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Fifth Edition

Informatics and Nursing Opportunities and Challenges

Informatics and Nursing Opportunities and Challenges

Fifth Edition

Jeanne Sewell, MSN, RN-BC Associate Professor, School of Nursing College of Health Sciences Georgia College & State University Milledgeville, Georgia

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5th edition

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Library of Congress Cataloging-in-Publication Data Sewell, Jeanne P., author. Informatics and nursing : opportunities and challenges / Jeanne Sewell. — Fifth edition. p. ; cm. Includes bibliographical references. ISBN 978-1-4511-9320-6 I. Title. [DNLM: 1. Nursing Informatics. 2. Computers. 3. Internet. 4. Medical Records Systems, Computerized. WY 26.5] RT50.5 610.73—dc23

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This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work.

This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication his- tory, laboratory data and other factors unique to the patient. The publisher does not provide medical advice or guidance and this work is merely a reference tool. Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments.

Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and health- care professionals should consult a variety of sources. When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contraindications, particu- larly if the medication to be administered is new, infrequently used or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or prop- erty, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work.

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Jeanne Sewell, an associate professor of nursing at Georgia College & State University in Milledgeville, Georgia, is board certified as an informatics nurse specialist. Her credentials include a postgraduate certificate in nursing infor- matics from Duke University, a Master of Science in Nursing at the University of Maryland at Baltimore, a Bachelor of Science in Nursing at Georgia Regents University–Medical College of Georgia, and a nursing diploma from Georgia Baptist School of Nursing, now Georgia Baptist College of Nursing at Mercer University.

Jeanne’s expertise is nursing informatics, nursing education, and the scholarship of teaching and learning. She has received several teaching awards, including the Georgia College & State University 2015 Scholarship of Teaching and Learning Award. She teaches traditional face-to-face classes, as well as blended and online classes, across the nursing curriculum in the following programs: baccalaureate in nursing, RN-BSN, master of science in

nursing, and doctor of nursing practice. She has served as a consultant in nursing education and as a speaker at statewide, national, and international conferences.

Jeanne has clinical nursing experience in a variety of settings, including nursing administration, out- patient care, critical care, medical-surgical care, and pediatric nursing. Her interest in nursing informat- ics began in the early 1980s as she was completing graduate studies, when different clinical information systems began integration.

About the Author

vi

Contributors to the Fifth Edition Omega Finney, MSN, RN-BC Informaticist Piedmont Healthcare Atlanta, Georgia

Karen Frith, PhD, RN, NEA-BC Professor and Associate Dean, Undergraduate Programs College of Nursing, The University of Alabama in Huntsville Huntsville, Alabama

Linda Q. Thede, PhD, RN-BC Professor Emerita of Nursing Kent State University Kent, Ohio

Contributors Contributors to the Fourth Edition Deborah Ariosto, PhD, MSN, RN Director, Patient Care Informatics Vanderbilt University Medical Center Nashville, Tennessee

Pamela J. Correll, RN, MS Nursing Informatics Consultant Maine Center for Disease Control and Prevention Public Health Nursing Program Bangor, Maine

Karen Frith, PhD, RN, NEA-BC Professor and Associate Dean, Undergraduate Programs College of Nursing, The University of Alabama in Huntsville Huntsville, Alabama

Judy Hornbeck, MHSA, BSN, RN Highland, Illinois

For a list of the contributors to the Student and Instructor Resources accompanying this book, please visit http:// thepoint.lww.com/sewell5e.

vii

Reviewers Kerry Allen, MSN Associate Professor Southern Adventist University Collegedale, Tennessee

Kim Amer, PhD, RN Associate Professor DePaul University Chicago, Illinois

Mary Boylston, MSN, EdD Professor Eastern University St. Davids, Pennsylvania

Elizabeth Carlson, PhD Associate Professor and Systems Leadership DNP Program Director Rush University, College of Nursing Chicago, Illinois

Laura Clayton, PhD, RN, CNE Assistant Professor of Nursing Education Shepherd University Shepherdstown, West Virginia

Prudence Dalrymple, PhD, MS in Informatics Research and Teaching Professor Drexel University Philadelphia, Pennsylvania

Jeff Dowdy, MLIS Graduate Librarian Ina Dillard Russell Library, Georgia College & State University Milledgeville, Georgia

Tresa Dusaj, PhD(c) Assistant Professor Monmouth University West Long Branch, New Jersey

Robert Elshaw, MSN, RN-BC, ANCC Board Certified Informatics Nurse Adjunct Faculty Ursuline College Pepper Pike, Ohio

Willy Fahlman, BScN, MEd, EdD Sociology Faculty Athabasca University Athabasca, Alberta

Mary Fairbanks, MS, DNP, RN, PHN Associate Professor Bemidji State University Bemidji, Minnesota

Matthew Gaines, AAS Technical Support Tech Division on Information Technology, Georgia College & State University Milledgeville, Georgia

Debbie Greene, PhD, RN, CNE Associate Professor and Assistant Director for Undergraduate Nursing Programs School of Nursing, Georgia College & State University Milledgeville, Georgia

Janis Hayden, EdD, MSN, RN Professor St. Francis Medical Center, College of Nursing Peoria, Illinois

viii    Reviewers

Arlene Holowaychuk, RN, MSN, CNE Assistant Professor, Preceptor Coordinator Bon Secours Memorial College of Nursing Richmond, Virginia

Michelle Hornack, MSN, BSN Assistant Professor of Nursing Graceland University Independence, Missouri

Janice Jones, PhD, RN, CNS Clinical Professor University at Buffalo Buffalo, New York

Rebecca Koeniger-Donahue, PhD, APRN Professor of Practice Simmons College Boston, Massachusetts

Elizabeth Kostas-Polston, PhD, APRN, WHNP-BC, FAANP Assistant Professor University of South Florida Tampa, Florida

Anne Krouse, PhD Professor Widener University Chester, Pennsylvania

Katherine Leigh, DNP, RN Assistant Professor Troy University Dothan, Alabama

Barry Lung, MSN, RN-BC Informaticist Byron, Georgia

Rosemary Macy, PhD, RN, CNE, CHSE Associate Professor Boise State University Boise, Idaho

Patricia Martin, MSN Associate Professor West Kentucky Community and Technical College Paducah, Kentucky

Priscilla Okunji, RN-BC, PhD Nursing Faculty Howard University Washington, District of Columbia

Jill Pence, MSN, BSN, RN, CNE Assistant Professor Samford University Birmingham, Alabama

Rorey Pritchard, EdS, MSN, RN-BC, CNOR, CNE Clinical Assistant Professor University of Wisconsin, Eau Claire Eau Claire, Wisconsin

Leandro Resurreccion, BSZ, BSN, MSN, EdD Professor of Nursing Oakton Community College Des Plaines, Illinois

Luis M. Cabret Rios, RN, MSN, APRN, FNP-BC, DNP(s) Nursing Instructor Turabo University Gurabo, Puerto Rico

Nicole Robert, MSN, RN Faculty Mentor Thomas Edison State College Zachary, Louisiana

Lisa Shaffer, MS, MBA Adjunct Instructor Galen College of Nursing Cincinnati, Ohio

Bonnie Stegman, PhD, MSN, RN Assistant Professor of Nursing and Coordinator of the BSN Online Completion Program Maryville University, St. Louis St. Louis, Missouri

Sharon Stoten, DNP Assistant Professor Indiana University East, School of Nursing Richmond, Indiana

Reviewers    ix

Debra Sullivan, PhD, MSN Assistant Professor Middle Tennessee State University Murfreesboro, Tennessee

Jeanne Tucker, PhD, MSN, RN, HSAD, CHES Assistant Professor of Nursing Patty Hanks Shelton School of Nursing Abilene, Texas

Laureen Turner, MSN, DNP Instructor University of San Francisco San Francisco, California

Denyce Watties-Daniels, MSN Assistant Professor Coppin State University Baltimore, Maryland

Bonnie K. Webster, MS, RN, BC Assistant Professor University of Texas, Medical Branch in Galveston, School of Nursing Galveston, Texas

Kathleen Williams, MSN, RN-BC (Informatics) Assistant Professor Charleston Southern University North Charleston, South Carolina

Ronda Yoder, PhD, ARNP Nursing Faculty Pensacola Christian College Pensacola, Florida

For a list of the reviewers of the Test Generator questions accompanying this book, please visit http://thepoint.lww. com/sewell5e.

x

Preface Advancements in computer technology and the Internet have made the use of informatics per- vasive in our society worldwide. Simply stated, informatics is the use of computers to dis- cover, manipulate, and understand information. Informatics is required to achieve the nursing transformation mentioned by the 2010 Institute of Medicine (IOM) report, The Future of Nursing, which includes enabling nurses to be full partners in redesigning healthcare in the United States and to engage in effective workforce planning and policymaking (Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine, Robert Wood Johnson Foundation, & IOM, 2011).

The first edition of this textbook, Computers in Nursing, which was published in 1999, was one of the first textbooks to address core informatics competencies for all nurses. Each edition, includ- ing this fifth edition, was designed to capture the innovative advancements in nursing informatics core competencies and applications and to teach students how informatics should be integrated into practice. This edition focuses on the best of the fourth edition, such as office computing software, interoperability, consumer informatics, telehealth, and clinical information systems, plus new topics that have entered the field since the last edition, such as social media use guidelines, software and hardware developments, and updates on mean- ingful use. Each chapter now includes a Quality and Safety Education for Nurses (QSEN) scenario designed to stimulate critical thinking. The book’s companion webpage at http://thepoint.lww.com/ sewell5e includes many resources for students— for example, a sample database and spreadsheets, as well information on APA templates and e-mail signatures—along with a wealth of resources

for instructors (see the “Additional Resources” section later in this preface for more informa- tion). The goal was to make it all interesting—and yes, thought-provoking—to you, the reader. For example, QSEN scenarios, as well as application and competencies critical thinking exercises, align with each chapter’s objectives. In the decade and a half since the first edition published, nursing and the entire healthcare arena have come to recognize the importance of informatics.

The major accrediting organizations for nurs- ing, American Association of Colleges of Nursing (AACN) and the National League for Nursing (NLN), have identified informatics as an essential competency for all nurses, ranging from the begin- ning practitioner to the doctor of nursing practice (DNP), doctor of philosophy (PhD), and doctor of nursing science (DNSc) (AACN, 1996, 2006, 2008, 2010, 2011; NLN, 2008, 2015). A call for nurs- ing education to adopt informatics competencies for all levels of education came from the TIGER Initiative, aimed at using informatics for improv- ing practice with evidence-based information (The TIGER Initiative Foundation, 2014).

Evidence-based decision making using infor- matics tools should be implemented in healthcare redesign as well as in improvements in data collec- tion and information infrastructure. The textbook includes information on how to discover schol- arly journal articles and websites with healthcare information for evidence-based decision making. The learner is introduced to Medline/PubMed, from the U.S. National Library of Medicine, a free library available to users worldwide. Clearly, there is agreement that informatics is an essential tool to address the need to provide evidence-based care with improved outcomes for individuals and populations.

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AUDIENCE The information in this textbook is what every nurse should know. Besides providing information for anyone who is just beginning to learn about nursing informatics, the book is designed for use either as a text for a course in nursing informat- ics or with a curriculum in which informatics is a vertical strand. Here is a unit-by-unit breakdown of how the material could be used: JJ Unit I, Informatics Basics, and Unit II, Computer

Applications for Your Professional Career, pro- vide background information that would be useful in undergraduate and graduate introduc- tory courses, or as an introduction to comput- ers and information management.

JJ Unit III, Information Competency, would be useful at any point in a curriculum.

JJ Unit IV, The Evolving Healthcare Paradigm, and Unit V, Healthcare Informatics, provide infor- mation that would be useful at more advanced levels.

JJ Unit VI, Computer Uses in Healthcare Beyond Clinical Informatics, can be used as a whole or its individual chapters matched with a course. International Council of Nurses, the Healthcare

Information and Management Systems Society (HIMSS) TIGER Initiative, and two United States nursing accrediting bodies provide direction for incorporating nursing informatics as a core com- petency into all levels of education programs.

ORGANIZATION AND STRUCTURE In this fifth edition, the six units were redesigned to improve the organization and flow of the content.

Unit I, Informatics Basics, introduces readers to new guidelines for use of electronic communi- cation with social and professional networking. Chapter 1 (Introduction to Nursing Informatics: Managing Healthcare Information) provides an overview of nursing informatics, including the differences between computers and informatics, the rationale for having basic informatics skills, and the need to be computer fluent and infor- mation literate. Chapters 2 (Essential Computer and Software Concepts) and 3 (Basic Computer

Networking Concepts) cover essential computer and software concepts, as well as information related to how computers network and communi- cate. Nurses often use computers without know- ing the terminology and the possibilities and limitations of information technology. Chapter 4 (Social and Professional Networking) examines guidelines for use of social and professional net- working media. Ethical and legal implications for use of social networking sites are discussed.

Unit II, Computer Applications for Your Profes- sional Career, provides information on the recent versions of office software, including Google Drive, Apache OpenOffice.org, and Microsoft Office. The chapters include additional information to assist the growing number of Mac users. Chapter 5 (Authoring Scholarly Word Documents) demonstrates how to use word processing software to format papers using American Psychological Association writing style. It also addresses the differences between writing a paper for a class assignment and writing for publication. Chapter 6 (Authoring Scholarly Slide Presentations) emphasizes best practices for presentation design. Chapter 7 (Mastering Spreadsheet Software to Assess Quality Outcomes Using Numbers) addresses best practices for designing worksheets and charts. Chapter 8 (Databases: Creating Information from Data) provides an explanation of how databases work, including a short tutorial to assist students in designing a simple database that addresses a nurs- ing care issue. The database concepts discussed are relative to any database, such as the digital library or Internet search engines.

Unit III, Information Competency, includes updated information on this topic. Chapter 9 (Information Literacy: A Road to Evidence-Based Practice) includes information on use of the PICO (patient/problem—intervention—comparison— outcome) research approach, and it includes how to evaluate health information found on the Internet and how to analyze scholarly articles. Chapter 10 (Finding Knowledge in the Digital Library Haystack) reviews how to search digi- tal libraries and use filters from PubMed, the free National Library of Medicine digital library. Chapter 11 (Mobile Computing) covers the latest mobile computing devices and resources.

In Unit IV, The Evolving Healthcare Paradigm, Chapters 12 (Informatics Benefits for the

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xii    Preface

Consumer) and 13 (The Empowered Consumer) address information for empowering healthcare consumers, the importance of personal health records, and challenges consumers face access- ing and understanding health information. Chapters 14 (Interoperability at the National and the International Levels) and 15 (Nursing Documentation in the Age of the Electronic Health Record) discuss standards and terminology neces- sary for interoperability and data abstraction from electronic records using standardized terminology for documenting the electronic health record.

Unit V, Healthcare Informatics, focuses on use of informatics in the healthcare setting. Chapter 16 (Nursing Informatics: Theoretical Basis, Education Program, and Profession) explores informatics as a nursing specialty, including information on the theory base for nursing infor- matics, educational programs, and professional organizations. Chapter 17 (Electronic Healthcare Information Systems, Electronic Health Records, and Meaningful Use) reviews the progress toward implementation of the electronic health record (EHR), as well as “meaningful use” and the implications for improving healthcare delivery. Chapter 18 (Design Considerations for Healthcare Information Systems) provides an overview of healthcare information systems, systems selec- tion, and the systems life cycle, a process used to plan and implement a computer system. Chapter 19 (Quality Measures and Specialized Electronic Healthcare Information Systems) reviews infor- mation on specialized electronic healthcare infor- mation systems and quality measures to improve care outcomes. Chapter 20 (Electronic Healthcare System Issues) covers issues associated with the use of information systems. When documenta- tion moved from paper to electronic systems, new problems emerged that nurses need to understand in order to mitigate. Finally, Chapter 21 (Evolving Trends in Telehealth) addresses exciting new developments in telehealth, which allows supple- mentation of face-to-face care with technology that supports care delivery in the patient’s home, emergency departments, and intensive care units.

Unit VI, Computer Uses in Healthcare Beyond Clinical Informatics, includes the use of infor- matics in other nursing settings. Chapter 22

(Educational Informatics: e-Learning) describes the use of informatics in nursing education. Chapter 23 (Informatics in Management and Quality Improvement) covers management infor- mation technology tools. Chapter 24 (Informatics and Research) discusses the use of informatics for nursing research. Chapter 25 (Legal and Ethical Issues) addresses the legal and ethical challenges that informatics introduces, encompassing data breaches and copyright issues.

Information on the newest computer and soft- ware features is included in the textbook appen- dix. This overview may serve as a course lesson, depending on the computer knowledge of the stu- dents. Key terms in each of the book’s chapters are defined in the glossary. Because nursing students often identify information technology terminol- ogy as new and challenging, the glossary terms provide learning support.

In summary, the topics in this textbook address informatics competencies and applications needed by all nurses, now and in the near future. Nurses with communication skills enhanced with the use of technology, computer fluency, information lit- eracy skills, and knowledge of informatics termi- nology and clinical information systems can assist in shaping nursing practice to improve patient outcomes and to contribute to the scholarship of nursing.

ADDITIONAL RESOURCES Informatics and Nursing includes additional resources for both instructors and students that are available on the book’s companion website at http://thepoint.lww.com/sewell5e.

Instructors Approved adopting instructors will be given access to the following additional resources: JJ Ebook: Allows access to the book’s full text and

images online. JJ PowerPoint Slides: Provide an easy way for you

to integrate the textbook with your students’ classroom experience through either slide shows or handouts.

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Preface    xiii

JJ Case Studies: Bring the content to life through real-world situations with these scenarios, which can be used as class activities or group assignments.

JJ Test Generator: Lets you put together exclusive new tests from a bank to help you assess your students’ understanding of the material. These questions are formatted to match the NCLEX (National Council Licensure Examination), so that your students can have practice with the question types covered in this important examination.

JJ Suggested answers to the QSEN scenarios found in the book.

JJ QSEN Map: Shows how the book content inte- grates QSEN competencies.

JJ BSN Essentials Competencies Map: Shows how the book content integrates American Association of Colleges of Nursing (AACN) Essentials of Baccalaureate Education for Professional Nursing Practice competencies.

JJ TIGER Competencies Map: Shows how the book content integrates Technology Informatics Guiding Educational Reform (TIGER) competencies.

JJ Image Bank: Contains all the illustrations and tables from the book in formats suitable for printing and incorporating into PowerPoint presentations and Internet sites.

JJ Strategies for Effective Teaching: Offer cre- ative approaches for engaging students.

JJ Learning Management System Cartridges.

Students Students who have purchased Informatics and Nursing, fifth edition, have access to the following additional resources: JJ Journal Articles: One article per chapter offers

access to current research available in Wolters Kluwer journals.

JJ Weblinks: These URLs point readers to helpful online resources for each chapter.

JJ Acronyms: This list of abbreviations and their spell outs demystifies the alphabet soup of the informatics field.

JJ Additional Information and Examples: Users can download digital versions of examples used for the office software chapters, among others, from thePoint.

JJ Plus a Spanish-English Audio Glossary, Nursing Professional Roles and Responsibilities, and Learning Objectives. See the inside front cover of this text for more

details, including the passcode you will need to gain access to the website.

REFERENCES American Association of Colleges of Nursing. (1996). The

essentials of master’s education for advanced practice nurs- ing. Retrieved from http://www.aacn.nche.edu/education- resources/MasEssentials96.pdf

American Association of Colleges of Nursing. (2006). The essentials of doctoral education for advanced nursing practice. Retrieved from http://www.aacn.nche.edu/publications/position/DNP Essentials.pdf

American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Retrieved from http://www.aacn.nche. edu/education-resources/BaccEssentials08.pdf

American Association of Colleges of Nursing. (2010). The research-focused doctoral program in nursing: Pathways to excellence. Retrieved from http://www.aacn.nche.edu/ education-resources/PhDPosition.pdf

American Association of Colleges of Nursing. (2011). The essentials of master’s education in nursing. Retrieved from http://www.aacn.nche.edu/education-resources/Masters Essentials11.pdf

Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine, Robert Wood Johnson Foundation, & Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press.

National League for Nursing. (2008). Preparing the next genera- tion of nurses to practice in a technology-rich environment: An informatics agenda. New York: NLN Press.

National League for Nursing. (2015). A vision for the chang- ing faculty role: Preparing students for the technological world of health care. Retrieved from http://www.nln.org/ docs/default-source/about/nln-vision-series-%28position- statements%29/a-vision-for-the-changing-faculty-role- preparing-students-for-the-technological-world-of-health- care.pdf?sfvrsn=0

Technology Informatics Guiding Education Reform. (2014). The TIGER initiative. Retrieved from http://www.thetiger- initiative.org/

http://www.aacn.nche.edu/education-resources/MasEssentials96.pdf
http://www.aacn.nche.edu/education-resources/MasEssentials96.pdf
http://www.aacn.nche.edu/publications/position/DNPEssentials.pdf
http://www.aacn.nche.edu/publications/position/DNPEssentials.pdf
http://www.aacn.nche.edu/education-resources/BaccEssentials08.pdf
http://www.aacn.nche.edu/education-resources/BaccEssentials08.pdf
http://www.aacn.nche.edu/education-resources/PhDPosition.pdf
http://www.aacn.nche.edu/education-resources/PhDPosition.pdf
http://www.aacn.nche.edu/education-resources/MastersEssentials11.pdf
http://www.aacn.nche.edu/education-resources/MastersEssentials11.pdf
http://www.nln.org/docs/default-source/about/nln-vision-series-%28position-statements%29/a-vision-for-the-changing-faculty-role-preparing-students-for-the-technological-world-of-health-care.pdf?sfvrsn=0
http://www.nln.org/docs/default-source/about/nln-vision-series-%28position-statements%29/a-vision-for-the-changing-faculty-role-preparing-students-for-the-technological-world-of-health-care.pdf?sfvrsn=0
http://www.nln.org/docs/default-source/about/nln-vision-series-%28position-statements%29/a-vision-for-the-changing-faculty-role-preparing-students-for-the-technological-world-of-health-care.pdf?sfvrsn=0
http://www.nln.org/docs/default-source/about/nln-vision-series-%28position-statements%29/a-vision-for-the-changing-faculty-role-preparing-students-for-the-technological-world-of-health-care.pdf?sfvrsn=0
http://www.nln.org/docs/default-source/about/nln-vision-series-%28position-statements%29/a-vision-for-the-changing-faculty-role-preparing-students-for-the-technological-world-of-health-care.pdf?sfvrsn=0
http://www.thetigerinitiative.org/
http://www.thetigerinitiative.org/
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Several colleagues contributed to this fifth textbook edition. Jeff Dowdy shared his librarian expertise for Chapter 10 edits on digital librar- ies. Linda Thede, who has expertise with nursing taxonomy, wrote the revisions for Chapter 15 on nursing documentation. Barry Lung, a nursing informatics expert and a recently retired infor- matics consultant, provided his expertise for Chapters 18, 19, and 20 edits on clinical informa- tion systems. Omega Finney, who is certified as an informatics nurse specialist and works as an infor- matics nurse specialist at Piedmont Healthcare, provided the updates for Chapter 16 on nursing informatics. She also wrote the section in that chapter titled A Day in the Life of an Informatics Nurse Specialist. Omega is a recipient of an Informatics Nurse of the Year award at Piedmont Healthcare. Karen Frith, who is board certified as

an advanced nurse executive, wrote and updated Chapters 23 and 24 on research and administra- tive tools. Matthew Gaines, an information tech- nology specialist, provided his technical support expertise for the updated appendix on hardware and software. In addition, the feedback from peer reviewers, faculty, and students who have used the textbook helped to guide the changes and updates. Numerous others assisted in editing and rewrit- ing, including Meredith Brittain, a Supervisory Product Development Editor at Wolters Kluwer.

I appreciate the opportunity to have coauthored the third and fourth editions of the textbook with Linda Thede. Thanks also go to my husband, fac- ulty colleagues, and friends for their support while preparing this edition. Finally, I extend a special thanks to my mother, Daisy Penny, for fostering my love of nursing and nursing informatics.

Acknowledgments

xv

About the Author ............................................ v Contributors ...................................................... vi Reviewers ........................................................... vii Preface ................................................................ x Acknowledgments .........................................xiv

UNIT I: INFORMATICS BASICS ����������������������1 1� Introduction to Nursing Informatics:

Managing Healthcare Information ����������2 Informatics Introduction ������������������������� 3

Informatics Discipline ������������������������������ 5 Healthcare Informatics .......................... 5 Nursing Informatics ................................ 6

Forces Driving More Use of Informatics in Healthcare ��������������������8 National Forces ....................................... 8 Nursing Forces ......................................... 8 Costs ..........................................................10

The Information Management Tool: Computers ���������������������������������� 11

Computers and Healthcare ������������������� 11 Early Healthcare Informatics Systems ..................................................... 12 Progression of Information Systems ..................................................... 12

Benefits of Informatics ���������������������������13 Benefits for Healthcare in General ...................................................... 13 Benefits for the Nursing Profession .................................................14

Skills Needed by All Nurses ������������������15 Computer Fluency ................................. 15 Information Literacy ..............................16

Summary ��������������������������������������������������17 Applications and Competencies ��������18

2� Essential Computer and Software Concepts ���������������������������������������������21 Operating Systems ���������������������������������22

Cloud Computing �����������������������������������22 Cloud Office Apps ................................ 23 Sharing Files in the Cloud ..................24 Advantages and Limitations of Using the Cloud .....................................24

Software Program Copyright ��������������24 Open Source ...........................................24 Shareware ............................................... 25 Freeware .................................................. 25 Public-Domain Software ..................... 25 Commercial Software .......................... 25 Software Piracy ..................................... 25

Managing Digital Files ���������������������������26 Keyboard Shortcuts .............................26 Managing File Extensions ...................26 Saving a File as a Different Type ..........................................................26 The Clipboard .........................................28

Disk and Data Encryption ...................28

Other Computer Features ��������������������28 Speech Recognition .............................28

Contents

xvi    Contents

Sleep Mode .............................................29 Handling Minor Problems ...................29

Summary ������������������������������������������������ 30 Applications and Competencies��������������������������������������� 30

3� Basic Computer Networking Concepts �������������������������������������������� 32 A Historical Perspective of the

Internet ��������������������������������������������������33

Network Connections Essentials ��������34 Types of Networks ................................35 Network Connections ..........................35 Network Connection Speed ..............36 IP Addresses ........................................... 37 Domain Name System ......................... 37

The World Wide Web ����������������������������37 Web Browsers ........................................ 37 Troubleshooting an URL .....................38

Online Security ����������������������������������������39 Computer Malware .............................. 40 Protection Against Malware ..............43 Hoaxes ......................................................44 Security Pitfalls ......................................45

Summary �������������������������������������������������45 Applications and Competencies ������ 46

4� Social and Professional Networking ����������������������������������������48 E-mail �������������������������������������������������������� 49

E-mail Signature ....................................49 Out-of-Office Replies ..........................50 Managing E-mail ....................................50 Spam .........................................................50 E-mail Etiquette ......................................51

Web 2�0 ����������������������������������������������������52

Social and Professional Networking �������������������������������������������52 Networking Sites ...................................53

Blogs .........................................................54 Content Sharing ....................................56 Pros and Cons for Using Social Media for Professional Networking ............................................. 57 Safe Networking ....................................58

Collaborative Sharing and Collective Intelligence �����������������������58 Group Discussion Forums ..................59 Internet Telephone .............................. 60 Teleconferencing ...................................61 Cloud Office Suite Software ...............61 Podcasts ...................................................61 Social Bookmarking .............................62

Summary �������������������������������������������������62 Applications and Competencies �������63

UNIT II: COMPUTER APPLICATIONS FOR YOUR PROFESSIONAL CAREER ������������������ 65

5� Authoring Scholarly Word Documents ����������������������������������������� 67 Steps for Writing a Scholarly

Paper ������������������������������������������������������68 Step 1: Researching the Paper Topic .........................................................68 Step 2: Choosing the Word Processing Tool .....................................68 Step 3: Writing the Paper ...................69

The APA Paper Formatting Requirements ����������������������������������������71 Title Page .................................................. 71 Abstract and Keywords ....................... 71 Body of the Paper .................................. 71 References .............................................. 73 APA Template ........................................ 73

Special Considerations for Scholarly Papers ���������������������������������74 Special Considerations for Academic Papers ..................................74

Contents    xvii

Special Considerations for Journal Manuscripts ............................. 75

Other Word Processing Tools �������������76 Spelling and Grammar Check ...........76 Page Ruler ...............................................76 Format Painter .......................................76 Automatic Bullets and Numbers ..................................................76 Find and Replace .................................. 77 Table of Contents ................................. 77 Footnotes and Endnotes .................... 77 Track Changes Tool .............................. 77 Collaboration ..........................................78 Mail Merge ...............................................78 Language Translation ..........................78

Learning New Word Processing Skills �������������������������������������������������������78

Summary ������������������������������������������������ 80 Applications and Competencies��������������������������������������� 80

6� Authoring Scholarly Slide Presentations ������������������������������������� 82 Using Electronic Slideshows in

Nursing ��������������������������������������������������83 Principles for All Presentations .........83 Computer Slide Models .......................85 Presentation Styles ...............................85

Presentation Software ���������������������������86 Compatibility of Software ..................87 Collaborating on Slideshow Software Design ....................................87

Basics of Slide Creation ������������������������87 Views of the Slides ...............................87 Layers .......................................................88

Creating the Presentation ��������������������89 Storyboarding ........................................89 Content ....................................................89 Special Effects ........................................91 Speaker Notes ........................................93

Creating a Show that Allows for Nonlinear Presentations ...............94

The Presentation ������������������������������������ 94 Handouts .................................................94 Transferring to the Web .....................94 The Oral Presentation ..........................94

Learning New Presentation Skills �������95 Summary �������������������������������������������������95 Applications and Competencies �������97

7� Mastering Spreadsheet Software to Assess Quality Outcomes Using Numbers ��������������������������������������������99 Uses of Spreadsheets in Nursing ������100

Tips for Better Spreadsheets ��������������101

Spreadsheets ����������������������������������������� 102 The Spreadsheet Window ................ 102 Spreadsheet Basics ............................ 102 Spreadsheet Power ............................ 104 Formulas ................................................ 104 Formatting Cells .................................. 105 Text to Columns .................................. 106 Freezing Rows and Columns ........... 106 Using Automatic Data Entry ............ 107 Data Validation .................................... 107 Forms ...................................................... 107 Formatting a Spreadsheet for Use in a Database ............................... 107 Linking Cells and Worksheets from Other Sources ............................ 108 Data Protection and Security .......... 108

Charts ������������������������������������������������������108 Chart Basics .......................................... 108 Creating the Chart ................................113 Dashboards ............................................ 114 Pivot Tables and Pivot Charts .......... 114

Printing �����������������������������������������������������114

Learning New Spreadsheet Skills ������114 Summary ������������������������������������������������ 116 Applications and Competencies ������ 116

xviii    Contents

8� Databases: Creating Information From Data ����������������������������������������� 118 Uses of Databases in Nursing ������������� 119

Anatomy of Databases ������������������������ 120 Tables ..................................................... 120 Queries ................................................... 120 Forms ........................................................121 Reports ....................................................122

Database Concepts and Terminology ��������������������������������������� 122

Database Models ���������������������������������� 123 Flat Database ........................................123 Hierarchical Database .........................123 Network Model .....................................123 Relational Database Model .............. 124 Object-Oriented Model ..................... 126

Database Software Solutions ������������ 126

Creating a Simple Database �������������� 126

Saving Data in a Database ����������������� 129

Manipulating Data ��������������������������������130 Sorting .................................................... 130 Querying .................................................132

Secondary Data Use����������������������������� 132

Discovering Knowledge in Large Databases ������������������������������� 133 Data Mining ............................................133 Online Analytical Processing ........... 134

Structured Query Language ............ 134 Summary ����������������������������������������������� 134 Applications and Competencies ����� 135

UNIT III: INFORMATION COMPETENCY ��������137 9� Information Literacy: A Road to

Evidence-Based Practice ��������������������138 Information Literacy Competencies

for Nurses ������������������������������������������� 139 Impact of the Healthcare Professional’s Information Literacy .................................................. 140

Teaching Information Literacy Skills ........................................................ 140 Critical Thinking and Clinical Reasoning ............................................... 141 Knowledge Generation ..................... 142 Knowledge Dissemination Activities ................................................ 142

Information Technology Skills ����������� 142

Discovering and Evaluating Health Information on the Internet ������������ 143 Website Source ................................... 143 Website Authority .............................. 143 Website Funding ................................. 143 Website Validity and Quality ........... 143

Website Privacy and Disclosure ..... 144

Nursing Information on the Internet ������������������������������������������������ 145 Clinical Practice and Informatics .... 145 Scholarly Journal Articles ................. 148 Government and Not-for-Profit Health and Disease Specialty Organizations .........................................151 Professional Nursing Organizations .........................................151 Laws, Rules, and Regulations ............151 Online Evidence-Based Resources ................................................151

Summary ������������������������������������������������ 151 Applications and Competencies ����� 153

10� Finding Knowledge in the Digital Library Haystack �������������������������������� 155 Digital Library Basics ��������������������������� 156

Reference Management Software ���� 156

Library Guides and Tutorials ������������� 157 Subject Headings .................................157 Searching Using MeSH Terms ..........157 Using a Search Interface ................... 158

Bibliographic Databases Pertinent to Nursing ������������������������������������������� 159 CINAHL .................................................. 159

Contents    xix

MEDLINE/PubMed .............................. 159 Cochrane Library .................................. 161 PsycINFO and PsycARTICLES.......... 161

Embarking on the Quest for Knowledge ����������������������������������������� 162 Step 1: Questioning Practice: Recognizing an Information Need ........................................................ 162 Step 2: Searching for Appropriate Evidence ................................................ 163 Step 3: Critically Analyzing the Literature Findings ............................. 165 Step 4: Applying/Implementing the Search Findings ........................... 166 Step 5: Evaluating the Result and Effectiveness of Practice Changes ..................................................167

Challenges to the Adoption of Evidence-Based Nursing ����������������� 167

Summary ����������������������������������������������� 167 Applications and Competencies ����� 168

11� Mobile Computing������������������������������170 Mobile-Computing Basics �������������������� 171

History of Mobile Computing ������������� 171

Understanding Mobile Computer Concepts ��������������������������������������������� 172 Smartphones and Tablet Devices Defined ....................................................172 Wi-Fi Mobile Computer Operating Systems ..............................172 Display .....................................................173 Battery .....................................................173 Memory ...................................................173 Data Entry ............................................. 174 Synchronization (Sync) ..................... 174 Connectivity.......................................... 174

Advantages and Disadvantages of Using Mobile Devices in Nursing and Nursing Education �������������������� 175 Use in Nursing Education ..................177

Use of Mobile Devices in Clinical Practice ....................................177 Use of Mobile Devices in Nursing Research .................................179 Use of Mobile Devices to Read eBooks .................................................... 180 Use of Mobile Devices for Library Searches ................................................ 180

Data Security Issues ������������������������������ 181

Future Trends ����������������������������������������� 181 Summary ����������������������������������������������� 182 Applications and Competencies ����� 182

UNIT IV: THE EVOLVING HEALTHCARE PARADIGM ������������������������������������������� 185 12� Informatics Benefits for the

Consumer ������������������������������������������187 Implementing the Promise of the

Internet in Healthcare ���������������������� 188 Electronic Medical Record ............... 189 Electronic Health Record .................. 190 Personal Health Record .................... 190

Summary ����������������������������������������������� 196 Applications and Competencies�������������������������������������� 196

13� The Empowered Consumer �����������������198 Consumer Informatics ������������������������� 199

Health/Numeracy Literacy Competencies for Consumers ������� 199

Assessing Health/Numeracy Literacy �����������������������������������������������201

Addressing Health Literacy Issues ���������������������������������������������������201 Oral Communication .......................... 201 Written Communication .................. 202 Empowering the Healthcare Consumer for Self-Management ... 203 Providing Supportive Systems ...... 208

xx    Contents

Providing Web-Based Patient Information ����������������������������������������209 Creating a Web Page ......................... 210

Summary ������������������������������������������������ 211 Applications and Competencies��������������������������������������� 211

14� Interoperability at the National and the International Levels ���������������214 Interoperability Defined���������������������� 215

Types of Interoperability �������������������� 215

Standards ����������������������������������������������� 215

U�S� Efforts for Promoting Interoperable Electronic Health Records ����������������������������������������������� 217 Office of the National Coordinator for Health Information Technology ............................................217 Health IT Adoption Surveys ............. 219 U.S. Public Health Information Network ................................................ 220 Unified Medical Language System ................................................... 220 Effect of U.S. Efforts on Nursing and Patient Care...................................221

International Standards Organizations ������������������������������������ 221 International Organization for Standardization ....................................221 International Electrical Commission ..........................................222 ASTM International .............................222 Health Level Seven .............................222 International Classification of Disease ...................................................223 International Classification of Functioning, Disability, and Health .............................................224 Digital Imaging and Communications in Medicine ..........224 Comité Européen de Normalisation .......................................224

International Health Terminology Standards Development Organisation .........................................225 Development of International Standards ..............................................225

Billing Terminology Standardization �������������������������������� 225 International Classification of Disease—Clinical Modification ........225 Medicare Severity Diagnosis- Related Groups ....................................226 The Healthcare Common Procedure Coding System ...............226 Outcome and Assessment Information Set ....................................226

Summary ���������������������������������������������� 226 Applications and Competencies �����227

15� Nursing Documentation in the Age of the Electronic Health Record ���������� 229 Nursing and Documentation ������������� 230

Types of Standardized Terminologies ������������������������������������ 231 Natural Language ................................231 Linear Lists or Vocabularies .............232 Taxonomic Vocabularies ...................232 Combinational Vocabularies ............233 Ontologies .............................................234

Overview of Standardized Healthcare Terminologies �������������� 234

Nursing-Related Standardized Terminologies ����������������������������������� 235 Minimum Data Sets ............................235 Nursing-Focused Standardized Terminologies .......................................236 Interdisciplinary Standardized Terminologies .......................................237

Attempts to Make Terminologies Interoperable ������������������������������������� 241 Mapping ................................................. 241 Harmonization...................................... 241

Contents    xxi

Linking .................................................... 241 Integration ............................................. 241

Benefits of Using Standardized Terminologies ����������������������������������� 242 Increasing Quality of Care ................242 Decreasing Costs of Care .................242 Contributing to Evidence-Based Practice and Clinical Decision Systems ..................................................242 Communication in Healthcare .........243

Standardized Terminologies Issues �������������������������������������������������� 243

Interdisciplinary Healthcare �������������� 243 Summary ����������������������������������������������244 Applications and Competencies ���� 245

UNIT V: HEALTHCARE INFORMATICS ���������247 16� Nursing Informatics: Theoretical

Basis, Education Program, and Profession ���������������������������������������� 249 Theories That Lend Support to

Informatics����������������������������������������� 250 Nursing Informatics Theory ............ 250 Sociotechnical Theory and Social Informatics ............................................252 Change Theories .................................252 General Systems Theory ...................254 Chaos Theory .......................................255 Cognitive Science ...............................256 Usability Theory ...................................256 Learning Theories ...............................257 Summary of Theories .........................257

Informatics in Educational Preparation �����������������������������������������257 Informatics for All Nurses .................258

Nursing Informatics as a Specialty �������������������������������������������� 259 Florence Nightingale’s Role in Nursing Informatics ........................... 260

Informatics Nurse Specialist Certification ......................................... 260

Roles for Nurses in the Informatics Specialty ��������������������������������������������260 Informatics Nurse ................................ 261 Informatics Nurse Specialist ............262

Informatics Organizations ����������������� 264 Multidisciplinary Groups .................. 264 Nursing Informatics Profession Associations ..........................................265

Summary ���������������������������������������������� 266 Applications and Competencies ���� 266

17� Electronic Healthcare Information Systems, Electronic Health Records, and Meaningful Use �������������������������� 268 EMR, EHR, ePHR, and Their

Relationships to Emerging Clinical Information Systems �������� 269 Data Standards ................................... 269

The Need for EHRs ������������������������������� 271 Paper Records ......................................271 Weaknesses of Paper Records ........271 Electronic Records .............................272

The Electronic Record and Meaningful Use ����������������������������������273

The Electronic Records Privacy and Security: HIPAA Revisited ����� 276

Summary �����������������������������������������������277 Applications and Competencies �����277

18� Design Considerations for Healthcare Information Systems ������������������������� 279 Workflow Redesign ���������������������������� 280

Technology Competencies ���������������� 281

Need for Interoperability ������������������� 282

Health IT System Cost–Benefits ������� 282

Project Management and the Systems Life Cycle �������������������������� 283

xxii    Contents

Project Management ..........................283 Systems Life Cycle .............................283

Business Continuity Plan �������������������290 Summary ����������������������������������������������� 291 Applications and Competencies�������������������������������������� 291

19� Quality Measures and Specialized Electronic Healthcare Information Systems ������������������������������������������� 293 Quality Measures for Health

Information Technology ����������������� 294 Physician Quality Reporting System ................................................... 294 EHR Certification .................................295 HIT Research and Analysis Reports ...................................................295 Specialty Healthcare Information Systems ����������������������� 295 Admission, Discharge, and Transfer ..................................................295 Financial Systems .............................. 296

Clinical Information Systems ������������ 296 Ancillary Systems ................................297 Clinical Documentation .....................297 Computerized Provider Order Entry ....................................................... 298 Medication Administration .............. 299

Managing Patient Flow ����������������������300 Tracking Systems Solutions ............. 301 Voice Communication Systems ..... 302

Point-of-Care Systems ����������������������� 302 Summary ���������������������������������������������� 303 Applications and Competencies ���� 303

20� Quality Measures and Electronic Healthcare System Issues ������������������ 305 The Adoption Model for the

Electronic Medical Record �������������306

Strategic Planning ������������������������������� 307

Return on Investment ������������������������� 307

Reimbursement ������������������������������������ 308

Issues Related to Electronic Health Information���������������������������309 Interoperability Standards .............. 309 User Design .......................................... 309 Workflow Redesign ........................... 309 Quality Measurement ......................... 310 Data Security ........................................ 310

Unintended Consequences of Introduction of Electronic System ������������������������������������������������� 312 CPOE ........................................................312 Decision Support Systems ................312

Rules and Regulations: The Joint Commission ���������������������������������������� 313

Disease Surveillance Systems and Disaster Planning ������������������������������ 313 Syndromic Surveillance ......................313 Disaster Response and Planning .... 314

Protection of Healthcare Data ���������� 314 Health Insurance Portability and Accountability Act .............................. 314 Privacy .....................................................315 Confidentiality .......................................315

Radiofrequency Identification ����������� 317 Summary ����������������������������������������������� 318 Applications and Competencies ����� 319

21� Evolving Trends in Telehealth ������������� 321 Telehealth Basics ����������������������������������322

Store and Forward Technology ......322 Real-Time Telehealth .........................322

Telenursing ���������������������������������������������322

Other Telehealth Examples ��������������� 323 Telehomecare .......................................323 Telemental Health ...............................326 Clinic Visits ............................................327 E-Intensive Care Units .......................327 Teletrauma Care ..................................329 Disaster Healthcare ............................329

Contents    xxiii

Education Component of Telehealth Projects �������������������������� 330

Issues with Telehealth ������������������������ 330 Reimbursement Issues ..................... 330 Medicolegal Issues ...............................331 Technical Issues ....................................331

Summary ����������������������������������������������� 331 Applications and Competencies ���� 332

UNIT VI: COMPUTER USES IN HEALTHCARE BEYOND CLINICAL INFORMATICS ������������� 335 22� Educational Informatics: e-Learning ���337

E-Learning Defined ����������������������������� 338

Benefits for the Learner ��������������������� 338

How We Learn �������������������������������������� 338 Dale’s Cone of Experience .............. 339 Learning Styles ................................... 339 Bloom’s Taxonomy and Learning Methods ................................................340

E-Learning Basics ��������������������������������340 Examples of E-Learning Purposes ...............................................340 Types and Methods of Instruction ............................................. 341 Quality of Instruction in E-Learning .............................................342 Role of Instructor in E-Learning .... 343 Accessibility of E-Learning ............. 343 Pros and Cons of E-Learning.......... 344

Types of E-Learning ���������������������������� 345 Drill and Practice ................................ 345 Tutorials ................................................ 345 Simulations........................................... 346 Virtual Reality (VR) ............................ 348 Resources Supporting Affective Component of Learning ................... 350 Instructional Games .......................... 350 Online Assessments and Surveys ....................................................351

MERLOT: Web-Based Learning Resources ������������������������������������������ 353

Future Trends ��������������������������������������� 354 Summary ���������������������������������������������� 355 Applications and Competencies ���� 355

23� Informatics in Management and Quality Improvement ������������������������ 358 Tools ������������������������������������������������������� 359

Financial Management: Spreadsheets ........................................359 Process Improvement ....................... 360 Human Resource Management...... 363

Using Data to Improve Outcomes: Quality Improvement and Benchmarking ����������������������������������� 364 Quality Safety Education for Nurses (QSEN) .................................... 364 Core Measures .....................................365 Consumer Assessment of Health Providers and Systems: Hospital Survey .....................................................365 National Database of Nursing Quality Indicators ................................365

Big Data ������������������������������������������������� 366 Business Intelligence in Healthcare Systems ......................... 366 Patient Care Management ................367

Workflow ����������������������������������������������� 368

Employee Scheduling ������������������������� 368

Patient Classification Systems (Acuity Applications) ���������������������� 369

Clinical Information Systems ������������ 369 Summary ���������������������������������������������� 370 Applications and Competencies ����� 371

24� Informatics and Research �������������������373 Data Analysis and Research in

Medicine and Nursing ����������������������373 History ....................................................373 Use of Technology Today .................374

Statistics Basics ����������������������������������� 374 Online Resources for Statistics Basics ......................................................375

xxiv    Contents

Software for Statistical Analysis ....375 BrightStat Software ...........................375

Obtaining Data Sets from the Internet ������������������������������������������������377

Research Evidence in Nursing ���������� 379

Research Findings in Informatics ����380 Internet Access and Health Information–Seeking Behaviors .....380 Use of Electronic Health Record Systems .................................................380 Use of Clinical Decision Support Systems .................................................. 381

Summary ���������������������������������������������� 383 Applications and Competencies ���� 383

25� Legal and Ethical Issues ��������������������� 387 Ethics ������������������������������������������������������ 388

Code of Ethics for Nurses ............... 388 Code of Ethics for Informatics Professional Organization Members ............................................... 389

Laws, Rules, and Regulations ����������� 389 Data Security Breaches .................... 389

The Limitations of HIPAA Protection ..............................................392

Legal and Ethical Issues Associated with Telehealth ����������� 392

Implications of Implantable Microchip Devices���������������������������� 393

Legal and Ethical Issues for the Use of Interactive Web Applications �������������������������������������� 393

Legal and Ethical Issues for the Use of Nanotechnology ������������������ 394

Legal and Ethical Issues for the Use of Wearable Computing ��������� 394

Copyright Law �������������������������������������� 394 Fair Use ..................................................395 Not Protected by Copyright ............395 History of Copyright ..........................395

Summary ���������������������������������������������� 397 Applications and Competencies ���� 398

Appendix A .....................................................400 Glossary ............................................................ 417 Index ..................................................................437

1

Informatics Basics Chapter 1 Introduction to Nursing Informatics: Managing Healthcare Information

Chapter 2 Essential Computer and Software Concepts

Chapter 3 Basic Computer Networking Concepts

Chapter 4 Social and Professional Networking

Informatics is too often viewed solely as one of its components instead of as a whole. Its primary goal is information management, but knowledge of each of these divisions is a necessary part of informatics. This opening unit introduces these components and then focuses on the tool of informatics: the computer.

Chapter 1 presents a brief overview of informatics (what it is, the factors that are making it increasingly important in healthcare) and takes a look at its components (information management, computer competency, and information literacy). Chapter 2 addresses essential computer and software concepts, including technical terminology that you may not be aware of even if you grew up using computers. Basic computer networking concepts are the focus of Chapter 3, whereas the last chapter in this unit, Chapter 4, addresses social and professional networking.

UNIT I

2

KEY TERMS Aggregated data

Computer fluency

Computer literacy

Data

Deidentified data

Electronic health record (EHR)

Electronic Numerical Integrator and Computer (ENIAC)

Evidence-based care

Genomics

Healthcare informatics

Health information technology (HIT)

Informatics

Information literacy

Information technology

Interoperable

Listserv

Nursing informatics

Office of the National Coordinator for Health Information Technology (ONC)

Protocols

Quality and Safety Education for Nurses (QSEN)

Secondary data

Technology Informatics Guiding Educational Reform (TIGER)

CHAPTER 1 Introduction to Nursing Informatics: Managing Healthcare Information OBJECTIVES After studying this chapter, you will be able to:

1. Distinguish between the computer and informatics.

2. Define nursing informatics.

3. Describe some of the forces inside and outside healthcare that are driving a move toward a greater use of informatics.

4. Explain the need for all nurses to have basic skills in informatics.

5. Interpret the need for nurses to be computer fluent and information literate in today’s healthcare environment.

Chapter 1 Introduction to Nursing Informatics: Managing Healthcare Information 3

In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purposes of compari- son. If they could be obtained, they would enable us to decide many other questions besides the ones alluded to. They would show subscribers how their money was being spent, what amount of good was really being done with it, or whether the money was not doing mischief rather than good … (Nightingale, 1863, p. 176).

INFORMATICS INTRODUCTION What is informatics? Isn’t it just about comput- ers? Taking care of patients is nursing’s primary concern, not thinking about computers! It is com- mon for some nurses to have these thoughts. Transitions are always difficult, and a transition to using more technology in managing information is no exception. The use of information tech- nology (IT) in healthcare is informatics, and its focus is information management, not comput- ers. The quality of future patient care and nurs- ing practice is dependent upon nurses effectively using informatics.

Information management is an integral part of nursing. Think about your practice for a minute. What besides your nursing education and expe- rience do you depend upon when providing care for patients? You need to know the patient’s his- tory, medical conditions, medications, laboratory results, and more. Could you care for a patient without this information? How this information is organized and presented affects the care that you can provide, as well as the time you spend finding it.

The old way is to record and keep the information for a patient’s current admission in a paper chart. Today, with several specialties, consults, medi- cations, laboratory reports, and procedures, the paper chart is inadequate. A well-designed informa- tion system, developed with you and for you, can facilitate finding and using information that you need for patient care. Informatics skills enable you to participate in and benefit from this process. Informatics does not perform miracles; it requires an investment by you, the clinician, to assist those who design information systems so the systems are helpful and do not impede your workflow.

If healthcare is to improve, it is imperative that there be a workforce that can innovate and imple- ment health information technology (HIT) (American Health Information Management Association & American Medical Informatics Association, 2006, p. 3). There are two roles in infor- matics: the informatics nurse specialist and the cli- nician who must use HIT. This means that in essence every nurse has a role in informatics. Information, the subject of informatics, is the structure on which healthcare is built. Except for purely technical pro- cedures (of which there are few, if any), a healthcare professional’s work revolves around information. Is the laboratory report available? When is Mrs. X for surgery scheduled? What are the contraindications for the prescribed drug? What is Mr. Y’s history? What orders did the physician leave for Ms. Z? Where is the latest x-ray report?

An important part of healthcare information is nursing documentation. When information sys- tems designed for nursing exist, the documenta- tion can expand our knowledge of what constitutes quality healthcare. Have you ever wondered if the patient for whom you provided care had an out- come similar to others with the same condition? From nursing documentation, are you easily able to see the relationship between nursing diagnoses, interventions, and outcomes for your patients? Without knowledge of these chain events, you have only your intuition and old knowledge to use when making decisions about the best interven- tions in patient care. Observations tend to be self- selective; however, there is better information on which to base patient care. Informatics can furnish the information needed to see these relationships and to provide care based on actual patient data, which are facts stored in the computer.

If Florence Nightingale were with us today, she would be a champion of the push toward more use of healthcare IT. Information in a paper chart essentially disappears into a black hole after dis- charging a patient. Because we cannot easily access it, we cannot learn from it and use it in future patient care. This realization is international. Many countries, especially those with a national health service, have long realized the need to be able to use information buried in charts. Tommy Thompson, the former United States Secretary of Health and Human Services, is quoted as saying “the most

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remarkable feature of this 21st century medicine is that we hold it together with 19th century paper- work” (Committee on Government Reform, 2004).

The introduction of bills in the U.S. Congress backed up Thompson’s statement. The President’s Information Technology Advisory Committee (PITAC) created support for greater use of infor- matics. PITAC responsibilities transferred to the President’s Council of Advisors on Science and Technology in the Office of Science and Technology Policy in 2005 (Office of Science and Technology Policy, 2013).

In 2004, President Bush called for adoption of interoperable electronic health records (EHRs) for most Americans by 2014. He also

established the position of National Coordinator for Health Information Technology. The Office of the National Coordinator for Health Information Technology (ONC) released the first Federal Health HIT strategic plan for 2008– 2012, which focused on two goals—patient- focused healthcare and population health. The common themes for the goals included privacy and security, interoperability, adoption, and col- laborative governance. The 2011–2015 strategic plan was released with a mission to improve health and healthcare for all Americans through informa- tion and technology. The strategic plan expanded on the initial plan with five goals that affect nurses and healthcare (Box 1-1).

BOX 1-1 2011–2015 Strategic Plan Goals

1. Achieve adoption and information exchange through meaningful use of health IT.

a. Accelerate adoption of electronic medical records.

b. Facilitate information exchange to support meaningful use of electronic health records.

c. Support health IT adoption and information exchange for public health and populations with unique needs.

2. Improve care, improve population health, and reduce healthcare costs through the use of health IT.

a. Support more sophisticated uses of EHRs and other health IT to improve health system performance.

b. Better manage care, efficiency, and population health through EHR- generated reporting measures.

c. Demonstrate health IT–enabled reform of payment structures, clinical practices, and population health management.

d. Support new approaches to the use of health IT in research, public and population health, and national health security.

3. Inspire confidence and trust in health IT.

a. Protect confidentiality, integrity, and availability of health information.

b. Inform individuals of their rights and increase the transparency regarding the uses of protected health information.

c. Improve safety and effectiveness of health IT.

4. Empower individuals with health IT to improve their health and the healthcare system.

a. Engage individuals with health IT.

b. Accelerate individual and caregiver access to their electronic health information in a format they can use and reuse.

c. Integrate patient-generated health information and consumer health IT with clinical applications to support patient-centered care.

5. Achieve rapid learning technological advancement.

a. Lead the creation of a learning health system to support quality, research, and public and population health.

b. Broaden the capacity of health IT through innovation and research.

Adapted from HealthIT.gov (2011).

Chapter 1 Introduction to Nursing Informatics: Managing Healthcare Information 5

To fulfill these goals, information, which is the structure on which healthcare is built, can no lon- ger be managed with paper. If we are to provide evidence-based care, we must make the moun- tains of data hidden in medical records reveal their secrets. Bakken (2001) proposed the need for five components to provide evidence-based care: 1. Standardization of terminologies and struc-

tures used in documentation. 2. The use of digital information. 3. Standards to permit healthcare data exchange

between heterogeneous entities. 4. The ability to capture data relevant to the actual

care provided. 5. Competency among practitioners to use these

data. All of these components are parts of informatics.

The Affordable Care Act (ACA), signed into law in 2010, made improvements in healthcare cover- age, lowered costs, and increased access to care (HHS.gov/HealthCare, 2014). To be able to assess ACA compliance and care outcomes, all nurses must have data analysis skills, and there is an increased need for informatics nurse specialists.

The complexity of today’s healthcare milieu, added to the explosion of knowledge, makes it impossible for any clinician to remember every- thing needed to provide high-quality patient care. Additionally, healthcare consumers today want their healthcare providers to integrate all known relevant scientific knowledge when providing care. We have passed the time when the unaided human mind can perform this feat. The changes in prac- tice that are needed as new knowledge becomes available require modern information manage- ment tools as well as a commitment by healthcare professionals to evidence-based practice.

INFORMATICS DISCIPLINE Informatics is about managing information. The tendency to relate it to computers comes from the fact that the ability to manage large amounts of information was born with the computer and progressed as computers became more powerful and commonplace. However, human ingenuity is the crux of informatics. The term “informatics” originated from the Russian term “informatika”

(Sackett & Erdley, 2002). A Russian publication, Oznovy Informatiki (Foundations of Informatics), published in 1968, is credited with the origins of the general discipline of informatics (Bansal, 2002, p. 10). At that time, the term related to the context of computers. The term “medical informatics” was the first term to identify informatics in healthcare. It meant information technologies concerned with patient care and the medical decision-making process. Another definition stated that medi- cal informatics is complex data processing by the computer to create new information.

As with many healthcare enterprises, there was debate about whether “medical” referred only to informatics focusing on physician concerns or whether it refers to all healthcare disciplines. We now recognize that other disciplines, such as nurs- ing, are a part of healthcare and have a body of knowledge separate from medicine. For this rea- son, we more commonly use the term healthcare informatics. In essence, informatics is the man- agement of information, by using cognitive skills and the computer.

Healthcare Informatics Healthcare informatics focuses on managing information in all healthcare disciplines. It is an umbrella term that describes the capture, retrieval, storage, presenting, sharing, and use of biomedical information, data, and knowledge for providing care, problem solving, and decision making (Shortliffe & Blois, 2001). The purpose is to improve the use of healthcare data, informa- tion, and knowledge in supporting patient care, research, and education (Delaney, 2001). The focus is on the subject, information, rather than the tool, the computer. This is analogous to using another data acquisition tool, the stethoscope, to gather information about heart and lung sounds (Figure 1-1). This distinction is not always obvious because mastery of computer skills is necessary to manage the information. We use the computer to acquire, organize, manipulate, and present the information. The computer will not produce anything of value without human direction. That includes human input for how, when, and where the data are acquired, treated, interpreted, manip- ulated, and presented. Informatics provides that human direction.

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Nursing Informatics Healthcare has many disciplines; thus, it is not surprising that healthcare informatics has many specialties, of which nursing is one. The American Nurses Association (ANA) recognized nursing informatics as a subspecialty of nurs- ing in 1992. The first administration of the informatics certification examination was fall of 1995 (Newbold, 1996). Managing informa- tion pertaining to nursing is the focus of nurs- ing informatics. Specialists in this area study how we acquire, manipulate, store, present, and use nursing information. Informatics nurse special- ists work with clinical nurses to identify nursing needs for information and support. These spe- cialists work with system developers to design systems that work to complement the practice needs of nurses.

Informatics nurse specialists bring to system development and implementation a viewpoint that supports the needs of the clinical end user. The objective is an information system that is not

only user friendly for data input but also presents the clinical nurse with needed information in a manner that is timely and useful. This is not to say that nursing informatics stands alone; it is an inte- gral part of the interdisciplinary field of healthcare informatics, hence related to and responsible to all the healthcare disciplines. (The nursing informat- ics subspecialty will be explored in more detail in Chapter 16.)

Definitions of Nursing Informatics The term nursing informatics was probably first used and defined by Scholes and Barber in 1980 in their address that year to the MEDINFO confer- ence in Tokyo. There is still no definitive agreement on exactly what this term means. As Simpson (1998) once said, defining nursing informatics is difficult because it is a moving target. The original definition said that nursing informatics was the use of computer technology in all nursing endeav- ors: nursing services, education, and research (Scholes & Barber, 1980). Hannah et al. (1994) wrote another early definition that followed the broad definition by Scholes and Barber. Hannah et al. (1994) defined nursing informatics as any use of information technologies in carrying out nursing functions. Like the definition by Scholes and Barber, the one by Hannah et al. focused on the technology. The interpretations of those defi- nitions meant any use of the computer, from word processing to the creation of artificial intelligence for nurses, as long as the computer use involved the practice of professional nursing.

The shift from a technology orientation in defi- nitions to one that is more information oriented started in the mid-1980s with Schwirian (Staggers & Thompson, 2002). Schwirian (1986) created a model for use as a framework for nursing infor- matics investigators. The model consisted of four elements arranged in a pyramid with a triangular base. The top of the pyramid was the desired goal of nursing informatics activity and the base was composed of three elements: (1) users (nurses and students), (2) raw material or nursing infor- mation, and (3) the technology, which is com- puter hardware and software. They all interact in nursing informatics activity to achieve a goal. The intention of the model was as a stimulus for research.

Figure 1-1. The computer as a data acquisition tool. (shutterstock.com/JIL Photo.)

Chapter 1 Introduction to Nursing Informatics: Managing Healthcare Information 7

The first widely circulated definition that moved from technology to concepts was from Graves and Corcoran (Staggers & Thompson, 2002). They defined nursing informatics as “a combination of computer science, information science and nurs- ing science designed to assist in the management and processing of nursing data, information and knowledge to support the practice of nursing and the delivery of nursing care” (Graves & Cocoran, 1989, p. 227). This definition secured the position of nursing informatics within the practice of nurs- ing and placed the emphasis on data, information, and knowledge (Staggers & Thompson, 2002). Many consider it the seminal definition of nursing informatics.

Turley (1996), after analyzing previous defini- tions, added another discipline, cognitive science, to the base for nursing informatics. Cognitive science emphasizes the human factor in informatics. Its focus is the nature of knowledge, its components, development, and use. Goossen (1996), thinking along the same lines, used the definition by Graves and Corcoran as a basis and expanded the mean- ing of nursing informatics to include the thinking that is done by nurses to make knowledge-based decisions and inferences for patient care. By using this interpretation, he felt that nursing informat- ics should focus on analyzing and modeling the cognitive processing for all areas of nursing prac- tice. Goossen also stated that nursing informatics should look at the effects of computerized systems on nursing care delivery.

In 1992, the first ANA definition added the role of the informatics nurse specialist to the defini- tion by Graves and Corcoran. The 2014 ANA defi- nition of the specialty of nursing informatics (NI) has expanded from the original 2001 definition. Originally, it stated that this specialty combines nursing, information, and computer sciences for the purpose of managing and communicating data, information, and knowledge to support nurses and healthcare providers in decision mak- ing (American Nurses Association, 2001). An update in 2008 included the term wisdom to the data, information, and knowledge continuum (American Nurses Association, 2008). The 2015 definition states that “NI supports consumers, patients, the interprofessional healthcare team, and other stakeholders in their decision making in

all roles and settings to achieve desired outcomes. This support is accomplished through the use of information structures, information processes, and information technology” (American Nurses Association, 2015, p. 12). ANA states that the goal of NI is to optimize information management and communication to improve the health of individu- als, families, populations, and communities.

Staggers and Thompson (2002), who believe that the evolution of definitions will continue, pointed out that in all of the current definitions, the role of the patient is underemphasized. Some early definitions included the patient, but as a passive recipient of care. With the advent of the Internet, more and more patients are taking an active role in their healthcare. This factor not only changes the dynamics of healthcare but also permits a defini- tion of nursing informatics that recognizes that patients as well as healthcare professionals are consumers of healthcare information. For exam- ple, patients may participate in keeping their medi- cal records current. Staggers and Thompson (2002) also pointed out that we overlooked the role of the nurse as an integrator of information. They recom- mended including it in future definitions.

Despite these definitions, the focus of much of today’s practice informatics is still on capturing data at the point of care and presenting it in a manner that facilitates the care of an individual patient. Although this is a vital first step, we must give thought to secondary data analysis, or analysis of data for purposes other than the purpose of the original collection. You can make decisions based on actual patient care data by using aggregated data, or the same piece(s) of data. For example, you can analyze outcomes of a given intervention for many patients. Understanding how informatics can serve you as an individual nurse, as well as the profession, puts you in a position to work with informatics nurse special- ists to retrieve data needed to improve patient care.

QSEN Scenario After sharing that you are learning about informatics with a nursing colleague, the colleague asks you what informatics has to do with the quality and safety of nursing practice. How would you respond?

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FORCES DRIVING MORE USE OF INFORMATICS IN HEALTHCARE

The ultimate goal of healthcare informatics is a lifetime EHR with decision support systems. These records will include standardized data, per- mit consumers to access their records, and provide for secondary use of healthcare data. Ultimately, when emergency medical services and primary care facilities have access to and can contribute to the EHR, there are immense possibilities to provide seamless care and communication with patients. Forces driving more use of informatics in healthcare include national initiatives, nurs- ing, healthcare consumer empowerment, patient safety, and costs.

National Forces Federal efforts behind a move to EHRs include the creation of the Office of the National Coordinator for Health Information Technology (ONC). Several seminal reports aimed at improv- ing healthcare, all of which foresee a large role for IT, were published by the Institute of Medicine (IOM), which is an independent body that acts as an adviser to the U.S. government to improve healthcare. Their report Health Professions Education: A Bridge to Quality (Greiner & Knebel, 2003) includes informatics as a core compe- tency required of all healthcare professionals. In the report Crossing the Quality Chasm: A New Health System for the 21st Century (Committee on Quality of Health Care in America & Institute of Medicine, 2001), HIT is seen as an important force in improving healthcare. Some of the HIT themes in this report are a national informa- tion infrastructure, computerized clinical data, use of the Internet, clinical decision support, and evidence-based practice integration. (See Chapter 14 for more information on U.S. gov- ernment efforts.)

The pervasive use of technology in health- care is another driving force. Technologies to manage care, such as electronic health records, smart beds, computerized intravenous pumps, and telehealth, are examples of technology that although it assists nurses to improve patient care outcomes (Needleman, 2013), needs to be under-

stood and managed. Other forces such as the changing healthcare environment and increa