Encompass home health hattiesburg ms

Health Informatics

An Interprofessional Approach

SECOND EDITION

Ramona Nelson, PhD, RN-BC, ANEF, FAAN Professor Emerita, Slippery Rock University, Slippery Rock, Pennsylvania President, Ramona Nelson Consulting, Allison Park, Pennsylvania

Nancy Staggers, PhD, RN, FAAN President, Summit Health Informatics; Adjunct Professor, College of Nursing and Department of

Biomedical Informatics, University of Utah, Salt Lake City, Utah

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Table of Contents

Cover image Title page Copyright Dedication About the Authors Contributors Reviewers and Ancillary Writers Acknowledgments Preface

Uses of the book Vendors, applications, foundations and institutions Organization of the book Teaching and learning package

Unit 1: Foundational Information in Health Informatics 1: An Introduction to Health Informatics

Abstract Introduction Definition of health informatics Topics and areas of study in informatics Conclusion and future directions Discussion Questions Case Study Case Study Questions

2: Theoretical Foundations of Health Informatics Abstract Introduction Understanding theories and models Additional informatics-related models Conclusion and future directions Discussion questions Case study Discussion Questions

3: Evidence-Based Practice, Practice-Based Evidence, and Health Informatics Abstract Introduction Evidence-based practice Evidence-based practice models Stevens star model of knowledge transformation Informatics and evidence-based practice Relationship of EBP and PBE Practice-based evidence Informatics and practice-based evidence Conclusion and future directions Discussion questions EBP case study Discussion Questions PBE Case study Pressure Ulcer Case Study Negative Association With Likelihood of Developing a Pressure Ulcer (Less Likely) Positive Association With Likelihood of Developing a Pressure Ulcer (More Likely) Discussion Questions

4: Models, Theories, and Research for Program Evaluation Abstract Introduction Purposes of evaluation Theories and frameworks Methods, tools, and techniques Conclusion and future directions Discussion questions Case study Discussion Questions

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5: Technical Infrastructure to Support Healthcare Abstract Introduction Electronic health record component model System integration and interoperability Networking systems Other infrastructure models Current challenges Conclusion and future directions Discussion questions Case study Discussion Questions

Unit 2: Information Systems and Applications for the Delivery of Healthcare

6: Electronic Health Records and Applications for Managing Patient Care Abstract Introduction Electronic health record components, functions, and attributes Sociotechnical perspectives Electronic health record applications used in the clinical setting Electronic health record benefits Stakeholder perspectives Key issues Conclusion and future directions Discussion questions Case study Discussion Questions

7: Administrative Applications Supporting Healthcare Delivery Abstract Introduction Major Types of Applications Conclusion and Future Directions Discussion questions Case Study Michael H. Kennedy, Kim Crickmore, and Lynne Miles Discussion Questions

8: Telehealth and Applications for Delivering Care at a Distance Abstract Introduction Telehealth technologies Telehealth clinical practice considerations for healthcare professionals Telehealth operational and organizational success factors and barriers Telehealth challenges: licensure and regulatory issues for healthcare professionals Telehealth and direct patient health services Conclusion and future directions Discussion questions Case Study Discussion Questions

9: Home Health and Related Community-Based Systems Abstract Introduction Evolution and milestones Practice models Standardized datasets Supporting home health with electronic health records and health information technology Standardized terminologies Omaha system Conclusion and future directions Discussion questions Case Study Discussion Questions

10: Clinical Decision Support Systems in Healthcare Abstract Introduction Clinical decision support types and examples Clinical decision support impact Clinical decision support best practices Recent progress toward disseminating clinical decision support on a national level Research challenges Conclusion and future directions Discussion questions Case study Discussion Questions

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11: Public Health Informatics Abstract Introduction Public health: A population perspective The value of informatics for the domain of public health Conclusions and future public health informatics strategies Discussion questions Case study Discussion Questions

Unit 3: Participatory Healthcare Informatics 12: The Engaged ePatient

Abstract Historical background and drivers of the epatient evolution Convergence of epatients, clinicians, patient-centered models of care, and informatics Health 3.0 emerges Conclusion and future directions Discussion questions Case study Discussion Questions

13: Social Media Tools for Practice and Education Abstract What is social media? Social media tools Social media statistics Benefits of social media Challenges of social media Social media in education Policy Conclusion and future directions Discussion questions Case study Social Media in Education and Healthcare Discussion Questions

14: Personal Health Records Abstract Definitions of the personal health record The development of the electronic personal health record Principles of an ideal personal health record Examples of existing personal health records Current evidence of benefits of personal health records Current use of personal health records Barriers to personal health record adoption The future of personal health records Discussion questions Case study Discussion Questions

15: mHealth: The Intersection of Mobile Technology and Health Abstract Introduction Driving forces of mobile health Mobile health benefits and challenges Future directions of mobile health and conclusions Discussion questions Case study Discussion Questions

Unit 4: Managing the Life Cycle of a Health Information System 16: Strategic Planning and Selecting an Information System

Abstract Introduction Strategic vision and alignment Systems life cycle Conclusion and future directions Discussion questions Case study Key Considerations for System Selection

17: Project Management Principles for Health Informatics Abstract Introduction The need for project management in healthcare organizations Project, program, and portfolio management Roles and responsibilities: project, program, and portfolio managers Project management tools Project and portfolio management software selection

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Conclusions and future directions Discussion questions Case study Discussion Questions

18: Contract Negotiations and Software Licensing Abstract Introduction Overview of licensing agreements Major steps or stages in the performance of a license agreement Specific components of the licensing agreement Conclusions and future directions Discussion questions Case study Discussion Questions

19: Implementing and Upgrading an Information System Abstract Introduction Reasons to implement or upgrade a healthcare information system New implementation versus an upgrade Implementation and the systems life cycle Preparing for go-live Go-live Post-live maintenance Conclusion and future directions Discussion questions Case study Discussion Questions Case Study Follow-Up Discussion Questions

20: Downtime and Disaster Recovery for Health Information Systems Abstract Introduction Downtime risk assessment Downtime And Response Planning Downtime policies and procedures Information technology impact and planning Disaster planning Conclusion and future directions Discussion Questions Case Study Discussion Questions

Unit 5: User Experience, Standards, Safety, and Analytics in Health Informatics

21: Improving the User Experience for Health Information Technology Abstract Introduction to improving the user experience Definitions of terms and their relationships The goals of usability User-centered design Human-computer interaction frameworks for health informatics Selecting methods to improve the user experience Formal user testing Selecting a type of usability test Conclusion and future directions Discussion questions Case study Discussion Questions

22: Informatics-Related Standards and Standards-Setting Organizations Abstract Introduction Standardized healthcare terminologies relevant to patient care Healthcare data standardization Data exchange efforts Application of standardized terminologies Conclusion and future directions Discussion questions Case study Discussion Questions

23: Data Science and Analytics in Healthcare Abstract Introduction Data science in healthcare Characteristics of big data

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Data science for clinical and translational research Benefits of data science Approaches to analyses Knowledge discovery and data mining Conclusions and future directions Discussion questions Case study

24: Patient Safety and Quality Initiatives in Health Informatics Abstract Introduction Definitions National initiatives driving adoption and use of health it National efforts related to quality data standards Evaluating quality and patient safety Success factors and lessons learned Conclusion and future directions Discussion questions Case study Discussion Questions

Unit 6: Governance Structures, Legal, and Regulatory Issues in Health Informatics

25: Legal Issues, Federal Regulations, and Accreditation Abstract Introduction Legal system Fraud and abuse and billing issues related to electronic health record use Accreditation The intersection of new technology and regulation Conclusion and future directions Discussion questions Case study Discussion Questions

26: Privacy and Security Abstract Introduction Definitions and concepts Legal and historical context Principles, laws, and regulations guiding practice The importance of information security Current security vulnerabilities Current security challenges Managing security risks with security controls Resources Conclusions and future directions Discussion questions Case study Discussion Questions

27: The Health Information Technology for Education and Clinical Health Act, Meaningful Use, and Medicare Access and CHIP Reauthorization Act of 2015

Abstract Introduction Federal initiatives to drive health information technology Conclusion and future directions Discussion questions Case study Discussion Questions

28: Health Policy and Health Informatics Abstract Introduction Developing and implementing health information technology policy Driving forces for creating health information technology policy Leadership competencies for developing and implementing health information technology policies Leading policy activities through organizational work and leadership Discipline-specific policies: nursing Conclusion and future directions Discussion Questions Case Study Discussion Questions

29: Health Information Technology Governance Abstract Introduction Health information technology governance: need and core components Key insights

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Recommendations Conclusion and future directions Discussion Questions Case study Discussion Questions

Unit 7: Education and Health Informatics 30: Informatics in the Curriculum for Healthcare Professionals

Abstract Introduction and background Teaching and learning in an evolving healthcare and technology environment Framework for informatics curriculum It takes a village: roles and competencies Conclusion and future directions Discussion questions Case study Discussion Questions

31: Distance Education: Applications, Techniques, and Issues Abstract Introduction Historical development Terminology Course delivery systems: course management systems Instructional design for distance education and learning Student (learner) support services Issues Conclusion and future directions Discussion Questions Case Study Discussion Questions

32: Informatics Tools for Educating Healthcare Professionals Abstract Introduction Comprehensive education information system Computerized teaching tools Impact on the teaching and learning process Impact on the faculty role Conclusion and future directions Discussion Questions Case study Discussion Questions

33: Simulation in Healthcare Education Abstract Introduction The simulation process Application of simulation Conclusion and future directions Discussion questions Case study Discussion Questions

Unit 8: International Health Informatics Efforts 34: International Efforts, Issues, and Innovations

Abstract Introduction Key initiatives in world regions International organizations with ehealth involvement International standards efforts Global challenges to ehealth Conclusion and future directions Discussion questions Case study Discussion Questions

Unit 9: Historical Implications and Future Directions in Health Informatics

35: The Evolution of Health Informatics Abstract Introduction The roots of informatics within the computer and information sciences Establishing the specialty of health informatics Recognition of the specialty Naming the specialty—naming the discipline Conclusion and future directions Discussion questions

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Case study Discussion Questions

36: Future Directions and Future Research in Health Informatics Abstract Introduction Futures research (futurology) The future of health informatics Clinical informatics Improving the user experience for health information technology Analytics (big data) and data visualization Predictive analytics Data visualization Conclusion and future directions Discussion questions Case study Discussion Questions

Glossary Index

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Copyright

3251 Riverport Lane St. Louis, Missouri 63043 HEALTH INFORMATICS: AN INTERPROFESSIONAL APPROACH, SECOND EDITION ISBN: 978-0-323-40231-6 Copyright © 2018 by Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means,

electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notices Knowledge and best practice in this field are constantly changing. As new research and

experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.

With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Previous edition copyrighted 2014. International Standard Book Number: 978-0-323-40231-6 Executive Content Strategist: Kellie White Content Development Manager: Lisa Newton Senior Content Development Specialist: Danielle M. Frazier Publishing Services Manager: Jeff Patterson Senior Project Manager: Jodi M. Willard Design Direction: Ryan Cook Printed in China Last digit is the print number: 9 8 7 6 5 4 3 2 1

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http://www.elsevier.com/permissions
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Dedication

To my husband, Glenn M. Nelson, who always manages to be there To my daughters, who managed to pick wonderful husbands,

Dorianne & Michael Hollis and Leslie-Ann & Kristopher Bidelson and

To my grandchildren, who are today’s joy and tomorrow's hope, Mackenzie, Hope, Ella, and Molly

Ramona Nelson To my father, Forest Thorpe, who supported education for women

during an age when it was deemed superfluous and

To my husband, Bob Staggers, who has always been a champion of strong women Nancy Staggers

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About the Authors

Ramona Nelson holds a baccalaureate degree in nursing from Duquesne University and a master's degree in both nursing and information science and a PhD in education from the University of Pittsburgh. In addition, she completed a postdoctoral fellowship at the University of Utah. Prior to her current position as president of her own consulting company, Ramona was a Professor of Nursing and Chair of the Department of Nursing at Slippery Rock University. Today Ramona continues her association with Slippery Rock University in the role of Professor Emerita. Her primary areas of interest include informatics education for health professionals, social media and empowered patients, and the application of theoretical concepts in health informatics practice.

Her past publications include textbooks, monographs, book chapters, journal articles, World Wide Web publications, abstracts, and newsletters. She has been recognized as a Nursing Informatics Pioneer by the American Medical Informatics Association. In addition, she was named a fellow in the American Academy of Nursing in 2004 and in the National League for Nursing Academy of Nursing Education Fellows.

Nancy Staggers is a nursing informatics pioneer who is actively involved in informatics user experience research. Her education was at the University of Wyoming and the University of Maryland School of Nursing, culminating in a PhD with a concentration on informatics and research. Her background includes both health informatics practice and academia. She was a health informatics executive in the Department of Defense and elsewhere, leading enterprise acquisitions and installations of inpatient electronic health records. Her academic career includes professorships at both the University of Utah and the University of Maryland. Nancy’s academic work began with developing nursing informatics competencies and later leading teams to revise the American Nurses’ Association document on the scope and practice of nursing informatics in the United States in 2002 and 2008. Her research program focuses health IT support and redesign for complex activities such as electronic medication administration records and handoffs/care transitions. Recently she led a team on the user experience community at the Healthcare Information and Management Systems Society to identify nursing user experience issues and solutions for nurses’ interactions with health IT. She was elected as a fellow in the American Academy of Nursing in 1999 and received the American Medical Informatics Association Virginia K. Saba nursing informatics award in 2013 for her contributions to informatics. She owns her own health informatics company, which focuses on research consultations and international collaborations. She is also adjunct professor of informatics at the Department of Biomedical Informatics and College of Nursing, University of Utah, and she teaches user experience research methods for the Health Informatics program at the University of Alabama Birmingham. Nancy publishes widely on health informatics topics, concentrating on user experience research.

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Contributors

Antonia Arnaert, RN, MPH, MPA, PhD Associate Professor, Ingram School of Nursing, McGill University Montreal, Quebec, Canada

Nancy C. Brazelton, RN, MS Application Service Director, Information Technology Services, University of Utah Health Care, Salt Lake City, Utah

Christine A. Caligtan, RN, MSN Health Data and Patient Safety Clinical Specialist, Health Data Integrity, PatientsLikeMe, Cambridge, Massachusetts

Robin L. Canowitz, AB, JD Senior Attorney, Vorys, Sater, Seymour and Pease, LLP, Columbus, Ohio

Heather Carter-Templeton, PhD, RN-BC Assistant Professor, Capstone College of Nursing, The University of Alabama, Tuscaloosa,

Alabama Associate Professor and Reference Librarian, Health Sciences Library, University of Tennessee

Health Science Center, Memphis, Tennessee Diane Castelli, RN, MS, MSN Adjunct Clinical Nursing Instructor Cape Cod Community

College West Barnstable, Massachusetts Kathleen G. Charters, PhD, RN, CPHIMS Clinical Information Systems Specialist, Defense

Health Agency Healthcare Operations Directorate, Clinical Support Division, Integrated System Support, Measurements & Clinical Reporting, Falls Church, Virginia

Jon C. Christiansen, BS, JD Attorney, TechLaw Ventures, PLLC, Salt Lake City, Utah Helen B. Connors, PhD, RN, DrPS (Hon), FAAN, ANEF Executive Director, Center for

Health Informatics; Associate Dean, University of Kansas School of Nursing, Kansas City, Kansas Vicky Elfrink Cordi, PhD, RN Clinical Associate Professor Emeritus, The Ohio State

University, Columbus, Ohio Mollie R. Cummins, PhD, RN, FAAN Associate Dean for Research and the PhD Program;

Associate Professor, College of Nursing; Adjunct Associate Professor, Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah

Andrea Day, RN, MS, PMP Informatics Nurse Consultant New Market, Maryland Mical DeBrow, PhD, RN Associate Director, Health Economics and Outcomes Research,

Boehringer Ingelheim Pharmaceuticals, Houston, Texas Guilherme Del Fiol, MD, PhD Assistant Professor, Department of Biomedical Informatics,

University of Utah, Salt Lake City, Utah Vikrant G. Deshmukh, PhD, MS, MSc Adjunct Assistant Professor, Population Health

Sciences, University of Utah School of Medicine; Adjunct Assistant Professor, College of Nursing, University of Utah; Lead Principal Data Warehouse Architect, Enterprise Data Warehouse, University of Utah Health Care, Salt Lake City, Utah

Patricia C. Dykes, PhD, RN, FAAN, FACMI Senior Nurse Scientist, Program Director, Center for Patient Safety Research and Practice, Program Director, Center for Nursing Excellence, Brigham and Women's Hospital, Boston, Massachusetts

William Scott Erdley, DNS, RN, CHSE Simulation Education Specialist, The Behling Simulation Center, Jacobs School of Medicine and

Biomedical Sciences, University at Buffalo, Buffalo, NY Adjunct Professor, School of Nursing, Niagara University, Niagara University, New York David L. Gibbs, PhD, CPHIMS, CHPS, CISSP Assistant Professor, Department of Health

Information Management, Texas State University, San Marcos, Texas Bryan Gibson, DPT, PhD Assistant Professor, Department of Biomedical Informatics,

University of Utah, Salt Lake City, Utah Teresa Gore, PhD, DNP, FNP-BC, NP-C, CHSE-A Associate Professor and Director of Experiential Learning College of Nursing, University of

South Florida, Tampa, Florida President, International Nursing Association for Clinical Simulation and Learning (INACSL),

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Morrisville, North Carolina Nicholas R. Hardiker, PhD, RN, FACMI Professor of Nursing and Health Informatics, School of Nursing, Midwifery, Social Work &

Social Sciences, University of Salford, Salford, England Director, eHealth Programme, International Council of Nurses, Geneva, Switzerland Adjunct Professor, College of Nursing, University of Colorado, Denver, Colorado Angel Hoffman, MSN, RN Principal/Owner, Advanced Partners in Health Care Compliance,

Pittsburgh, Pennsylvania Susan D. Horn, PhD Adjunct Professor, University of Utah School of Medicine, Health

System Innovation and Research Program, Salt Lake City, Utah Valerie M. Howard, EdD, MSN, RN Dean and University Professor, School of Nursing and

Health Sciences, Robert Morris University, Moon Township, Pennsylvania Sarah J. Iribarren, PhD, RN Postdoctoral Research Fellow, School of Nursing, Columbia

University, New York City, New York Jonathan M. Ishee, JD, MPH, MS, LLM Assistant Professor, School of Biomedical

Informatics, University of Texas Health Science Center; Partner, Vorys, Sater, Seymour and Pease, LLP, Houston, Texas

David E. Jones, PhD Applied Public Health Informatics Fellow, Utah Department of Health, Salt Lake City, Utah

Irene Joos, PhD, MSIS, MN, BSN, RN Professor & Former Director, Online Learning, Department of Information Technology; Adjunct Faculty, Department of Nursing, La Roche College, Pittsburgh, Pennsylvania

Kensaku Kawamoto, MD, PhD, MHS Associate Chief Medical Information Officer, University of Utah Health Care; Assistant Professor, Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah

Jacob Kean, PhD, MA, BS Research Speech-Language Pathologist, VA Salt Lake City Health Care System; Associate Professor, Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah

Michael H. Kennedy, PhD, MHA, FACHE Associate Professor, Department of Health Services and Information Management, East Carolina University, Greenville, North Carolina

Tae Youn Kim, PhD, RN Associate Professor, Betty Irene Moore School of Nursing, University of California, Davis, Sacramento, California

Gerald R. Ledlow, PhD, MHA, FACHE Chair and Professor, Department of Health Policy and Management, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, Georgia

Kim Leighton, PhD, RN, ANEF Assistant Dean, Research & Simulation Faculty, Development, Institute for Research & Clinical Strategy, DeVry Medical International, Iselin, New Jersey

Louis Luangkesorn, PhD Research Assistant Professor, Industrial Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania

Ann M. Lyons, PhD, RN Medical Informaticist, Data Science Service, University of Utah, Salt Lake City, Utah

Kathleen MacMahon, RN, MS, CNP Telehealth Nurse Practitioner, American Telecare, Minneapolis, Minnesota

Michele P. Madison, JD Partner, Morris, Manning and Martin, LLP, Atlanta, Georgia Shannon Majoras, JD Associate, Vorys, Sater, Seymour and Pease, LLP, Cleveland, Ohio E. LaVerne Manos, DNP, RN-BC Faculty, School of Nursing, University of Kansas; Program

Director, Interprofessional Master of Science in Health Informatics and Post-Master's, Interprofessional Certificate in Informatics Center for Health Informatics, University of Kansas; Director of Nursing Informatics, Center for Health Informatics, University of Kansas, Kansas City, Kansas

Karen S. Martin, RN, MSN, FAAN Health Care Consultant, Martin Associates, Omaha, Nebraska

Cynthia M. Mascara, RN, MSN, MBA Principal Clinical Consultant, Strategic Clinical Consulting, Cerner Corporation, Kansas City, Missouri

Susan A. Matney, PhD, RN-C, FAAN Medical Informaticist, Healthcare Data Dictionary (HDD) Team, 3M Health Information Systems, Salt Lake City, Utah

Christine D. Meyer, PhD, RN Healthcare IT, Independent Consultant, Bridgeville,

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Pennsylvania Michele Mills, MBA.PM, PMP, CPHIMS, FHIMSS Director, Information Technology

Services, University of Utah Health Care, Salt Lake City, Utah Sandra A. Mitchell, PhD, CRNP, FAAN Research Scientist, Outcomes Research Branch,

National Cancer Institute, Rockville, Maryland Judy Murphy, RN, BSN, FACMI, FHIMSS, FAAN Chief Nursing Officer, Global Healthcare

& Life Sciences, IBM, Washington, DC Daniel A. Nagel, RN, BScN, MSN, PhD(c) Lecturer, Department of Nursing & Health

Sciences, University of New Brunswick, Saint John, New Brunswick, Canada Scott P. Narus, PhD Medical Informatics Director, Intermountain Healthcare Associates;

Professor, Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah Ramona Nelson, PhD, RN-BC, ANEF, FAAN Professor Emerita, Slippery Rock University, Slippery Rock, Pennsylvania President, Ramona Nelson Consulting, Allison Park, Pennsylvania Sally Okun, RN, MMHS Vice President, Advocacy, Policy, and Patient Safety,

PatientsLikeMe, Cambridge, Massachusetts Hyeoun-Ae Park, PhD Professor, College of Nursing, Seoul National University, Seoul, South

Korea Mitra Rocca, Dipl. Inform. Med. Senior Medical Informatician, Center for Drug Evaluation

and Research U.S. Food and Drug Administration, Silver Spring, Maryland Kay M. Sackett-Fitzgerald, BSN, RN, MEd, MSN, EdD Fitzgerald Consulting, Jenkintown,

Pennsylvania Loretta Schlachta-Fairchild, RN, PhD, FACHE, LTC (Ret.) U.S. Army Nurse Corps Health

Information Sciences Research Program Manager, Joint Program Committee-1 (JPC-1), U.S. Army Medical Research and Materiel Command/Department of Defense Health Agency, Fort Detrick, Maryland

Rebecca Schnall, PhD, MPH, RN-BC Assistant Professor, School of Nursing, Columbia University, New York, New York

Kumiko O. Schnock, PhD, RN Research Fellow, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts

Charlotte A. Seckman, PhD, RN-BC, CNE Assistant Professor, Course Director, Organizational Systems and Adult Health, School of Nursing University of Maryland, Baltimore, Maryland

Joyce Sensmeier, MS, RN-BC, CPHIMS, FHIMSS, FAAN Vice President, Informatics, Healthcare Information and Management Systems Society, Chicago, Illinois

Catherine Janes Staes, BSN, MPH, PhD Assistant Professor, Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, Utah

Nancy Staggers, PhD, RN, FAAN President, Summit Health Informatics; Adjunct Professor, College of Nursing and Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah

Teresa Stenner, MA Program Manager, Center for Health Informatics, University of Kansas Medical Center, Kansas City, Kansas

Kathleen R. Stevens, RN, MS, EdD, ANEF, FAAN Professor and Director, Improvement Science Research Network, School of Nursing, University of Texas Health Science Center, San Antonio, Texas

Jim Turnbull, DHA, MBA, BA Chief Information Officer, University of Utah Health Care, Salt Lake City, Utah

Karen B. Utterback, MSN, RN Independent Consultant, Homecare, Mitre, Hattiesburg, Mississippi

Dianna Vice-Pasch, MSN, RN, CCM, CTCP Associate Degree Nursing Faculty Kentucky Community and Technical College Systems Lexington, Kentucky

Judith J. Warren, PhD, RN, FAAN, FACMI Professor Emeritus, School of Nursing, University of Kansas Medical Center, Kansas City, Kansas

Charlene R. Weir, PhD, RN Associate Professor, Department of Biomedical Informatics, University of Utah School of Medicine; Associate Director, IDEAS Center of Innovation, Veterans Affairs Salt Lake City, Salt Lake City, Utah

Kathy H. Wood, PhD, FHFMA, CHFP Assistant Professor, College of Health, Human Services, and Science, Ashford University, San Diego, California

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Reviewers and ancillary writers

Reviewers Joanna V. Bachour, MSN, RN Assistant Professor and Lab Manager, MCPHS University,

School of Nursing, Worcester, Massachusetts Carol J. Bickford, PhD, RN-BC, CPHIMS, FHIMSS, FAAN Senior Policy Advisor,

Department of Nursing Practice & Work Environment, American Nurses Association, Silver Spring, Maryland

Connie B. Bishop, DNP, MBA, RN-BC Clinical Assistant Professor, College of Health and Human Services, School of Nursing, North Carolina A&T State University, Greensboro, North Carolina

Barbara Blackwell, EdD, RN-BC Director, School of Nursing (RN and LPN School), Holy Name Medical Center School of Nursing, Teaneck, New Jersey

Mary T. Boylston, RN, MSN, EdD, AHN-BC Professor of Nursing, Nursing Department, Eastern University, St. Davids, Pennsylvania

Kathleen M. Burke, PhD, RN Assistant Dean in Charge of Nursing, Professor of Nursing, Adler Center for Nursing Excellence, Ramapo College of New Jersey, Mahwah, New Jersey

Pat Callard, DNP, RN, CNL Associate Professor of Nursing, College of Graduate Nursing, Western University of Health Sciences, Pomona, California

Karen Chang, PhD, RN Associate Professor, School of Nursing, College of Health and Human Services, Purdue University, West Lafayette, Indiana

Amanda Dorsey, MSHI, FHIMSS Assistant Professor, UAB MS in Health Informatics Program, University of Alabama at Birmingham, Birmingham, Alabama

Judith A. Effken, PhD, RN, FACMI, FAAN Professor Emerita, College of Nursing, The University of Arizona, Tucson, Arizona

Matthew J. Fox, MSN, RN-BC Assistant Professor of Nursing, Ohio University-Zanesville, Zanesville, Ohio

Robert L. Garrie, MPA, RHIA Associate Professor, Health Services Administration, University of Alabama at Birmingham, Birmingham, Alabama

Lynda R. Hardy, PhD, RN Associate Dean for Research, College of Nursing, University of Tennessee, Knoxville, Knoxville, Tennessee

Gayle McGinty, MSN, RN Assistant Professor of Nursing, MCPHS University, School of Nursing, Worcester, Massachusetts

Carol M. Patton, PhD, FNP-BC, CRNP, CNE Informatics Health Certificate, CNE, Associate Clinical Professor, Drexel University, Philadelphia, Pennsylvania

Alison Pittman, RN, MSN, CPN Clinical Assistant Professor, Texas A&M Health Science Center, College of Nursing, Bryan, Texas

Teresa L. Scherer, MS, RN Clinical Instructor, School of Nursing, Idaho State University, College of Technology, Pocatello, Idaho

M. Kathleen Smith, MScEd, RN-BC, FHIMSS Managing Partner, Informatics Consulting and Continuing Education, L.L.C., Weeki Wachee, Florida

Nadia Sultana, MBA, RN, BC Clinical Assistant Professor, College of Nursing, New York University, New York, New York

Lindsay Tucker, BA, AAA, CPC Training and Education Manager, Moses Cone Health System, Adjunct Professor, Guilford Technical Community College, Greensboro, North Carolina

Dorothea M. Winter, PhD, RN Professor of Nursing, Nursing Department, Salisbury University, Salisbury, Maryland

ANCILLARY WRITER Jane M. Brokel, PhD, RN, FNI Adjunct Faculty, College of Nursing, University of Iowa, Iowa

City, Iowa; Section Instructor, School of Nursing and Health Sciences, Simmons College, Boston, Massachusetts

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Acknowledgments

Ramona Nelson; Nancy Staggers First, we would like to acknowledge Kellie White, Executive Content Strategist, whose overview

and coordination of this second edition is greatly appreciated. We also thank Danielle Frazier, Senior Content Development Specialist, who was responsible for providing support during the process of writing and editing; and especially Jodi Willard, Senior Project Manager, whose attention to detail was invaluable during the editing process. Finally, we would like to acknowledge Jeff Patterson, Publishing Services Manager, and Ryan Cook, Designer. Their expertise was imperative for developing a polished and professional product.

Each chapter of this book is supported with Evolve resources. We also wish to acknowledge the support of Umarani Natarajan, Senior Project Manager, and Hariprasad Maniyaan, Multimedia Producer, for the Evolve resources, as well as ancillary writer Jane Brokel and various content experts for their development of these resources.

Finally, we would like to acknowledge the reviewers. Their many suggestions, tips, and comments were invaluable in creating this book.

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Preface

Health informatics and our current information technology (IT) environment are inherently interdisciplinary. Over our many years of working in health informatics practice and teaching health informatics content, we recognized the need for a health informatics textbook that provides a solid overview of the field using an interdisciplinary approach. Therefore the title, authors, and content of this book reflect the comprehensive nature of contemporary informatics practice. The contributors to this book are leaders in health informatics and represent various disciplines and a wide variety of settings, areas of expertise, and positions.

Health Informatics: An Interprofessional Approach provides readers with a comprehensive understanding of health informatics, its practice, and relevant research on health informatics topics. Each chapter opens with key terms, learning objectives and an abstract that outlines the topics covered within the chapter. Chapter headings give readers a conceptual framework for understanding the content in the chapter. Each chapter ends with conclusions that include thoughts about future directions for the topic. Every chapter includes a set of discussion questions to encourage critical thinking and to encourage the reader to consider how the content in the chapter can be applied in the ever-changing world of healthcare. Case studies with analytic questions demonstrate how informatics applies in real-life practice.

Uses of the book This textbook is an excellent resource for use within and across various health disciplines. Every

attempt has been made to be culturally sensitive to the various disciplines within healthcare while encouraging readers to recognize themselves as key members of an interprofessional team. This book is written to be used for both intradisciplinary and interdisciplinary informatics courses. The text can span levels of education depending on the program of study, depth of informatics material needed, and the needs of faculty and students. This book is targeted to students needing introductory health or nursing informatics knowledge. As with the first edition, it is useful at several levels: for upper division or advanced undergraduate courses, for RN to BSN/MSN programs, for introductory health informatics content or courses in master’s programs and, particularly, for DNP students.

Vendors, applications, foundations and institutions Vendors, health IT applications, commercial products, and organizations and institutions are

discussed throughout the textbook. They are included for information purposes and to provide readers with examples of the variety of resources available. No endorsement of a specific company, product, or organization is intended.

Organization of the book The book is organized into nine units. The first unit is Foundational Information in Health

Informatics and focuses on material that is basic to understanding the discipline as a whole. Content includes the definition and significance of the field, theories and models, evidence-based practice and practice-based evidence, program evaluation, and technical infrastructures for health IT.

The second unit is Information Systems and Applications for the Delivery of Healthcare. This unit begins with an overview of electronic health records, followed by a discussion of financial and other administrative applications and clinical decision support systems. Remaining chapters focus on health IT in non–acute care settings: telehealth, home health, and public health informatics. This unit provides readers with content on major health applications in institutions and relevant settings.

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The third unit, Participatory Healthcare Informatics, recognizes the shift toward patient engagement in recent years. Patients are now more involved in their own healthcare and are equipped with health IT applications. Topics in this unit include epatients, social media, personal health records and, new to the second edition, mHealth (mobile health). Readers are introduced to the impact of this movement on patients, providers, and the patient-provider relationship as well as the partnership between each of these groups and health IT.

The fourth unit is entitled Managing the Life Cycle of a Health Information System, and the first chapter outlines strategic planning and selecting an information system. Salient topics are then introduced to readers: project management, contract negotiations, implementing and upgrading a system, and downtime and disaster recovery. This material gives readers the knowledge and skills to lead and participate in health informatics systems projects in every phase of the systems life cycle. The chapters on contract negotiations and project management are new to this edition.

The fifth unit, User Experience, Standards, Safety and Analytics in Health Informatics, explains complex interactions among health IT and safety, user experience, and needed standards. This unit introduces concepts and practical uses for data science and analytics, which represent a major focus of health organizational leaders, health professionals, and informatics specialists today. This unit focuses on creating a culture of safety, effective and efficient health IT interactions, and methods for knowledge building. The analytics chapter provides new material on data science.

The sixth unit, Governance Structures, Legal, and Regulatory Issues in Health Informatics, deals with local and national structures, laws, and regulations important to health informatics. At the local level, contributors discuss how organizations develop support structures for managing health IT. On a national level, the development of federal programs and regulations dealing with HITECH, MU, MACRA, MIPS, and ACO are carefully explained. Other chapters outline privacy and security concerns and health policy issues and also provide the reader with directions for professional involvement in these activities.

The seventh unit, Education and Health Informatics, focuses on the role of education in informatics and the role of informatics in health provider education. It includes chapters that discuss educational applications and issues, educational tools, simulation, distributive education, and informatics in the health curriculum.

The eighth unit, International Health Informatics Efforts, contains a chapter on the aspects, initiatives, and progress of health informatics worldwide.

The ninth unit, Historical Implications and Future Directions in Health Informatics, provides an overview of the history of health informatics. It then concentrates on future directions and future research needed in the field of health informatics, including a unique section about nanotechnology.

Teaching and learning package Health informatics is a fast-changing field. Resources and emerging developments related to

each chapter are available on the Evolve website. For example, new government reports and other important documents are posted or referenced for easy student access. These materials are targeted to all faculty, including those newer to the field as well as those with additional experience in the discipline of informatics. Each chapter includes a number of discussion questions and a case study. These questions and case studies are carefully designed to represent the reality of health informatics, including the typical ill-defined problems common in informatics practice. Numerous approaches are available to manage these challenges. Thus the discussion questions and case studies can stimulate discussion, and faculty and students can explore how the material in the chapters can be applied for developing approaches for practice situations. Students should be especially encouraged to consider how these materials apply to their own experiences and situations.

For the Instructor • TEACH Lesson Plans contain objectives and key terms from the text. Topics from the book

are mapped to Quality and Safety Education for Nurses (QSEN) standards, American Association of Colleges of Nursing (AACN) Essentials Series, concept-based learning, and American Health Information Management Association (AHIMA) competencies. These lesson plans tie in all of the chapter resources for effective presentation of material and include additional highlights and

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learning activities tied to content within the chapters. Online Activities for each chapter provide additional assignments to deepen students' understanding of the content of the text.

• PowerPoint Presentations are available to accompany the TEACH Lesson Plans. Pulling content and figures from the text, the PowerPoint slides provide students with chapter highlights and provide instructors with additional relevant topics of conversation.

• A Test Bank containing more than 300 questions is compliant with the NCLEX® standards and provides text page references and cognitive levels. The ExamView software allows instructors to create new tests; edit, add, and delete text questions; sort questions; and administer and grade online tests.

• The Image Collection contains all of the art from the text for use in lectures or to supplement the PowerPoint presentations.

For the Student • Student Review Questions provide additional practice for students trying to master the

content presented within the text. • Most chapters have Additional Readings to provide sources of additional research on the

subject.

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UNIT 1 Foundational Information in Health

Informatics

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1

An Introduction to Health Informatics Ramona Nelson; Nancy Staggers

Abstract This chapter provides the reader with an introduction to health informatics as both a discipline and a profession. It begins

by introducing the reader to the significance of health informatics. Health informatics is then defined, and example applications are listed. The next section of the chapter provides an overview of the topics inherent in the discipline and profession of health informatics. These topics are organized around the nine units in the book. The ultimate goal of health informatics is to empower populations, communities, families, and

individuals with the opportunity to improve the quality and increase the quantity of their days by maximizing the use of technology in healthcare.

OBJECTIVES At the completion of this chapter, the reader will be prepared to: 1. Define healthcare informatics. 2. Discuss the significance of health informatics within healthcare delivery. 3. Provide an overview of health informatics-related topics. KEY TERMS

health informaticians 2 health informatics 2

Introduction Almost 20 years after the Institute of Medicine (IOM) report To Err Is Human1 was released, John

T. James published a seminal article on the same topic in The Journal of Patient Safety. Using a carefully designed methodology, he analyzed data published from 2008 to 2011 to estimate the number of preventable adverse events occurring in American hospitals. James found that each year, an estimated 440,000 hospitalized Americans experience a preventable adverse event that contributed to their death. In addition, serious harm is estimated to be 10- to 20-fold more common than lethal harm.2 These findings were reinforced in 2016 when Martin Makary and Michael Daniel published a study in The BMJ entitled “Medical Error—The Third Leading Cause of Death in the US.”2a

The numbers are astounding, but the personal consequences are even greater for the people and the families who suffer such “preventable events.” Dr. James, whose distinguished professional career was in healthcare, maintains a website that provides some insight into his strong interest in patient safety.3 The website is dedicated as follows:

This site is dedicated to my 19-year-old son, John Alexander James, who died as a result of uninformed, careless, and unethical care by cardiologists at a hospital in central Texas in the late summer of 2002.

In 2016, 3 years after publication of the James article, this same journal published another research study in which the question is asked Can electronic health records prevent harm to patients?4 Key points from this research include the following:

• The investigators analyzed Medicare Patient Safety Monitoring System (MPSMS) patient medical record data for 1351 hospitals from the years 2012 and 2013. They found 347,281 exposures to adverse events. Of these exposures, 7820 adverse events actually took place, resulting in a 2.25% occurrence rate.

• Of the patients, 13% (5876) received care that was captured by an electronic health record

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(EHR). • The analysis of these data demonstrated that cardiovascular, surgery, and pneumonia

patients whose complete treatment was captured in an EHR were between 17% and 30% less likely to experience in-hospital adverse events.5 The studies2,2a,4 taken together suggest that if EHRs were in use in American hospitals,

somewhere between 74,800 and 132,000 preventable fatal hospital-based events each year might never occur.

Going forward, if health informaticians and knowledgeable healthcare providers are fully involved in the design, selection, and implementation of health information systems, these numbers are just the beginning of what would be possible in terms of improved healthcare. Improved patient safety is just one of the many reasons why the study of health informatics is imperative for all healthcare professionals. Throughout this book, other vital reasons will become obvious. Competent, compassionate healthcare depends on healthcare providers who understand and can maximize their use of health information technology (IT) and informatics knowledge in providing care to patients. This book provides the foundation required to develop that competence.

Definition of health informatics Today health informatics is an exciting and well-established field. It is recognized as both a

discipline and a profession. As a discipline, it is a field of study in the same sense that medicine, sociology, and pharmacy are fields of study. Core disciplines, including informatics, along with terminal competencies or learning outcomes, provide the framework for developing curricula within the healthcare professions. Learning outcomes include the skills, knowledge, and professional aptitudes expected of all graduates within the profession. In 2003 the IOM identified five core competences that should be achieved by all healthcare professionals:

• Delivering patient-centered care • Working as part of interdisciplinary teams • Practicing evidence-based medicine • Focusing on quality improvement • Using informatics6

Other professional groups and accrediting agencies are now including an informatics-related requirement. For example, the American Association of Colleges of Nursing (AACN) developed a group of documents titled the Essentials Series.7–9 The Essentials outline the necessary curriculum content and expected competencies of graduates from baccalaureate, master’s, and doctor of nursing practice programs. Each of these documents includes a technology or informatics requirement and cites the IOM report as the rationale for this requirement.

Health informatics is also a profession within the healthcare arena. Thousands of informaticians practice the specialty in varied roles that include, for example:

• Installing and evaluating new technologies such as EHRs • Developing mHealth (mobile health applications) for patients • Analyzing users’ interactions with health IT to create applications that mirror the way

clinicians think and do work • Leading telehealth initiatives in a region or nationally • Developing and implementing national policies for health IT and informatics • Building terminologies to support interoperability • Doing research on the effect of health IT on patients, providers, or organizations

Although the existence of health informatics as both a discipline and as a profession is well accepted, it is interesting to note there is currently no consensus or generally accepted name and standard definition for this profession. Current titles for members of this profession include health informatics specialist, informaticist, or informatician (sometimes spelled informaticien). Table 1.1 lists several accepted definitions and the source of those definitions. The history, reasons, and issues presented by this lack of consensus are discussed in detail in Chapter 35.

Table 1.1 Common Definitions of Health Informatics

Source Definition AHIMA Health informatics is the scientific discipline concerned with the cognitive, information-processing, and communication tasks of healthcare practice, education, and research,

including the information science and technology to support these tasks.28 HIMSS Health informatics is the interdisciplinary study of the design, development, adoption, and application of IT-based innovations in healthcare services delivery, management, and

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planning as defined by the U.S. National Library of Medicine.29

AMIA Biomedical informatics is the interdisciplinary field that studies and pursues the effective uses of biomedical data, information, and knowledge for scientific inquiry, problem solving and decision making, motivated by efforts to improve human health.30

US NLM

Health informatics is “the interdisciplinary study of the design, development, adoption, and application of IT-based innovations in healthcare services delivery, management, and planning.”31

In this book, health informatics is defined as an interdisciplinary professional specialty and scientific discipline that integrates the health sciences, computer science, and information science, as well as a number of other analytic sciences, with the goal of managing and communicating data, information, knowledge, and wisdom in the provision of healthcare for individuals, families, groups, and communities. A review of this definition as well as the definitions in Table 1.1 demonstrates three common themes within each of these definitions. That is, health informatics is:

• An interdisciplinary professional specialty • Tied to the use of IT in healthcare • Focused on assisting healthcare providers with tasks related to collecting data, processing

information, and applying that information to processes such as problem solving, knowledge development, and decision making Health IT touches nearly every aspect of healthcare today, even less obvious ones such as

providing emotional support to patients. A few examples include: • Tele-intensive care units (ICUs). Patients in ICUs in more remote geographical areas are

monitored by experienced ICU nurses and physicians using telehealth technology. • Robotics. DaVinci is a widely used surgical robot guided by a surgeon. It is used to translate

hand movements during minimally invasive surgery, using tiny instruments inserted into small incisions.

• Behavioral health at-a-distance. The U.S. Army has a telehealth network that spans 50 countries. Behavioral health telehealth makes up 55% of their services, followed by cardiology and dermatology.10

• Sensors. Sensors in long-term care settings can help monitor residents’ health status, detect emergency situations, and contact health providers.11 In the future, clinicians may monitor patients with wearable sensors, such as clothing, after discharge.12

• Healthcare for islanders. People living on four islands off the coast of Maine have no available healthcare providers. A 72-foot boat beams health services via live video conferencing with a nurse.

Topics and areas of study in informatics This book is divided into nine units outlining the key topics and areas of study within health

informatics. This section of the chapter is built around these nine units. Each subsection presented here focuses on one of the nine units, and begins by describing the theme of the unit. This is followed by an example taken from professional reports, research studies, or a news story. As you read each subsection, you are encouraged to think about how informaticians using information technology could improve the quality of healthcare and the satisfaction of both providers and patients, while decreasing costs.

Unit 1: Fundamental Information in Health Informatics The content of the first five chapters of the book can be applied to each of the remaining

chapters. These chapters introduce the reader to terms, definitions, concepts, theories, and models that are used throughout the book, thereby providing the mental infrastructure for understanding the discipline of health informatics.

Why Informatics Is Needed in Healthcare: An Example The weblog GeriPal is an online community of interdisciplinary providers interested in

geriatrics or palliative care. In August 2013, they published an article titled “Transfers from the hospital to nursing home: an F-grade for quality.”13 The article reviews a study published in Journal of the American Geriatrics Society.14 GeriPal describes the finding from this research as follows: “A rather stunning study in the Journal of the American Geriatrics Society suggests the quality of communication between the hospital and the nursing home is horrendous.”13 Patients arrived at skilled nursing facilities (SNF) with missing or inaccurate information on their health status, their medication orders, and their functional abilities. The research found that care was routinely delayed

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and nursing hours were wasted trying to obtain the required information. Poor-quality discharge communication was identified as the major barrier to safe and effective transitions. Interestingly, nurses from the SNFs in the study identified a specific list of information and components that they need to facilitate a safe, high-quality transition. Nevertheless, the lack of an interoperable healthcare system providing clear, concise patient data/information between institutions makes the situation described in their study a common occurrence in SNFs across the country. Healthcare providers and informaticians who have a mental infrastructure and understand what is possible are the first requirement for building such an interoperable system.

Unit 2: Information Systems and Applications for the Delivery of Healthcare

The Health Information Management Systems Society (HIMSS) provides a searchable website for applications used in healthcare. As of this writing, HIMSS listed 30 categories of applications ranging from Ambulatory to Web/Internet Solutions. Under each of these categories are subcategories: for example, under Operating Room, one can find Peri-Operative Systems, Post- Operative Systems, Pre-Operative Systems, and Scheduling. The point is that an enormous number of applications are used in healthcare and more are being developed every day. As healthcare providers discover and explore different applications used in healthcare, three questions can be used to provide an overview of each application.

• What is the purpose of this application? Each healthcare application will have a specific purpose or list of purposes: for example, a scheduling system helps schedule staff or patients within a particular clinical unit.

• What functions can this application perform? Function is how an application achieves its purpose: For example, can the scheduling system assign staff to work shifts of any length or does it function with predetermined shifts only?

• How is this application internally and externally structured? Internal structure determines how efficiently and effectively the application actually functions; for example, a poorly designed user interface can increase the number of user errors. External structure determines how the application fits into the environment, especially how the application interfaces with other applications. The six chapters in this unit explore the common applications used across the healthcare

settings.

Healthcare Applications Improving Healthcare: An Example A study conducted in 2008 entitled The Balancing Act: Patient Care Time Versus Cost explored how

nursing time is distributed in a clinical setting.15 This research correlated the time spent on various activities with the nurses’ wages, thereby measuring the cost of nursing care. The authors reported that $757,000 of nursing wages was spent on tasks such as hunting for equipment. Nursing Times, in 2009, published an article based on an online survey of over 1000 nurses16 entitled “Nurses Waste ‘an Hour a Shift’ Finding Equipment.” A 2011 study from the Robert Wood Johnson Foundation estimated that only 20% to 30% of a nurse’s time is actually spent at the bedside, and as much as 70% of their time can be spent on documentation, finding supplies, and carrying out other duties, such as tracking down equipment.17

One informatics-based solution to this well-documented waste of nursing time is the use of an autonomous mobile robot (AMR) with tracking software, RFID (radio-frequency identification), and barcode technology to manage supplies needed on a clinical unit. One example of such a robot is RoboCourier®, developed by Swisslog (Fig. 1.1). Automated robots such as RoboCourier® can safely and securely transport laboratory specimens, medications, clinical supplies, and other materials throughout the healthcare setting, thereby allowing healthcare professionals to focus on patient care instead of searching for the materials they need to provide that care.18

28

FIG 1.1 RoboCourier® Autonomous Mobile Robot. Used with permission of Swisslog.

As you consider this technology, think about how the robot would be programed to

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automatically interface with elevators and doors so the robot can move independently throughout the facility on programmed paths with no human interference. Also consider how the robot would know what supplies to deliver where. To gain the maximum benefit of AMRs, they need to be interfaced with other information systems in the hospital, thus diminishing the human effort needed to maintain needed supplies on a clinical unit. For example, could the pharmacy system be interfaced with the AMR so that new medication orders could be quickly delivered to the clinical unit? Fig. 1.2 demonstrates an AMR in relation to the people and information systems that direct the AMR as well as other institutional systems that might be interfaced with the AMR.

FIG 1.2 RoboCourier® Autonomous Mobile Robot in a healthcare setting with the people and information systems that direct the robot. Used with permission of Swisslog.

Unit 3: Participatory Healthcare Informatics (Healthcare on the Internet)

Since the beginning of healthcare, providers have been proactive in meeting the needs of patients. Historically, patients and their families have looked to healthcare providers both to assess/diagnosis their health problems and to tell them what was needed. Today patients are no longer exclusively dependent on providers to determine what is wrong and what options they might consider in dealing with their health problem. Patients, whether well or facing problems, are assuming an increasingly proactive role in maintaining or obtaining a higher level of health. These proactive patients are often referred to as ePatients. ePatients are equipped, empowered, engaged, and electronically connected. They are informed about their health and have gained much of that knowledge via the internet. Knowledge is power, and as more patients are becoming ePatients, the traditional relationship between the patient and the provider is shifting from a parent–child-type relationship toward more collegial ones.

Now providers and patients have access to much of the same information. However, both patients and providers are overwhelmed by the amount of quality information they can access. In addition, they differ greatly by the scope of the information that each group needs to access. Providers must focus on a much larger scope of data/information. First, they need to be aware of the growing literature base across their specialty and also the information available to patients. Second,

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they must be aware of trends and changes across the broad area of healthcare delivery: for example, providers need to be aware of the role that social media plays in healthcare delivery.

Patients and their families can limit research to their own health issues rather than all disorders within a specific specialty. When working together in social media groups, individuals can become experts in every sense of the word about their own expression of their specific health problems.

However, when confronted with this massive amount of information, providers have one significant advantage not available to most patients. Their experience and education makes it much easier to assess the quality of the information and incorporate new findings into their current knowledge. Patients, on the contrary, must often spend a great deal of time and effort correctly interpreting information and determining its significance in terms of their health issues. This is especially true for patients with a new health problem or diagnosis.

The solution may seem obvious. Working together as colleagues, patients and providers can take advantage of each other’s strengths in meeting the challenges presented by various healthcare problems. The amount of responsibility for leading this effort will vary at different points in the wellness–illness continuum. As patients move toward a high level of health, they are increasingly responsible for maintaining their own health through diet, exercise, and avoiding poor health habits. As they move toward the other end of the continuum, with, for example, a severe acute episode or illness, the provider has a higher level of responsibility. However, even in these situations, patients and/or their families must sign the consent form and, therefore, must make the final decision.

In Unit 3, the reader will explore the changing relationship between ePatients and health informatics. As an introduction to the unit, these authors suggest that the reader do a quick search of the internet for the term ePatient and note the variety of examples presented by searching with this one term.

Unit 4: Managing the Life Cycle of a Health Information System As the title suggests, Unit 4 is focused on the life cycle of a health information system. Fig. 2.8

provides a model of this life cycle. The systems life cycle (SLC) is one of the oldest and yet still widely used methods for selecting/tailoring or building, implementing, and evaluating software applications in the IT arena. The lifecycle has evolved over the years in response to ever-changing scenarios and paradigm shifts pertaining to the building or acquiring of software; however, its central tenants are as applicable now as they ever were. Lifecycle stages have gone through iterations, with different names and numbers of steps, but the SLC is resilient as a tried and true method in a wide variety of settings including healthcare. Thus, learning about the SLC remains important to students.18

Healthcare providers, whether they are informaticians or working in other areas of the healthcare system, play a major role in the life cycle of healthcare information systems. Acquiring new systems is a complicated process that affects the entire facility. In the past, a common mistake has been selecting healthcare systems that affect patient care with little or no input from providers across the healthcare team. Healthcare providers often discover these new applications when they are requested to change their practice to “work around” an issue with a new system in another department. Therefore it is imperative that healthcare providers not only understand the life cycle of healthcare information applications but also be involved in systems selection.

Using the Systems Life Cycle: An Example A few years ago, Mark McMurtrey, PhD, a faculty member at the University of Central

Arkansas, and a colleague were invited to serve as consultants for the selection of a home health software application in a medium-sized regional hospital. The 149-bed facility included an emergency department; a hospice; intensive care, obstetrics, pediatrics rehabilitation, and home units; an imaging center; primary care clinics; a health and fitness center; and a wound healing center. After completing this project, McMurtrey published a paper describing how the use of the systems life cycle provided the project with a systemic and structured process. He concluded the paper with the following statement: “While both researchers hold terminal degrees, each learned quite a bit from the application of principles taught in the classroom to the complexities surrounding real-world utilization of them.”19, p. 23

Unit 4 contains five chapters exploring the application of life-cycle–related principles to the

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complexities surrounding their real-world use in healthcare. With this background, the reader is prepared to participate actively and effectively in real-life use of the life cycle in healthcare.

Unit 5: User Experience, Standards, Safety, and Analytics in Health Informatics

This unit is focused on discovering and using information and knowledge to improve the way that healthcare is delivered, and in turn, to improve healthcare outcomes. Currently, there is a large body of knowledge concerning drug-drug and drug-diet interaction. In addition, there is extensive knowledge about lab tests, diet, and drug interactions. The human mind is not designed to remember this type of extensive detail. In addition, when a computer is used for order entry, deciding the specific medications, diagnostic tests, and diet to order for an individual patient can carry a heavy cognitive load, thereby leaving less mental resources for remembering details related to interactions. In such a situation, health providers benefit from using a clinical decision support (CDS) system to analyze the details and offer suggestions. However, a CDS system will not make a difference unless the information the provider needs is presented in a way that meshes with the mental workflow of the provider. In other words, the provider must be able to use the information and knowledge. Therefore this unit begins by discussing usability.

The process of discovering and using knowledge is highly dependent on standards. It is only through standards that technologies interface and interact. For example, it would be impossible to use a computer and a printer if there were no standards on how these two pieces of technology are connected. Every piece of technology becomes an isolated and useless piece of equipment without an agreement on how the pieces of equipment physically and logically communicate. This agreement is called a standard. In this unit, current standards and the processes for establishing these standards in healthcare are explored.

Establishing standards, analyzing data, discovering knowledge, and making the information/knowledge useful to healthcare providers is executed with the overall goals of providing safe, effective, quality care. The unit ends with an analysis of methods, programs, and procedures used to ensure safe, effective, quality care.

Using Big Data: A Real-Life Example Dr. John D. Halamka is the chief information officer of Beth Israel Deaconess Medical Center in

Boston. In 2011 his wife, a healthy 49-year-old Korean woman, was diagnosed with breast cancer. Using big-data technology available at all Harvard hospitals, Dr. Halamka was able to ask the big- data questions: Of the last 10,000 Asian women near age 50 who were treated for the same tumor, what medications were used? Was surgery or radiation necessary, and what were the outcomes? From his queries, he was able to ascertain the most effective treatment approach for a person with this history. His wife was treated successfully and is now cancer free.20 The challenge for informatics is: How do we develop information systems that can provide this level of care to patients in all settings?

Unit 6: Governance Structures, Legal, and Regulatory Issues in Health Informatics

Unit 6 is built on the concept of governance, beginning with health informatics governance at the federal level. The U.S. government and related legal systems have established processes for achieving justice, defense, promotion of the general welfare of citizens, and security. Unit 6 is built around these concepts. The first chapter explains how health informatics-related legislation, programs, and regulations are developed and implemented. Major legislation is analyzed, from the Health Insurance Portability and Accountability Act (HIPAA) to the Health Information Technology for Economic Clinical Health (HITECH) Act, soon to be followed by the Medicare and CHIP Reauthorization Act (MACRA). Healthcare leaders, including informaticians, and health IT users must play active roles in developing these policies, as described in Chapter 28. Finally, this unit concludes by describing how the concepts of governance apply to the management and operation of a Health IT department.

Health Policy in Operation: An Example

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The HITECH Act, which provided financial incentives for the adoption of EHRs, was implemented in 2009 with the goal to modernize the IT infrastructure of the U.S. healthcare system.21

• As of 2009, only 12% of hospitals had adopted a basic EHR system.22 By 2014, 75% of U.S. hospitals had adopted at least a basic EHR system, up from 59% in 2013.

• The EHRs also showed significant improvement in functionality. By 2014, hospitals able to meet the stage 2 criteria used in the implementation of the HITECH Act increased to 40.5%, up from 5.8% in 2013.23

• By 2013, 63% of physicians had implemented an EHR, and another 20% were in the process of implementing one.21 Going forward, healthcare providers must be involved in governance at the institutional, local,

state, and federal levels. This unit provides the foundation for that involvement as it relates to health informatics.

Unit 7: Education and Health Informatics In today’s networked healthcare world, all healthcare professionals require a foundational

understanding of health informatics. However, a significant number of healthcare professionals currently in the workforce were educated before this was true, and this is especially true for faculty teaching in health education programs today. According to AACN’s report on 2013–14 Salaries of Instructional and Administrative Nursing Faculty in Baccalaureate and Graduate Programs in Nursing, the average age of faculty varied from 51.2 to 61.6.24 The Association of American Medical Colleges (AAMC) reported in 2007 that the average age of medical school faculty is growing older, a finding that held regardless of degree, department type, rank, or demographic characteristic. At that time, the average age of MD faculty teaching in the basic sciences was 52.9.25 This might explain why the introduction of computers in healthcare has been a slow process, and the introduction of informatics into the curriculum has been even slower. This unit begins by analyzing where informatics fits in the curriculum for healthcare professionals.

The following three chapters in this unit discuss how technology is changing the pedagogy of healthcare education. Initially technology made the educational process more efficient. For example, using a computerized spreadsheet is more efficient than using a paper-and-pencil gradebook and calculating grades by hand. Moreover, technology is changing the teaching and learning process. Distance education often uses more interactive learning experiences in comparison to the more passive process of taking notes during a lecture. Simulation provides the opportunity to analyze one’s own performance and try again, and learning the same procedures in the clinical setting does not offer the “do-over” option. Professors are increasingly seen not as authorities or all-knowing experts, but rather as learning coaches encouraging the student to develop their own expertise, knowledge, and skills.