
efficiently.
4. Performance Management: The PMO monitors project performance and provides
feedback to project managers and teams. The PMO measures project success and
identifies areas for improvement.
5.  Risk Management: The PMO identifies and manages project risks. This includes
identifying potential risks, assessing their likelihood and impact, and developing plans to
mitigate or manage them.
6. Training and Development: The PMO provides training and development opportunities
for project managers and teams. This ensures that they have the necessary skills and
knowledge to manage projects effectively.

The PMO provides a framework for project management that helps the organization
achieve its strategic goals. It ensures that projects are managed effectively, efficiently,
and consistently, and that the organization's resources are utilized optimally.

The Project Management Institute (PMI) is a global professional organization for

project management professionals. It was founded in 1969 and is headquartered in the
United States. PMI offers a range of certifications, education, and professional
development programs in project management.

PMI also conducts research and publishes reports on project management trends and
best practices. It collaborates with academic institutions, governments, and other
organizations to advance the field of project management and promote the importance
of project management as a strategic competency for organizations.

In addition to its professional development offerings, PMI has established a Code of

Ethics and Professional Conduct that guides the behavior of project management
professionals. The Code outlines the ethical principles and values that project managers
should uphold in their work, including responsibility, respect, fairness, and honesty.
 Overall, PMI plays a significant role in advancing the profession of project management,
promoting best practices, and providing opportunities for professional development and
networking for project management professionals.

PMPs are sought after by organizations that value project management expertise and
competency. They are often responsible for managing complex projects, leading project
teams, and ensuring that projects are delivered on time, within budget, and to the
satisfaction of stakeholders.

PMPs are also required to maintain their certification by earning Professional

Development Units (PDUs) through continuing education and professional development
activities. This ensures that PMPs stay current with the latest project management
trends, best practices, and technologies. PMPs are highly skilled and knowledgeable
professionals who have demonstrated their competency in project management. They
are respected in the industry and play a critical role in helping organizations achieve their
strategic goals through effective project management.

1. ProjectManagement.com: This website, hosted by the Project Management Institute,

offers a wide range of resources, including articles, webinars, templates, and discussion
forums. It also features a job board and a directory of project management consultants
and service providers.
2. ProjectManager.com: This cloud-based project management software provider also
offers a variety of resources, including blog posts, videos, and webinars. The website
also features a project management glossary, a project management calculator, and a
community forum.
3. PMI.org: The Project Management Institute's website offers a wealth of resources for
project managers, including research reports, whitepapers, and case studies. The site
also features information about PMI's certifications and professional development
programs.
4. GanttPRO: This project management software provider offers a blog with articles on
various project management topics, including planning, team management, and
resource management. The website also features a project management academy with
free online courses.
5. Trello: This project management software provider offers a blog with articles on
productivity, collaboration, and project management. The website also features a
template gallery with pre-made templates for various project management needs.
6. Wrike: This project management software provider offers a blog with articles on project
management best practices, leadership, and collaboration. The website also features a
resource center with eBooks, guides, and webinars.

Atlassian: This software company offers a range of project management tools, including
Jira, Confluence, and Trello. Its website features a blog with articles on project
management, Agile methodology, and team collaboration.
TOPIC 3: THE PRACTICE SPECIALTY OF NURSING INFORMATICS

INFORMATICS NURSE/INFORMATICS NURSE SPECIALIST

An informatics nurse (IN) is a registered nurse who has an interest or experience in

nursing informatics. Informatics nurse specialists (INSs) are registered nurses prepared
at the graduate level (master’s degree or higher) in nursing informatics, informatics, or
an informatics related field. An INS functions as a graduate-level prepared specialty
nurse.

INFORMATICS AND HEALTHCARE INFORMATICS

Informatics is a science that combines domain science, computer science, information

science, and cognitive science. Thus, it is a multidisciplinary science drawing from varied
theories and knowledge applications.

Healthcare informatics may be defined as “the integration of healthcare sciences,

computer science, information science, and cognitive science to assist in the
management of healthcare information”

Nursing Informatics as a Specialty

Characteristics of a nursing specialty include differentiated practice, a well-derived

knowledge base, a defined research program, organizational representation, educational
programs, and a credentialing mechanism.

The core phenomena of nursing are the nurse, person, health, and environment. Nursing
informatics focuses on the information of nursing needed to address these core
phenomena. Within this focus are the metastructures or overarching concepts of nursing
informatics: data, information, knowledge, and wisdom.

Nursing informatics is represented in international, national, regional, and local

organizations.

Nursing informatics is part of the clinical section of the Healthcare Information and
Management Systems Society (HIMSS). There are additional organizations such as the
American Nursing Informatics Association (ANIA) and the American Academy of Nursing
(AAN) Informatics and Technology Expert Panel (ITEP).

Models for Nursing Informatics

A clinical-information-system (CIS) model shows how modeling can be used to

organize different concepts into a logical whole. The purpose of this model is to depict
system components, influencing factors, and relationships that need to be considered
when attempting to capture the complexities of professional nursing practice.

Graves and Corcoran’s seminal work included a model of nursing informatics. Their
model placed data, information, and knowledge in sequential boxes with one-way arrows
pointing from data to information to knowledge. The management processing box was
directly above, with arrows pointing in one direction from management processing to
each of the three boxes (Graves & Corcoran, 1989). The model is a direct depiction of
their definition of nursing informatics.

Turley, writing in 1996, proposed another model in which the core components of
informatics (cognitive science, information science, and computer science) were
depicted as intersecting circles. In Turley’s model, nursing science was a larger circle
that completely encompassed the intersecting circles.

McGonigle and Mastrian (2012) developed the foundation of knowledge model. The
base of this model showed data and information distributed randomly. From this base,
transparent cones grew upward and intersected. The upward cones represented
acquisition, generation, and dissemination of knowledge. Knowledge processing was
represented by the intersections of these three cones. Feedback circled and connected
all of the cones. The cones and feedback circle were dynamic in nature (McGonigle &
Mastrian, 2012).

In 2015, McGonigle and Mastrian expanded on the model as a framework for NI

Practice. The three overarching standards of NI practice were incorporation of theories,
concepts and principles from appropriate sciences into informatics practice; the
integration of ergonomics and human–computer interaction (HCI) into the informatics
care plan; and the systematic determination of the social, legal, and ethical impact of an
informatics solution within nursing and healthcare.

The Empowerment Informatics Framework (EIF) model provides a framework where

nurses use technology to
(a) guide chronic illness interventions through the integration of patient
self-management and nursing informatics,
(b) focus on self-management research, and
(c) promote ethical technology use by practicing nurses. The model is used to guide
intervention design as well as evaluation and support nurses’ ethical use of technology
to guide nursing practice using technology that prioritizes patient needs.

Theories and Other Models Supporting Nursing Informatics

A theory is a scholarly, organized view of some aspect of the world (reality). Theories
can describe, explain, predict, or prescribe selected phenomena within this reality.
 Theories can be classified as grand, middle-range, and situation-specific or practice
theories.
Theories are part of an interrelated, circular triad: research, theory, and practice.

Theories related to and supportive of nursing informatics are numerous. These theories
include—but are not limited to—information, cognitive, computer science, systems,
change management, organizational behavior, management, and group dynamics.

Nursing Theories. Nursing theories are about nursing practice—a nurse’s interactions or
relationships with individuals, families, groups, communities, or populations (also known
as patients, clients, healthcare consumers)—focused on applying the nursing process.

Novice to Expert
Benner’s theory is based on the 1980 Dreyfus Model of Skills Acquisition (Dreyfus &
Dreyfus, 1980, as cited in Benner, 1984/2001) which maintains that nurses advance
through five stages in their professional development but may return to an earlier stage if
they move to a different practice.

In 1986, Patricia Schwirian proposed a model of nursing informatics intended to

stimulate and guide systematic research in this specialty. The model provided a
framework for identifying significant information needs, which, in turn, can foster
research.

There are many models and theories of planned change, two of the most frequently
used to provide a framework for change management are Lewin’s theory of planned
change—also known as force field analysis—and Rogers’ diffusion of innovations model.

Lewin's Force Field Analysis

Lewin’s basic planned-change model has three stages: unfreezing, moving, and
refreezing. Unfreezing involves overcoming inertia and dismantling the existing mindset.
In the second stage, called "moving," the behavioral change occurs. Typically, this stage
is a period of confusion. The third—and final—stage is “refreezing.” A new mind-set has
formed, and the comfort level is returning to previous levels.

Rogers Change Theory: Diffusion of Innovation

Rogers identified characteristics of an innovation that most affect the rate of
adoption—defined as either positive or negative. These characteristics are relative
advantage, compatibility, complexity, trialability, and observability. Positive characteristics
include the following:
● Relative advantage
● Compatibility
● Trialability
● Trialability
Rogers defined complexity as a negative characteristic. It is the degree to which an
innovation is perceived as difficult to understand and use.
Along with the concept of different categories of innovation adopters, Rogers proposed a
five-stage model for the diffusion of innovation:
• Stage 1 is knowledge
• Stage 2 is persuasion
• Stage 3 involves the adopter making a decision
• Stage 4 is implementation
• Stage 5 is confirmation

Information science
Information science focuses on the gathering, manipulation, classification, storage, and
retrieval of recorded knowledge. Information science can be socially oriented, focused
on humans and machines, and closely linked to communications and human behavior.

Communication
Within a communication model, Bruce Blum presented a taxonomy, with definitions, of
the central concepts of data, information, and knowledge concepts adopted by NI.
• Data is defined as discrete entities that are described objectively without
interpretation— sometimes referred to as being “raw.”
•Information is data that are interpreted, organized, structured, or processed so that it
can be displayed or presented for human use (Blum, 1985).
•Knowledge is information that has been synthesized so that interrelationships of data
and information are identified and formalized.

Systems theory
Systems theory relates to the properties of systems as a whole and focuses on the
organization and interdependence of relationships within a system. A system is any set
(group) of interdependent or temporarily interacting parts.

Behavioral and Social Sciences

The study of behavior is the focus of the behavioral and social sciences. These two
terms are often combined or used interchangeably when examining how people act
alone (as individuals) and with others.

Organizational Behavior
Organizational behavior is a distinct field focused on the study of organizations where
organizations are examined, using methods drawn from economics, sociology, political
science, anthropology, and psychology

Management Science
Management science uses mathematics and other analytical methods to help make
better decisions, generally in a business context. Management science processes
 involve using rational, systematic, science-based techniques to inform and improve
decisions of all kinds.

Group Dynamics
Group dynamics is a social science field that focuses on the nature of groups. Urges to
belong or to identify may make for distinctly different attitudes (recognized or
unrecognized), and the influence of a group may rapidly become strong, influencing or
overwhelming individual activities.
Tuckman’s model states that the ideal group decision-making process should occur in
four stages:
• Forming (pretending to get on or get along with others)
• Storming (letting down the politeness barrier and trying to get down to the issues even
if tempers flare up)
• Norming (getting used to each other and developing trust and productivity)
• Performing (working in a group to a common goal on a highly efficient and cooperative
basis)

TOPIC 4: NURSING INFORMATICS AND HEALTHCARE POLICY

INTRODUCTION
● To practice effectively in today’s continually changing healthcare environment,
informatics professionals need to be aware of existing and proposed healthcare
policy.
● Policy - a course of action that guides present and future decisions. Healthcare
policy is established on local, state, and national levels to guide the
implementation of solutions for the populations health needs.
● The number of informatics programs for nurses has significantly increased,
preparing more informatics nurse specialists to practice in the field, and or a
number of trends and events have placed information technology (IT),
information systems(IS), and informatics at a center of attention in healthcare.

CHAPTER OVERVIEW
Given the critical importance of nurses and health IT Professionals to the future of
healthcare transformation, it is important to understand the key components driv-ing
change in the industry: the primary influencers, orga-nizations, programs, and processes
that have shaped or defined policies for the integration of health IT that will affect all
segments of healthcare. Therefore, the purpose of this chapter is to identify and define
the historic and present roles of such influencers, including sections on:

- Forces of Change in Today’s National Healthcare System

- Mandate for Reform: ARRA and its HITECH Act Provision
- State and Regional Health IT Programs
- Health IT Federal Advisory Committees and Agencies
- Nursing Informatics and Healthcare Reform
- The Road Ahead

Forces of Change in Today’s National Healthcare System

- These reports were call to action for a paradigm shift from reliance on paper and verbal
communication professionals are supported by their clinical decision-making by
technology while providing patient care.

● The President’s Information Technology Advisory Committee

- In 1997, an Executive Order of the President established the visionary, 24-member
President’s Information Technology Advisory Committee (PITAC), which was composed
of both corporate and academic leaders from across the United States. Since its
inception, the com-mittee has provided the President, Congress, and those federal
agencies involved in networking and information technology (IT) research and
development with expert,independent advice on maintaining American preemi-nence in
advanced information technologies.

● President’s Council of advisory for Science and Technology

- The National Coordinating Office for IT called it an elevation of the role of external
information technology advice in the White House, and assigned a broader charter than
the former committee’s narrow focus on IT (Harsha, 2005). Over the next few years,
PCAST studied and produced reports on issues ranging from energy and technology to
nanotechnology to personalized medicine.

● Presidents Bush’s Executive Order and the Birth of ONC

- ONC remains today the principal federal entity charged with coordination of nationwide
efforts to implement and use the most advanced health IT and the electronic exchange
of health information. ONC is a key player in the execution of ARRA and its HITECH Act
provision. ARRA authorized the creation of two committees the Health IT Policy
Committee and the Health IT Standards Committee that make recommendations to the
ONC.

● Health IT Training Programs: An Essential Element of Reform

- As discussed in the introduction, today’s urgent need for health IT experts is challenged
by a shortage of the very professionals who are best positioned to carry transformation
forward.With Consensus around the essential requirement for advanced health IT and
the mounting pressures of shortages in nursing, health IT experts, and other medical
professions.

● The Health insurance Portability and Accountability Act: Privacy and Security
- The Health Insurance Portability and Accountability Act (HIPAA), which passed in 1996,
required HHS to develop regulations protecting the privacy and security of electronic
health information as well as facilitate its efficient transmission. HIPAA’s goals are to
 allow the flow of health information needed to provide and promote high quality
healthcare while protecting the public’s health and well-being;

HIPAA Privacy Rule

- The HIPAA Privacy Rule. The HIPAA Privacy Rule, which took effect on April 14, 2003,
established national standards for the protection of individually identifiable health
information. As such, the rule regulates the use and disclosure of an individual’s health
information, referred to as Protected Health Information (PHI), and sets forth standards
for individuals’ privacy rights to understand and control how their health information is
used.

The HIPAA Security Rule

- The HIPAA Security Rule. The HIPAA Security Rule took effect on April 21, 2003, with a
compliance date of April 21, 2005, for most covered entities. The Security Rule
complements the Privacy Rule; while the Privacy Rule pertains to all PHI including paper
and electronic records, the Security Rule deals specifically with Electronic Protected
Health Information (ePHI).

● EHR Certification and Testing

- With the passage of ARRA and HITECH, ONC has become the driving force behind the
definition of meaningful use of EHRs and the certification of EHR systems.This new
reality changed the operating environment for the Certification Commission for
Healthcare InformationTechnology (CCHIT), which until 2009 had been the sole
organization to certify EHR systems.

● Standard and the Nationwide Health Information Network

- As envisioned then and now, NwHIN is intended to provide a set of standards that
regulate the connections among providers, consumers, and others involved in
supporting health and healthcare. The purpose of these stan-dards is to enable
normalized health information to follow the consumer; it is intended to make health
records,laboratory results, medication information, and related medical data readily
available and accessible to providers, pharmacists, and even consumers over the
Internet,thereby helping achieve the goals of the HITECH Act. At the same time, NwHIN
is also dedicated to ensuring that consumers’ health information remains secure and
confidential in the electronic environment.

● Non-Profit Organizations Driving Reform

- Among the many non-profit organizations today advancing health IT and nursing
informatics, few have had such positive impact on the industry than the American
Medical Informatics Association (AMIA) and the HealthcareInformation andManagement
Systems Society (HIMSS).

Mandate for Reform: ARRA and its HITECH Act Provision

 As noted in this chapter’s introduction, the incentives were intended to help healthcare
providers purchase and implement health IT and EHR systems, and the HITECH Act
also stipulated that clear penalties would be imposed beyond 2015 for both hospitals
and physician providers who failed to adopt the use of EHRs in a meaningful way. This
section describes some of the key components of ARRA and HITECH.

● Incentives for Meaningful Use of EHRs

The majority of the HITECH funding will be used to reward hospitals and eligible
providers for “meaningful use” of certified EHRs by “meaningful users” with increased
Medicare and Medicaid payments. The law specifies that eligible healthcare
professionals and hospitals can qualify for both programs when they adopt certified EHR
technology and use it in a meaningful way.

Stage 1: Beginning in 2011 as the incentive program’s starting point for all
providers; “meaningful use” here consists of transferring data to EHRs and
beginning to share information, including electronic copies and visit summaries
for patients.
Stage 2: To be implemented in 2014 “meaningful use” includes significant new
exchange functionality such as online patient access to their health information
and electronic health information exchange during transitions between providers.
Stage 3: Expected to begin in 2017, “meaningful use” in this stage is projected to
include measures that demonstrate improvement in the quality of healthcare.

● Milestones in Meaningful Use Program

Milestone dates and their significance to the Meaningful Use Program in the
United State are summarized in the following paragraphs:
December 31, 2009
July 28,2010
November 30, 2011
February 23-24, 2012
August 23,2012
● What is New in Stage 2?
- HHS expanded the meaningful use of EHR technology The Stage 2 criteria for
meaningful use focuses on increasing the electronic capture of health information
in a structured format, as well as increasing the exchange of clinically relevant
information between providers of care at care transitions.
- The Stage 2 rule also proposes new objectives that have greater applicability to
many specialty providers.

● Proposed Stage 3
- Meaningful use is improved outcomes. An ONC presentation in July 2013
outlines the adoption of a new model of care that is team based, outcome
oriented, and population management driven. In addition, it should address
national health priorities and have broad applicability.
● Quality Measures
- Quality measurement is considered one of the most important components of the
incentive program under ARRA/HITECH, since the purpose is to promote reform
in the delivery, cost, and quality of healthcare in the United States.
● ONC and Establishment of the HIT Policy and Standards Committees
- To drive the rapid, health IT-based reform under such an aggressive plan, the
HITECH legislation re-energized ONC with specific accountability and significant
funding. It also created the two new Federal Advisory Committees under its
control: the HIT Policy Committee and the HIT Standards Committee, which have
already been discussed in this chapter. Members of the two committees are
public and private stakeholders who are tasked to provide recommendations on
the HIT policy framework, standards, implementation specifications, and
certification criteria for the electronic exchange and use of health information
Additional information regarding these two committees is provided in the next
section: “Health IT Federal Advisory Committees and Agencies.”

● Challenges to Achieving Widespread Health Information Exchange

- The Information Exchange Workgroup (IEW) makes recommendations to the
Health IT Policy Committee on policies, sustainability, and implementation
approaches to enhance the flow of health information. However, widescale
interoperability challenges exist, leaving some primary care physicians and other
providers with few options for meeting the health information exchange objectives
included in meaningful use Stage 2 (MU2).

● Patient-Centered Outcomes Research

- ARRA and HITECH increased funding by more than $1 billion for Comparative
Effectiveness Research (CER) and established the Federal Coordinating Council
for Comparative Effectiveness Research (FCC-CER). This group is an advisory
board composed of clinical experts responsible for reducing duplication of efforts
and encouraging coordination and complementary uses of resources,
coordinating related health services research, and making recommendations to
the President and Congress on CER infrastructure needs.

State and Regional Health IT Programs

- With recognition that the regional electronic exchange of health information is
essential to the successful implementation of NwHIN and to the success of
national healthcare reform in general, the HITECH Act authorized and funded the
State HIE Cooperative Program and a Regional HITExtension Program. Taken
together, these grant programs offer much-needed local and regional assistance
and technical support to providers while enabling coordination and alignment
within and among states.

● State Health Information Exchange Cooperative Agreement Program

 - The State HIE Cooperative Agreement Program funds states’ efforts to rapidly
build capacity for exchanging health information across the healthcare system
both within and across states. Awardees are responsible for increasing
connectivity and enabling patient-centric information flow to improve the quality
and efficiency of care

● Beacon Communities
- Also funded by HITECH, ONC’s Beacon Community Program will help guide the
way to a transformed healthcare system. The program is working to fund more
than a dozen demonstration communities that have already made inroads into
the adoption of health IT, including EHRs and health information exchange.
Beacon Communities are designed to advance new, innovative ways to improve
care coordination, improve the quality of care, and slow the growth of healthcare
spending. Their goals are to show how health IT tools and resources can
contribute to communities’ efforts and make breakthrough advancements in
healthcare quality, safety, efficiency, and in public health at the community level,
demonstrating that these gains are sustainable and replicable.

● Health IT Regional Extension Program

- The regional centers offered technical assistance, guidance, and information on
best practices to support and accelerate healthcare providers’ efforts to become
meaningful users of Electronic Health Records (EHRs). The extension program
established 62 regional centers, each serving a defined geographic area. The
regional centers supported over 120,000 primary care providers through
participating non-profit organizations in achieving meaningful use of EHRs and
enabling nationwide health information exchange. The Extension Program also
established an HITRC, funded separately, to gather relevant information on
effective practices and help the regional centers collaborate with one another and
with relevant stakeholders to identify and share best practices in EHR adoption,
effective use, and provider support.

Health IT Federal Advisory Committees and Agencies

In 1972, decades before ARRA, HITECH, and ACA, the Federal Advisory
Committee Act became law and is still the legal foundation defining how Federal
Advisory Committees and Agencies (FACAs) should operate.

● Health IT Policy Committee

- HIT Policy Committee is charged with making recommendations to ONC on a
policy framework for the development and adoption of a nationwide health
information infrastructure, including standards for the exchange of patient
medical information (Office of the National Coordinator for Health Information
Technology, 2013c)
 ● The Health IT Standards Committee
The HIT Standards Committee is charged with making recommendations to ONC
on standards, implementation specifications, and certification criteria for the
electronic exchange and use of health information (Office of the National
Coordinator for Health Information Technology, 2013m). In harmonizing or
recognizing standards and implementation specifications, the HIT Standards
Committee is also tasked with providing for all associated testing by the National
Institute of Standards and Technology (NIST).

● The National Committee on Vital and Health Statistics

- he National Committee on Vital and Health Statistics (NCVHS) was originally
established more than 60 years ago by Congress to serve as an advisory body to
the HHS on health data, statistics, and national health information policy
(National Committee on Vital and Health Statistics, 2009)

● The National Quality Forum

- The National Quality Forum (NQF) is a non-profit organization that aims to
improve the quality of healthcare for all Americans through fulfillment of its
three-part mission: to set national priorities and goals for performance
improvement; to endorse national consensus standards for measuring and
publicly reporting on performance; and to promote the attainment of national
goals through education and outreach programs.

NURSING INFORMATICS AND HEALTHCARE REFORM

- In 2009, a survey sponsored by HIMSS’ Nursing Informatics community entitled
Informatics Nurse Impact Survey concluded that the passage of the ARRA and
its provision of incentives to promote the meaningful use of EHRs created new
opportunities for informatics nurses “to apply their ability not only to understand
all sides of the IT process, but to act as a translator between those who
understand the language of the technology and the language and needs of
clinicians and patients” (HIMSS, 2009).

● Nursing Informatics Competencies

- Today’s informatics nurse combines clinical knowledge with IT to improve the
ways nurses diagnose, treat, care for, and manage patients. Essentially,
informatics nurses support, change, expand, and transform nursing practice
through the design and implementation of information technology. The ANI
defines nursing practice as “a specialty that integrates nursing science, computer
science and information science to manage and communicate data, information,
knowledge, and wisdom in nursing practice” (RNDegrees, n.d.).

● The Intersection of HIT Policy and Nursing Informatics

- Informatics nurses are poised to play pivotal leadership roles in defining new
policies that help make the goals of ARRA and HITECH a reality over coming
 years. To make such a profound difference in today’s constantly changing
healthcare environment, informatics professionals must be aware of existing and
proposed healthcare policy on an ongoing basis.

● Influencing Health IT Transformation Through Testimony and Comment

- This chapter has discussed the need for health IT competencies, awareness of
how health IT is changing the way we diagnose, treat, care for, and manage
patients, as well as healthcare policies that affect healthcare practices and the
global healthcare landscape. In addition, healthcare informatics professionals
should never underestimate the power of communication to bring about
meaningful change in our Nation’s healthcare delivery system.

THE ROAD AHEAD

- Leaders in healthcare agree: the future depends on a system that will continue
to innovate using health IT and to rely on informatics to play instrumental roles in
patient safety, change management, and quality improvement, as evidenced by
quality outcomes, enhanced workflow, and user acceptance. These areas
highlight the value of an informatics-trained workforce and their roles in the
adoption of health information technologies that deliver higher quality clinical
applications across healthcare organizations