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Fifth Edition

Informatics and Nursing Opportunities and Challenges

Informatics and Nursing Opportunities and Challenges

Fifth Edition

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

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5th edition

Copyright © 2016 Wolters Kluwer

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

2015013707

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

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

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

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

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

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

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

About the Author

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

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

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

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

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

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

Judy Hornbeck, MHSA, BSN, RN Highland, Illinois

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

viii    Reviewers

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

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

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

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

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

Anne Krouse, PhD Professor Widener University Chester, Pennsylvania

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

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

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

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

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

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

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

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

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

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

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

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

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

Reviewers    ix

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Preface    xiii

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

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

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

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

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

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

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

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

JJ Learning Management System Cartridges.

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

access to current research available in Wolters Kluwer journals.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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