Handbook of informatics for nurses & healthcare professionals free pdf

Handbook of Informatics for Nurses and

Healthcare Professionals TONI HEBDA I KATHLEEN HUNTER I PATRICIA CZAR

SIXTH EDITION

Handbook of Informatics for Nurses and Healthcare Professionals

Sixth Edition

Toni Hebda, PhD, RN-C, CNE MSIS Professor MSN Program Chamberlain College of Nursing, Downers Grove, IL 60515

Kathleen Hunter, PhD, FAAN, RN-BC, CNE Professor MSN Program Chamberlain College of Nursing, Downers Grove, IL 60515

Patricia Czar, RN Information Systems Consultant Pittsburgh, PA

330 Hudson Street, NY NY 10013

A01_HEBD1010_06_SE_FM.indd 1 3/16/18 8:36 PM

Publisher: Julie Alexander Director of Portfolio Management, Nursing: Katrin Beacom Editorial Assistant: Erin Sullivan Managing Content Producer: Melissa Bashe Content Producer: Michael Giacobbe Design Coordinator: Mary Siener Vice President of Sales and Marketing: David Gesell Vice President, Director of Marketing: Brad Parkins Director, Digital Studio: Amy Peltier Digital Project Manager: Jeff Henn Full-Service Project Management and Composition: SPi Global Full-Service Project Managers: Sreemeenakshi Raghothaman, Anitha Vijayakumar, SPi Global Editorial Project Manager: Dan Knott, SPi Global Manufacturing Buyer: Maura Zaldivar-Garcia, LSC Communications, Inc. Cover Designer: Laurie Entringer

Copyright © 2019 by Pearson. All rights reserved. Manufactured in the United States of America. This publication is protected by Copyright, and permission should be obtained from thepublisher prior to any prohibited reproduction, storage in a retrieval system, or transmission in anyform or by any means, electronic, mechanical, photocopying, recording, or likewise. For informationregarding permissions, request forms and the appropriate contacts within the Pearson EducationGlobal Rights & Permissions Department, please visit www.pearsoned.com/ permissions/

Pearson® is a registered trademark of Pearson plc

Notice: Care has been taken to confirm the accuracy of information presented in this book. Theauthors, editors, and the publisher, however, cannot accept any responsibility for errors or omissionsor for consequences from application of the information in this book and make no warranty, expressor implied, with respect to its contents.

Cataloging in Publication data is available at the Library of Congress

ISBN 10: 0-13-471101-7 ISBN 13: 978-0-13-471101-0

A01_HEBD1010_06_SE_FM.indd 2 3/16/18 8:36 PM

iii

Preface ix Acknowledgments xiii Contributors xv Reviewers xvii About the Authors xix

1 An Overview of Informatics in Healthcare 1 Jennifer A. Brown, Taryn Hill, Toni Hebda

Informatics 2

The Relevance of Informatics for Healthcare 3

Creating an Informatics Culture 8

Caring for the Patient Not the Computer 12

Future Directions 13

Summary 14

2 Informatics Theory and Practice 20 Maxim Topaz

Overview of Theory 20

Critical Theories Supporting Informatics 22

Informatics Specialties within Healthcare 30

Informatics Competencies for Healthcare Practitioners 33

TANIC AND NICA 37

Future Directions 37

Summary 38

3 Effective and Ethical Use of Data and Information 42 Toni Hebda, Kathleen Hunter

Overview of Data and Information 42

Using Data for Quality Improvement 44

Data Management 46

Big Data, Data Analytics, and Data Modeling 47

Ethical Concerns with Data and Information Use 52

Future Directions 52

Summary 53

4 Electronic Resources for Healthcare Professionals 58 Brenda Kulhanek

Information Literacy 58

Critical Assessment of Online Information 59

Social Media—Responsibilities and Ethical Considerations 61

Healthcare Information and Services 62

Online Services for Healthcare Professionals 64

Professional Organizations and Watchdog Groups 65

Healthcare Websites of Interest for Healthcare Providers 66

ELearning 67

Using Information Technology to Organize and Use Information Effectively 68

Future Directions 70

Summary 70

5 Using Informatics to Support Evidence-Based Practice and Research 73 Melody Rose

History 74

Levels of Evidence 75

Applying Information Literacy to Find the Highest Levels of Evidence 77

Contents

A01_HEBD1010_06_SE_FM.indd 3 3/16/18 8:36 PM

iv Content

Integration of EBP into Clinical Systems and Documentation 78

Managing Research Data and Information 80

Creating and Maintaining the Infrastructure to Support Research 81

Ethical and Legal Principles for Handling Data and Information in Research 83

Practices for Collecting and Protecting Research Data 84

Supporting Dissemination of Research Findings 86

Effecting Practice Change 87

Future Directions 88

Summary 89

6 Policy, Legislation, and Regulation Issues for Informatics Practice 94 Sunny Biddle, Jeri A. Milstead

The Policy Process 95

Legislation and HIT/Informatics 98

Regulation (Rule-Making) and Implications for Informatics 101

Accreditation 104

Policy Making, Interprofessional Teams, and Informatics 106

Future Directions 108

7 Electronic Health Record Systems 112 Rayne Soriano, Kathleen Hunter

Meaningful Use 114

Benefits of EHRSs 119

Current Status of EHRSs 121

Considerations When Implementing the EHRS 123

Future Directions 128

Summary 129

8 Healthcare Information Systems 135 Carolyn Sipes, Jane Brokel

Clinical Information Systems 136

Administrative Information Systems 139

Smart Technology 141

Current Topics in Healthcare Information Systems 143

Summary 145

9 Strategic Planning, Project Management, and Health Information Technology Selection 149 Carolyn Sipes

Overview of Strategic Planning 150

Information Management Components 152

One Vendor versus Best of Breeds 155

Configurability 156

Interoperability 156

Ease of Use/Usefulness of Systems 156

Planning at the Project Level—The Project Management Process 157

The Informatics Nurse’s Role as Project Manager 161

Essential Skills in Other Advanced Nurse Practice Roles 162

Future Directions 163

Summary 164

10 Improving the Usability of Health Informatics Applications 167 Nancy Staggers

Introduction to Usability 168

Definitions of Terms and Interrelationships of Concepts 169

The Goals of Usability 171

A01_HEBD1010_06_SE_FM.indd 4 3/16/18 8:36 PM

Content v

Information System Security 242

Security Mechanisms 249

Administrative and Personnel Issues 256

Levels of Access 257

Audit Trails 260

Handling and Disposal of Confidential Information 260

Special Considerations with Mobile Computing 262

Security for Wearable Technology/Implanted Devices/Bedside Technology 263

Future Directions 266

Summary 266

14 Information Networks and Information Exchange 271 Jane M. Brokel

Introduction 271

Health Information Network Models 272

Clinical Data Networks or Health Information Networks 273

Interoperability 274

International Standards 278

Nationwide Health Information Network 279

Implications of Interoperability 280

Process and Use Cases for Health Information Exchange 280

Key Factors 281

Driving Forces 284

Current Status 285

Obstacles 285

Future Directions 286

Summary 287

Usability and the System Life Cycle 172

Human–Computer Interaction Frameworks 172

Usability Methods 175

Usability Tests 179

Steps in Conducting Usability Tests 183

Future Directions 185

Summary 186

11 System Implementation, Maintenance, and Evaluation 191 Sue Evans

System Implementation 192

System Installation 203

System Evaluation 206

Summary 207

12 Workforce Development 210 Diane Humbrecht, Brenda Kulhanek

Workforce Population 210

Devising a Workforce Development Preparation Plan 212

Identifying the Scope of Efforts 214

Target Technology and Related Competencies 217

Education Methods 219

Training Resources 225

Evaluating Success 226

When Information Technology Fails (Training on Backup Procedures) 228

Future Directions 229

Summary 229

13 Information Security and Confidentiality 238 Ami Bhatt, Patricia Mulberger

Privacy, Confidentiality, Security, and Consent 239

A01_HEBD1010_06_SE_FM.indd 5 3/16/18 8:36 PM

vi Content

15 The Role of Standardized Terminology and Language in Informatics 293 Susan Matney

Introduction to Terminology 293

Languages and Classification 297

Benefits of Implementing Standardized Terminologies 309

National Healthcare Reporting Requirements 312

Issues and Concerns 313

Future Directions 313

Summary 314

16 Continuity Planning and Management (Disaster Recovery) 320 Carolyn S. Harmon

Introduction and Background 320

What Is Continuity Planning? 321

Steps in the Developing a Preparedness Program 324

Advantages of Continuity Planning 328

Disasters Versus System Failure 329

Continuity and Recovery Options 329

Planning Pitfalls 337

Using Post-Disaster Feedback to Improve Planning 338

Legal and Accreditation Requirements 338

Future Directions 340

Summary 340

17 Using Informatics to Educate 343 Diane A. Anderson, Julie McAfooes, Rebecca J. Sisk

Why Informatics? 344

Preparing the Learner 344

Educational Software Sources 344

Barriers and Benefits 345

Necessary Tools 346

Simulation and Virtual Learning Environments 354

Future Directions 363

Summary 363

18 Consumer Health Informatics 370 Melody Rose, Toni Hebda

Evolution 371

Driving Forces 372

Issues 372

Consumer Health Informatics Applications 377

The Role of the Informatics Nurse with CHI 385

The Future of CHI 388

Summary 389

19 Connected Healthcare (Telehealth and Technology-Enabled Healthcare) 398 Lisa Eisele

Introduction 398

History of Connected Health 399

Current State 400

Driving Forces 400

Connected Health Modalities 403

Implications for Practitioners 408

The Role of the INS in Connected Health 412

Future Directions 413

Summary 414

20 Public Health Informatics 418 Marisa L. Wilson

Introduction 418

Exploring Public Heath 419

Public Health Mandate 419

A01_HEBD1010_06_SE_FM.indd 6 3/16/18 8:36 PM

Content vii

Public Health Informatics 422

Public Policy Driving Informatics Change 425

Current Public Health Informatics Systems 426

New Technological Sources of Public Health Information 428

Future Directions 430

Summary 432

Appendix A: Hardware and Software 435 Athena Fernandes

Appendix B: The Internet and the Worldwide Web 439 Athena Fernandes

Appendix C: An Overview of Tools for the Informatics Nurse 441 Carolyn Sipes

Glossary 446 Index 454

A01_HEBD1010_06_SE_FM.indd 7 3/16/18 8:36 PM

This page intentionally left blank

A01_PERL5624_08_GE_FM.indd 24 2/12/18 2:58 PM

ix

The idea for Handbook of Informatics for Nurses & Healthcare Professionals first came from the realiza-tion that there were few resources that provided practical information about computer applications and information systems in healthcare. From its inception, this book served as a guide for nurses and other health- care professionals who needed to learn how to adapt and use computer applications and informatics in the work- place. Over time, this text became a reliable resource for students in a variety of healthcare professions who needed to develop informatics competencies. This book serves undergraduates who need a basic understanding, as well as those who require more depth, such as infor- matics nurse specialists, clinical nurse leaders, doctoral students, and other healthcare professionals.

After a thorough revision in response to reviewers and users of the book, the sixth edition reflects the rapid changes in healthcare information technology (HIT) and informatics. The authors endeavour to provide an understanding of the concepts, skills, and tasks that are needed for healthcare professionals today and to achieve the federal government’s national information technology goals to help transform healthcare delivery.

The sixth edition builds upon the expertise pro- vided by contributors currently involved in day-to-day informatics practice, education, and research. Both the primary editors and the contributors share an avid inter- est and involvement in HIT and informatics, as well as experience in the field, involvement in informatics groups, and a legacy of national and international pre- sentations and scholarly publications.

New to This Edition • New! All chapters thoroughly revised to reflect the

current and evolving practice of health information technology and informatics

• New! Chapter on informatics theory and prac- tice connects theoretical concepts to applications (chapter 2)

• New! Coverage of technology and caring and their symbiotic relationship

• New! Content on ethical use of information lays encompasses appropriate and inappropriate behav- iour and actions, and of right and wrong.

• New! Information on analytics and data science that explains how Big Data applies to healthcare

• New! Cutting-edge content on wearable and mobile technology security, and its impact on nursing and patient care

• New! Academic electronic health record resources and the role they play in educating the next generation of healthcare providers on documentation principles

• New! Hardware and software appendix (appendix A)

• New! Guide to the Internet (appendix B)

• New! An Overview of Tools for the Informatics Nurse (appendix C)

Changes to This Edition • The sixth edition streamlines content by combining

chapters with topics that fit together, and shifting hardware, software, and information on the Inter- net to new appendices.

• This edition reworks previous content on informa- tion systems training and presents it within the context of workforce development. The content still retains the emphasis upon privacy and confidential- ity, introduction of information policies, educational methods and resources. New content on evaluation models and training on backup procedures has also been added.

• Former content on integration, interoperability and health information exchange is now presented within the context of information networks and information exchange.

• Moves from defining evidence-based practice to a discussion of levels of evidence and using informat- ics to support evidence-based practice and research.

• Separate chapters on policy, legislation, regulatory, reimbursement, and accreditation issues were com- bined to better show the connection among these

Preface

A01_HEBD1010_06_SE_FM.indd 9 3/16/18 8:36 PM

x Preface

areas and the relationship between them and infor- mation system design and use.

• Experts from various health disciplines cover the latest on the interprofessional aspects of infor- matics with more emphasis on interdisciplinary approaches.

• Increases focus on current electronic health record issues while decreasing coverage of the historical evolution of EHRs.

• Highlights strategic planning and project management.

• Underscores the importance of patient engagement and shared decision making.

• Expands content on simulation and virtual learning environments.

Hallmark Features Learning Objectives—Learning Objectives appear at the beginning of each chapter and identify what readers can expect to learn in the chapter.

Future Directions—As the last section in each chapter, Future Directions forecasts how the topic covered in the chapter might evolve in the upcoming years.

Case Study Exercises—Case studies at the end of each chapter discuss common, real-life appli- cations, which review and reinforce the concepts presented in the chapter.

Summary—The Summary at the end of each chapter highlights the key concepts and information from the chapter to assist in the review.

References—Resources used in the chapter appear at the end.

Glossary—The glossary familiarizes read- ers with the vocabulary used in this book and in healthcare informatics. We recognize that healthcare professionals have varying degrees of computer and informatics knowledge. This book does not assume that the reader has prior knowledge of computers. All computer terms are defined in the chapter, in the glossary at the end of the book, and on the Online Student Resources Web site.

Organization The book is divided into three sections: Information and Informatics, Information Systems Development Life Cycle, and Specialty Applications. The major themes of privacy, confidentiality, and information security are woven throughout the book. Likewise, project manage- ment is a concept introduced in the strategic planning chapter and carried through other chapters. Chapters include content on the role of the informatics profes- sional, future directions relative to the topic, summary bullet points, and a case study.

Section I: Information and Informatics This section provides a foundation for why information and informatics are important to healthcare. It details the relationship between policy, legislation, regulation and accreditation and reimbursement and information system use.

• Chapter 1: Provides a definition of informatics and its significance for healthcare, discusses healthcare professionals as knowledge workers, addresses the need for uniform data and the relationship between data, big data, and evidence. This chapter also addresses the increased prevalence of information technology in healthcare, major issues in healthcare that are driving the adoption of information tech- nology, what is necessary to create an informatics culture, and includes a special section on caring and technology.

• Chapter 2: Provides information on informatics theory and practice, and nursing informatics as a discipline.

• Chapter 3: Emphasizes effective and ethical use of data and information, and includes a discussion of big data challenges and issues. Data characteristics, types, integrity, and management are covered. Cli- nician and informaticist roles pertaining to this area are discussed.

• Chapter 4: Addresses electronic resources for healthcare professionals, basic concepts and appli- cations of the Internet, including criteria for evalu- ating the quality of online information.

• Chapter 5: Discusses informatics to support evidence-based practice and research. Concepts include levels of evidence, information literacy, managing research data and information, creating

A01_HEBD1010_06_SE_FM.indd 10 3/16/18 8:36 PM

Preface xi

and maintaining the infrastructure needed to sup- port research, dissemination of evidence, and effect- ing practice change.

• Chapter 6: Examines the relationship between pol- icy, legislation, accreditation, reimbursement and HIT design and use.

• Chapter 7: Provides information on electronic health records including definition, components, incentives for adoption, benefits, current status, selection criteria, implications for collection of meaningful data and big data, current issues, and future directions.

• Chapter 8: Provides an overview of types of health- care information systems, including clinical infor- mation systems and administrative information systems, as well as decision support, knowledge representation, and smart data.

Section II: Information Systems Development Life Cycle This section covers information and issues related to the information systems development life cycle.

• Chapter 9 This chapter discusses the importance of strategic planning for information management, HIT acquisition and use and provides an overview of project management and information system selection considerations. The role of informatics professionals, particularly informatics nurse spe- cialists, in the planning process and project manage- ment are addressed, as is the process to introduce change.

• Chapter 10: Addresses the concepts of usability and health informatics applications inclusive of the role that usability plays in the system life cycle and methods of usability assessment.

• Chapter 11: Covers information system implemen- tation, maintenance, and evaluation.

• Chapter 12: Provides a comprehensive look at workforce development in relation to health infor- mation technology use.

• Chapter 13: Discusses information security and confidentiality, including practical information on ways to protect information housed in informa- tion systems and on mobile devices and addresses security for wearable and implantable information technology.

• Chapter 14: Provides detailed information about health information exchanges.

• Chapter 15: Provides an overview of the role of standardized terminology and language in infor- matics. Also includes an outline of individual lan- guages and classifications used in healthcare.

• Chapter 16: Discusses the relationship between strategic planning for the organization and the sig- nificance of maintaining uninterrupted operations for patient care. Also touches on legal requirements to maintain and restore information. Much of this chapter is geared for the professional working in information services.

Section III: Specialty Applications This section covers specialty applications of informatics.

• Chapter 17: Details ways that information tech- nology and informatics can support education of healthcare professionals, including sections on sim- ulation and virtual learning environments.

• Chapter 18: Emphasizes the relationship between health and information literacy, patient engage- ment, shared decision-making, changing healthcare delivery models, patient satisfaction, outcomes, and healthcare reform. Discusses applications of con- sumer health informatics.

• Chapter 19: Examines telehealth and connected healthcare applications, starting with a historical perspective and including driving forces, appli- cations, and implications for providers as well as informatics professionals.

• Chapter 20: Explores public health informatics and its use to maintain and improve population health.

Three appendices are included. Appendix A pro- vides basic information on hardware and software for the reader who needs a better understanding of this area. Appendix B provides information on the Internet. Appendix C provides an overview of some tools for the informatics nurse.

Instructor Resources Lecture PowerPoint showcases key points for each chapter.

Test Generator offers question items, making test creation quick and simple.

A01_HEBD1010_06_SE_FM.indd 11 3/16/18 8:36 PM

xii Preface

Student Resources New! eText offers a rich and engaging experi- ence with interactive exercises. Readers can ac- cess online or via the Pearson eText app. Note: Faculty can opt to package an eText access code card with the print textbook, or students can purchase access to the eText online.

Notice Care has been taken to confirm the accuracy of information pre- sented in this book. The authors, editors, and the publisher, however, cannot accept any responsibility for errors or omissions or for conse- quences from application of the information in this book and make no warranty, express or implied, with respect to its contents.

A01_HEBD1010_06_SE_FM.indd 12 3/16/18 8:36 PM

xiii

Special thanks to Kathy Hunter, who agreed to join me on this 6th edition, lending her knowledge, insights, and support when I most needed it and never said “no” despite her many other commitments. A special thanks to Patricia Czar, RN, without whom there would be no

Handbook of Informatics for Nurses & Healthcare Professionals today. Pat actively contributed to the book from the original outline through to the present, provid- ing her knowledge, insights, organizational skills, support, and friendship. Pat was active in informatics for more than 25 years, serving as manager of clini- cal systems at a major medical center where she was responsible for planning, design, implementation, and ongoing support for all of the clinical information systems. Pat was also active in several informatics groups, presented nationally and internationally, and served as a mentor for many nursing and health infor- matics students. She is now fully retired and enjoying time with her family.

We acknowledge our gratitude to our loved ones for their support as we wrote and revised this book. We are grateful and excited to have work from our contributors who graciously shared their knowledge and expertise for this edi- tion. We are grateful to our co-workers and professional colleagues who provided encouragement and support throughout the process of conceiving and writing this book. We appreciate the many helpful comments offered by our reviewers. Finally, we thank Lisa Rahn, Michael Giacobbe, Susan Hannahs, Daniel Knott, Taylor Scuglik, and all of the persons who worked on the production of this edi- tion for their encouragement, suggestions, and support.

Thank You

This edition brings in work from multiple contributors for a robust coverage of topics throughout the book. We thank them for their time and expertise. We would also like to thank all of the reviewers who carefully looked at the entire manuscript. You have helped shape this book to become a more useful text for everyone.

Acknowledgments

A01_HEBD1010_06_SE_FM.indd 13 3/16/18 8:36 PM

This page intentionally left blank

A01_PERL5624_08_GE_FM.indd 24 2/12/18 2:58 PM

Contributors

Diane A. Anderson, DNP, MSN, RN, CNE Chapter 17: Using Informatics to Educate Associate Professor, MSN Specialty Tracks ~ Nurse Educator, Chamberlain College, Downers Grove, IL

Ami Bhatt, DNP, MBA, RN, CHPN, CHCI Chapter 13: Information Security and Confidentiality Dr. Bhatt is currently enrolled in the DNP to PhD program at University of Nevada, Las Vegas, NV

Sunny Biddle, MSN, RN Chapter 6: Policy, Legislation, and Regulation Issues for Informatics Practice Circulating Nurse in the Operating Room at Genesis Healthcare in Zanesville, OH and Clinical Instructor for Central Ohio Technical College in Newark, OH

Jane M. Brokel, PhD, RN, FNI Chapter 8: Healthcare Information Systems Chapter 14: Information Networks and Information Exchange Section Instructor at Simmons College, Boston, MA Adjunct faculty for the University of Iowa College of Nursing, Iowa, City, IA

Jennifer A. Brown, MSN, RN, HNB-BC Chapter 1: An Overview of Informatics in Healthcare Faculty, Bronson School of Nursing at Western Michigan University in Kalamazoo, Michigan in the undergraduate and RN-BSN programs.

Lisa Eisele, MSN, RN Chapter 19: Connected Healthcare (Telehealth and Technology-enabled healthcare) Chief - Quality, Performance & Risk Management Manchester VA Medical Center, Manchester VA

Sue Evans, MSN RN-BC Chapter 11: System Implementation, Maintenance, and Evaluation Informatics Nurse II University of Pittsburgh Medical Center East, Monroeville, PA

Athena Fernandes DNP, MSN, RN-BC Appendix A: Hardware and Software Appendix B: A Guide to the Internet and World Wide Web Senior Physician Systems Analyst, Penn Medicine Chester County Hospital, West Chester, PA

Carolyn S. Harmon, DNP, RN-BC Chapter 16: Continuity Planning and Management Clinical Assistant Professor and Program Director for the Masters of Nursing Informatics and the Masters of Nursing Administration at University of South Carolina, Columbia, SC

Toni Hebda, PhD, RN-BC, MSIS, CNE Chapter 3: Effective and Ethical Use of Data and Information Chapter 18: Consumer Health Informatics Professor, Chamberlain College of Nursing MSN Program, Downers Grove, IL

Taryn Hill, PhD, RN Caring for the Patient Not the Computer in Chapter 1: An Overview of Informatics in Healthcare Dean of Academic Affairs for Chamberlain College of Nursing, Columbus, OH

Diane Humbrecht, DNP, RN Chapter 12: Workforce Development Chief Nursing Informatics Officer, Abington Jefferson Health, Abington, PA

Kathleen Hunter, PhD, RN-BC, CNE Chapter 3: Effective and Ethical Use of Data and Information Chapter 7: Electronic Health Record Systems Professor, Chamberlain College of Nursing MSN Program, Downers Grove, IL

Brenda Kulhanek, PhD, MSN, MS, RN-BC Chapter 4: Electronic Resources for Healthcare Professionals Chapter 12: Workforce Development AVP of Clinical Education for HCA in Nashville, TN

xv

A01_HEBD1010_06_SE_FM.indd 15 3/16/18 8:36 PM

xvi Contributors

Susan Matney, PhD, RN-C, FAAN Chapter 15: The Role of Standardized Terminology and Language in Informatics Senior Medical Informaticist, Intermountain Healthcare, Murray, UT

Julie McAfooes, MS, RN-BC, CNE, ANEF, FAAN High-fidelity simulation, software, support, and certification in Chapter 17: Using Informatics to Educate Web Development Manager for the online RN-to-BSN Option at the Chamberlain of Nursing, Downers Grove, IL

Jeri A. Milstead, PhD, RN, NEA-BC, FAAN Chapter 6: Policy, Legislation, and Regulation Issues for Informatics Practice Professor and Dean Emerita, University of Toledo College of Nursing, Toledo, OH

Patricia Mulberger, MSN, RN-BC Special Considerations with Mobile Computing in Chapter 13: Information Security and Confidentiality Clinical Informatics Quality Supervisor, Kalispell Regional Healthcare, Kalispell MT

Melody Rose, DNP, RN Chapter 5: Using Informatics to Support Evidence-based Practice and Research Chapter 18: Consumer Health Informatics Assistant Professor of Nursing. Cumberland University Jeanette C. Rudy School of Nursing, Lebanon, TN

Carolyn Sipes, PhD, CNS, APN, PMP, RN-BC Chapter 8: Healthcare Information Systems Chapter 9: Strategic Planning, Project Management, and Health Information Technology (IT) Selection Appendix C: An Overview of Tools for the Informatics Nurse Professor, Chamberlain College, Downers Grove, IL

Rebecca J Sisk, PhD, RN, CNE Virtual Learning Environment in Chapter 17: Using Informatics to Educate Professor, Chamberlain College Downers Grove, IL

Rayne Soriano, PhD, RN Chapter 7: Electronic Health Record Systems Regional Director for Medicare Operations and Clinical Effectiveness. Kaiser Permanente, San Francisco, CA

Nancy Staggers, PhD, RN, FAAN Chapter 10: Improving the Usability of Health Informatics Applications President, Summit Health Informatics and adjunct professor, Biomedical Informatics and College of Nurs- ing University of Utah College, Salt Lake City, UT

Maxim Topaz PhD, MA, RN Chapter 2: Informatics Theory and Practice Harvard Medical School & Brigham Women’s Health Hospital, Boston, MA, USA

Marisa L. Wilson DNSc MHSc RN-BC CPHIMS FAAN Chapter 20: Public Health Informatics Associate Professor and Specialty Track coordinator for the MSN Nursing Informatics program at the Uni- versity of Alabama at Birmingham School of Nursing.

A01_HEBD1010_06_SE_FM.indd 16 3/16/18 8:36 PM

xvii

Janet Baker DNP, APRN, ACNS-BC, CPHQ, CNE Associate Dean Graduate Nursing Programs Ursuline College, The Breen School of Nursing Pepper Pike, Ohio

Theresa L. Calderone, EdD, MEd, MSN, RN-BC Assistant Professor of Nursing Indiana University of Pennsylvania Indiana, PA

Vicki Evans, MSN, RN, CEN, CNE Assistant Professor of Nursing University of Mary-Hardin Baylor Belton, TX

Kathleen Hirthler DNP, CRNP, FNP-BC Chair, Graduate Nursing; Associate Professor Wilkes University, Passan School of Nursing Wilkes Barre, PA

Arpad Kelemen, Ph.D. Associate Professor of Informatics University of Maryland School of Nursing Baltimore, MD

Michelle Rogers, PhD, MS, MA, BS Associate Professor of Information Science Drexel University Philadelphia, PA

Charlotte Seckman, PhD, RN-BC, CNE, FAAN Associate Professor, Nursing Informatics Program University of Maryland School of Nursing Baltimore, MD

Nadia Sultana, DNP, MBA, RN-BC Program Director and Clinical Assistant Professor, Nursing Informatics Program New York University New York, NY

Reviewers

A01_HEBD1010_06_SE_FM.indd 17 3/16/18 8:36 PM

This page intentionally left blank

A01_PERL5624_08_GE_FM.indd 24 2/12/18 2:58 PM

Toni Hebda, PhD, RN-C, CNE, is a professor with the Chamberlain College of Nursing. MSN Program teaching in the nursing informatics track. She has held several academic and clinical positions over the years and worked as a system analyst. Her interest in informatics provided a focus for her dissertation, subse- quently led her to help establish a regional nursing informatics group, obtain a graduate degree in information science, and conduct research related to informat- ics. She is a reviewer for the Online Journal of Nursing Informatics. She is a member of informatics groups and has presented and published in the field.

Kathy Hunter, PhD, FAAN, RN-BC, CNE, is a professor with the Chamberlain College of Nursing MSN Program, teaching in the nursing informatics track. She has more than 40 years of experience in the fields of nursing informatics, healthcare informatics, and nursing education. After conducting clinical prac- tice in critical care and trauma nursing for several years, she began practicing nursing informatics (NI), working with end users and with information systems design, development, testing, implementation and evaluation. She has presented nursing-informatics research in national and international meetings as well as publishing numerous articles in peer-reviewed journals. Collaborating in a com- munity of practice with nursing-informatics faculty at Chamberlain, Dr. Hunter led the work resulting in the development of the TIGER-based Assessment of Nursing Informatics Competencies (TANIC) tool.

About the Authors

xix

A01_HEBD1010_06_SE_FM.indd 19 3/16/18 8:37 PM

This page intentionally left blank

A01_PERL5624_08_GE_FM.indd 24 2/12/18 2:58 PM

1

H er

o Im

ag es

/G et

ty Im

ag es

Chapter 1

An Overview of Informatics in Healthcare Jennifer A. Brown, MSN, RN, HNB-BC Taryn Hill, PhD, RN Toni Hebda, PhD, RN-C

Learning Objectives

After completing this chapter, you should be able to:

• Provide an overview of the current state of healthcare delivery.

• Discuss the role that technology plays in healthcare.

• Provide a definition for informatics.

• Discuss the significance of informatics for healthcare.

• Describe the process required to create an informatics culture.

• Examine the relationship between technology, informatics, and caring.

The healthcare delivery system today is a complex system faced with multiple, competing demands. Among these demands are: calls for increased quality, safety, and transparency; evolving roles for practitioners; a shift in consumer-provider relationships; eliminating dis- parities in care; adopting new models of care; the development of a learning health sys- tem (LHS); advanced technology as a means to support healthcare processes and treatment options; and providing a workforce with the skills needed to work in a highly technology- laden environment that is reliant upon data and information to function.

Technology is a pervasive part of every aspect of society including healthcare delivery. Many suggest that health information technology (HIT) provides the tools to enable the delivery of safe, quality care in an effective, efficient manner while improving communication and decreasing costs (Institute of Medicine, 2012). HIT was named as one of nine levers that stakeholders could use to align their efforts with the National Strategy for Quality Improve- ment in Health Care, a collaborative effort also known as the National Quality Strategy, a mandate of the 2010 Affordable Care Act (ACA). The National Quality Strategy, published in 2011, represented input from more than 300 groups and organizations from various sectors of

M01_HEBD1010_06_SE_C01.indd 1 3/16/18 1:53 PM

2 Chapter 1

healthcare industry and the public (Agency for Healthcare Research and Quality, 2017). Yet, the healthcare sector has been slow to adopt and use technology to its full potential. Lucero (2017) noted that the failure for technology in healthcare to live up to its full promise to the present is not surprising given the complexity of healthcare delivery. So, what is information technology? Information technology (IT) is a broad term referring to the process of search- ing, organizing, and managing data supported by the use of computers. It has also come to include electronic communication. IT represents only a portion of the technology found in healthcare today, but is significant because data leads to information, which in turn provides knowledge. This chapter and the book as a whole will discuss the role that informatics plays to help address the multiple challenges facing healthcare today.

Informatics Before we can discuss the role of informatics in healthcare, infomatics must first be defined. The American Medical Informatics Association (AMIA) (2017, Para. 1) states that informatics is an interdisciplinary field that draws from, as well as contributes to, “computer science, decision science, information science, management science, cognitive science, and organi- zational theory.” Informatics drives innovation in how information and knowledge man- agement are approached. Its broad scope encompasses natural language processing, data mining, research, decision support, and genomics. Health informatics encompasses several fields that include:

• Translational bioinformatics. This area deals with the storage, analysis, and interpretation of large volumes of data. It includes research into ways to integrate findings into the work of scientists, clinicians, and healthcare consumers.

• Clinical research informatics. This area concentrates on discovery and management of new knowledge pertinent to health and disease from clinical trials and via secondary data use.

• Clinical informatics. The concentration here is on the delivery of timely, safe, efficient, effective, evidence-based and patient-centered care (Levy, 2015). Examples include nursing informatics and medical informatics. Nursing informatics has its own scope and standards for practice as set forth by the American Nurses Association (ANA) as well as certification established by the American Nurses Credentialing Center (ANCC) ( American Nurses Association, 2015a). AMIA began the process, in 2007, of defining clini- cal informatics and its competencies, to lay the foundation for a credentialing process to recognize competence of clinical informaticists (Shortliffe, 2011). There is also discussion at a global level on specialty-board certification for physicians in clinical informatics (Gundlapall et al., 2015).

• Consumer health informatics. The focus here is the consumer, or patient, view and the structures and processes that enable consumers to manager their own health.

• Public health informatics. Efforts here include surveillance, prevention, health promotion, and preparedness.

As might be surmised from a review of the above list, there are areas of overlap among the fields.

Informatics and its subspecialties—including nursing informatics—continue to evolve as has the terminology used to discuss this field. For example, medical informatics was previously used as the umbrella term under which the subspecialties of health informatics fell.

M01_HEBD1010_06_SE_C01.indd 2 3/16/18 1:53 PM

An Overview of Informatics in Healthcare 3

The Relevance of Informatics for Healthcare Informatics is an essential component of healthcare today. The Institute of Medicine (2013a) noted its vision for the development of a continuously learning health system in which sci- ence, informatics, incentives, and culture are aligned for continuous improvement and inno- vation, and new knowledge is captured as a by-product of care processes. Together, HIT and informatics have been hailed as tools that can streamline processes, improve the quality of care delivered, reduce mortality, cut costs, and collect data to support learning (Institute of Medicine, 2012, 2015; Kohli & Tan, 2016; Lucero, 2017; Luo, Min, Gopukumar, & Yiqing, 2016; McCullough, Parente, & Town, 2016; Pinsonneault, Addas, Qian, Dakshinamoorthy, & Tamblyn, 2017). In fact, the Institute of Medicine (2013b, p. 1) stated that “digital health data are the lifeblood of a continuous learning health system.” Achieving this learning health system will require the work of many individuals and organizations.

There are several factors to consider on the journey to a learning healthcare system. These include:

• Healthcare professionals are knowledge workers.

• Structures must be in place to support the collection, interpretation, and reuse of data in a meaningful way.

• Evidence-based practices are a pre-requisite to achieving optimal outcomes.

• Big data and data analytics are quickly becoming a major source of evidence, augment- ing, and even replacing, other traditional forms of evidence such as clinical trials.

• HIT and all forms of technology are present but best use is inconsistent.

• Healthcare reform and a learning healthcare system are intricately linked.

• Patient safety and the need to improve quality of care are drivers for healthcare reform.

Each of these will be discussed briefly.

Knowledge Work Nurses and other healthcare professionals have a long tradition of gathering data, which is then used to create information and knowledge. When previous knowledge and experience are applied appropriately to take action or intervene in some fashion, it is known as wisdom. These processes constitute a major part of the clinician’s day and, when done well, yield good outcomes. As an example, a piece of data without context has no meaning. The number 68 in isolation conveys nothing. It could be an age, a pulse rate, or even a room number, but in and of itself, there is no way to know what it means. However, if 68 is determined to be a pulse rate, the nurse can make the determination that this falls within the normal range, indicating that the patient is in no distress and requires no intervention. On the other hand, if that same number represents the rate of respirations per minute, the patient is in respiratory distress and immediate intervention is required.

Gaberson and Langston (2017) noted that changes in the healthcare system, inclusive of demands for safe, accessible, quality care, have increased both the awareness of and demand for well-prepared knowledge workers. Gaberson and Langston also cited the assertion of the landmark 2010 Institute of Medicine report, The Future of Nursing: Leading Change, Advancing Health, that nursing is an appropriate profession to play a major role in transforming the healthcare system; yet, nursing education has not adequately prepared its graduates for this role. As a consequence, there is a need to better prepare nurses—and other healthcare professionals—during their basic education for this role and to provide better options to aid

M01_HEBD1010_06_SE_C01.indd 3 3/16/18 1:53 PM

4 Chapter 1

the new professional to assume the knowledge-worker role and to maintain essential com- petencies in this area.

Structures to Support Meaningful Use of Data To be useful, data and information must be available when needed, to whom it is needed, and in a form that can be analyzed or used. Historically, the healthcare delivery system has collected huge amounts of data and information from different sources and in different formats, creating data silos within departments and facilities. Without organization, this data and information has limited value, even at its collection site, and is not amenable to sharing for learning purposes. The use of electronic health records (EHRs) moved data and information to a digital format, which is conducive to organization, analysis, and sharing, but differences in format still make analysis difficult. Data exists in raw and processed states and unstructured and structured forms. Examples of unstructured data include docu- ments, email, and multimedia. Structured data fits into predetermined classifications such as that seen with a list of selectable options that can easily be quantified. Even before the widespread adoption of EHRs, there was a growing recognition that improved commu- nication among professionals required the adoption of standardized languages and ter- minologies to ensure that a concept had the same meaning in all settings; this also makes generalization of research findings possible. One example of a standardized language that is familiar to most nurses is NANDA, which was created by the North American Nursing Diagnosis Association to provide standardized terms for nursing diagnoses. Standardized languages and terminologies can be integrated into EHRs. A lack of data standardization jeopardizes opportunities for learning because important data may not be available for analysis ( Auffray et al., 2016). Standardization of data and its collection in a digital format in databases facilitate collecting, sorting, retrieval, selection, and aggregation of data to a degree never before possible. Aggregate data can be analyzed to discover trends and, subsequently, to inform and educate.

Researchers use both qualitative and quantitative methods to analyze data. Qualitative methods focus on numbers and frequencies, with the goal of finding relationships or vari- ables specific to an outcome. Qualitative methods are variable and not focused on counting. These methods can include any data captured. This data can be in the form of questionnaires, surveys including web surveys, interviews, list serves, and email. Electronic data collection tools include personal digital assistants or laptop computers.

Another important facet of information access is related to the electronic literature data- bases for the health sciences, business, history, government, law, and ethics that healthcare professionals and administrators use to keep up-to-date and inform their practices. Libraries purchase electronic literature databases that users can easily search using keywords, Boolean search operators, title, author, or date to find relevant information. Literature databases use key terms to index collections. Medical subject headings (MeSH) are used by the controlled vocabulary thesaurus of the National Library of Medicine (NLM) to index articles in PubMed, a free search engine maintained by the NLM. PubMed is used to access the MEDLINE biblio- graphic database. Some other examples of literature databases relevant for healthcare include EBSCO, Ovid, ProQuest, CINAHL, and Cochrane Library. Becoming familiar with the data- bases most relevant to one’s purpose or focus is important. Adept use requires time and practice. When searching a database, one should define the subject and the question; then, search for the evidence in multiple components of the literature: for example, use evidence from multiple studies (not just one random study), incorporate what was learned into prac- tice, and evaluate the impact of what was implemented.

M01_HEBD1010_06_SE_C01.indd 4 3/16/18 1:53 PM

An Overview of Informatics in Healthcare 5

Evidence-Based Practice Evidence-based practice (EBP) entails using the current best evidence for patient-care decisions in order to improve the consistency and quality of patient outcomes (Mackey & Bassendowski, 2017). It requires critical thought processes. EBP provides the foundation for clinical-practice guidelines and clinical decision-support tools that are widely found in health- care organizations today. EBP in nursing evolved from Florence Nightingale’s idea that she could improve patient outcomes through systematic observations and application of subse- quent learning. EBP has been further defined by the International Council of Nurses (2012) as an approach that incorporates a search for the best available, current evidence with clinical expertise and patient preferences.

Big Data and Big Data Analytics According to the National Academies of Sciences, Engineering, and Medicine (2017), a learning health system is one that uses real-time evidence for continuous improvement and innovation. The implications of real-time evidence are that traditional research and publication cycles where months, or even years, transpire from the time of research until dissemination of results no longer satisfy the criteria for best evidence because data may no longer be current or timely. Real-time data for analysis requires different methods, tools, and dissemination methods. Enter big data and big data analytics.

Big data are very large data sets that are beyond human capability to manage, let alone ana- lyze, without the aid of information technology. Big data has been collected for years by retail- shopping organizations. As an example, consider the shopper’s card that nearly everyone has for their favorite grocery store. In exchange for special store discounts on select merchandise or points earned for discounts, the store collects information on shopper preferences every time the card is used. The aggregate data that healthcare providers collect via their EHRs is a type of big data. Another example of big data is seen when healthcare providers submit data collected for meaningful use core data (with one exemplar being smoking status) to the US Centers for Medicare and Medicaid Services (CMS) (2010), CMS analyzes the data for trends, with the intent to better allocate funds and services to improve care coordination and population health.

Big data, and the technologies used to reveal the knowledge within it, provide new opportunities for healthcare to discover new insights and create new methods to improve healthcare quality (Luo, Min, Gopukumar, & Yiqing, 2016). Furthermore, the computing speed associated with big data (Kaggal et al., 2016) provides a promising development to make the LHS possible. A new science, known as data science, has emerged to deal with all aspects of big data including data format, cleaning, mining, management, and analysis.

Analysis of big data, or analytics, looks for patterns in data, then uses models to recommend actions (Wills, 2014). Analytics can be used to forecast the likelihood of an event. Real-time analytics use current data from multiple sources to support decisions; this may result in powerful tools useful at the bedside as well as to support executive-level thought processes. Business intelligence is another term that is used when discussing best use of data, although business intelligence is a broader term that encompasses a plan, strategy, and tool sets to support decisions.

Increased Prevalence of Technology in Care Settings According to recent projections, US hospital adoption of EHRs is expected to surpass 98% by the end of 2017, with adoption by physicians running slightly below that figure (Bulletin Board, 2016; Orion Market Research, 2017). EHRs are also found in long-term care settings,

M01_HEBD1010_06_SE_C01.indd 5 3/16/18 1:53 PM

6 Chapter 1

although adoption rates there lag behind hospital and physician-office settings (EHR Adop- tion, 2017) . There are also many different types of technology found at the bedside, or point of care. These range from point of care computer terminals to access patient records or lit- erature databases to monitoring biometric measures such as pulse, heart rate and rhythm, blood pressure, oxygen saturation, and many tests that were formally only done in labora- tory settings. There are also medication-dispensing cabinets, smart-technology that includes medication-administration infusion pumps that link with provider order entry, pharmacy, and medication-administration systems for greater safety. A growing number of implantable devices such as insulin pumps, pacemakers, and defibrillators, and various telehealth appli- cations such as telestroke consultations that allow the neurologist at another site to evaluate and communicate with the stroke victim and attending family and care givers. There are also telesitter applications that allow an individual at a central location to monitor several patients at one time, observing them for attempts to get out of bed without assistance, and having the capability to verbally reorient them or call for further assistance. Many of these technologies already have the capability to communicate and input data into EHRs. There are also voice- activated, hands-free communication devices for staff use. Technology is supplementing work once done by ancillary staff. There are robots that deliver supplies while other robots use ultraviolet light to disinfect patient rooms and operating rooms.

The range of technology available in the home includes telemonitoring and care devices to track congestive heart patients, the mentally ill, and many more conditions. The number and range of mobile applications available to track wellness and manage chronic healthcare conditions is growing at an exponential rate. Patients have implantable devices to monitor their cardiac function, control seizures, control pain, and control the function of prosthetics. Robots to assist with care are expected to become commonplace in the near future.

The move to a technology-laden environment has implications for informatics. Informat- ics specialists are prepared to design, implement, and evaluate technologies that support healthcare providers and consumers.

Healthcare Reform Health reform has many drivers. The United States spends more per capital on healthcare than any other nation in the world, without commensurate results (Robert Wood Johnson Foundation, 2017). In one effort to enact change, value-based payment models reward pro- viders for quality of care provided and efficient resource use rather than volume of services. In another effort, the enactment of the American Recovery and Reinvestment Act (ARRA) in 2009, along with its component Health Information Technology for Economic and Clinical Health (HITECH) Act, provided economic stimuli and incentives for the adoption of EHRs, in alignment with the goal that each person in the United States would have a certified digital health record by 2014. As of 2016, this goal was achieved by more than 98% of nonfederal acute care hospitals. These digital records meet the technical capabilities, functionality, and security criteria promulgated by the Center for Medicaid and Medicare Services (Office of the National Coordinator for Health Information Technology, 2017a). The push for EHRs was consistent with the thinking that a longitudinal health record would improve access to infor- mation and consequently improve care. HITECH also ensured the collection of aggregate data that could be used to improve policy decisions relative to allocation of services and population health. Digital data also facilitates collection of data needed to measure quality of healthcare delivery, as well as improving data dissemination, as digitation allows easier data sharing.