Informatics in nursing

Reading Hood, L. J. (2014). Leddy & Pepper’s conceptual bases of professional nursing (8th ed.). Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkins.  Chapter 15: pp. 380–383 and 397–402 380 Section 2 The Changing Health Care Context Real-Life Reflections (Continued) computer systems and technology they use in practice. Susan poses the following questions during their discussion: “I know that computers are wonderful, but how can I get my older staff members to overcome their computer phobia? How can we ensure confidentiality of client information with computerized medical records? What key elements need to be included in an employee policy related to computer use and confidentiality of information? How much time is actually required of staff for computer documentation? What are the legal implications for nurses who use technology for remote client monitoring?” For optimal professional practice and client care, nurses must have well-refined computer skills. This chapter provides an overview of the informatics and technology used in today’s nursing practice and explores the implications for professional nurses as technology plays an increasingly important role in health care delivery. Key computer competencies for professional nursing and advances in technology for clinical practice are presented. Finally, the chapter challenges students to consider the advantages, dis- advantages, and ethical issues of technology use for client care. Changes in technology occur quickly. In fact, by the time this chapter is published, some of the information presented will likely already be obsolete. Faster, improved models of computer equipment seem to be introduced just as soon as the latest model has been purchased. New materials superior to silicon continue to make computer chips smaller and faster. In fact, purchasing a hard copy of any book (including this one) may one day be a rarity, especially with the proliferation of e-readers capable of storing hundreds of books. Every day, more and more nurses access, record, and store clinically relevant information via computer. InformatIcs and HealtHcare: The average person today has access to more information online than a single person could possibly comprehend in a lifetime. Information science deals with the discovery of “efficient collection, storage, and retrieval of information” (Agnes, 2005, p. 733). Informatics, or the science of information (Agnes, 2005), has emerged as the practical application of organizing information for a specific purpose. Because of the wide array of information avail- able, devising effective methods for organizing and managing it is imperative. Essential information in one area of life may be irrelevant in another. For example, how informatics is used to generate, store, manage, and communicate information for computer gaming has little relevance to health care providers (unless a provider is working in the field of neuroscience and is studying the effects of computer gaming on memory). Take Note! In professional nursing, informatics plays a critical role in how nurses access, enter, manage, and store key knowledge essential for professional practice and client care. Informatics and Professional nursing Nurses use a variety of computers in daily clinical practice. Nurses document various aspects of client care using computers, thereby creating an electronic health record (EHR) for each client. An EHR stores client health information digitally in a secure database. When consumers receive care from an integrated health system, EHRs can be accessed nearly seamlessly. Section 1561 of the 2010 Affordable Care Act sets regulations for EHR use across the care continuum and for the security of the protected health information contained in them, and sets specific dates for regulation implementation (HealthIT.gov, 2010). In the future, all health care providers across the continuum of care will be able to access EHRs when consumers receive care services. Many people keep personal health records. Informatics in nursing

Those who are computer savvy keep personal electronic health record (PEHR). PEHRs emerged when people entered their personal health information into their home computers. Today, a number of insurance companies and primary care provider practices offer software or online tools for consumers to develop and maintain. Some PEHRs are stored in secure electronic databases; others can be accessed using smart phones. Benefits of a PEHR include error reduction and seamless health care delivery. A PEHR enables a new care provider to access specific health information about a client, including diagnostic tests (including viewing digitalized radiographic films if the PEHR is linked to an integrated health care delivery system), accurate lists of currently prescribed medications, and up-to-date thirdparty payment information (Nelson, 2007). Unfortunately, there are no universal or standardized versions of EHRs or PEHRs. The American Health Information Management Association keeps records of progress toward standardization and policy development about electronic health information on its website. The “Putting Patients First” initiative from the National Health Council was the first to specify that health information to be “portable, belong to the patient, and empower the patient to make informed decisions regarding care” (Nelson, 2007, p. 27). The National Health Council also emphasized the importance of standardization of electronic platforms used for PEHRs so that when a person changes insurance coverage or health care providers there is no loss of health information. The Affordable Care Act has also set regulations defining criteria for standardization of PEHRs (HealthIT.gov, 2010). Informatics in nursing

Currently, more than 60 software programs are available for PEHRs; some offer the ability of transfer of data between software programs. Hospitals, outpatient facilities, physician offices, and integrated health care systems currently purchase computer platforms and software for keeping client EHRs and some offer clients access to PEHR software programs. Some physician offices send annual reminders to clients to update PEHRs. Logue and Effken (2012) developed the Personal Health Records Adoption Model to explain why some people decide to use PEHRs. This model identifies four interactive factors that contribute to behavior required for PEHR adoption by health care consumers. 1. Personal factors encompass cognitive abilities, emotional attributes, and biologic characteristics that influence decisions for changing behaviors (intention to act and actual action). 2. Environmental factors include social and physical conditions that influence behavior. 3. Technology factors include resource avail- ability, compatibility, and cost; perceived usefulness; perceptions of external control; ability to observe and try the system; complexity; and relative advantage. 4. Chronic disease factors are separated from personal factors based on the belief that self- management of and chronic diseases them- selves create specific contexts and a variety of influencing factors, especially when people with chronic disease have specific care preferences, understand the complex nature of their disease, see multiple health care providers in various settings, engage in negotiated collaboration with health team members, and prefer to self-manage their condition. Before people adopt PEHRs, they need to have some ability to understand and use computer technology, perceive that PEHRs would be useful and advantageous, and have the time to enter and update personal health data. Nurses can assist clients directly by helping them enter data or indirectly by providing education, sup- port, and guidance as clients develop and maintain their PEHRs. Many nurses currently use computer tab- lets, smartphones, and other electronic devices with software or apps for managing daily tasks, keeping calendars, calculating medication dos- ages or complex clinical calculations (e.g., body mass index, corrected serum calcium levels), and consulting clinical references (e.g., medication information and terminology, disease references, medical calculation software programs).Informatics in nursing

Some health care organizations issue unit cell phones to nurses for use in the clinical setting to facilitate staff communications. Most health care organizations provide convenient ways for nurses to access and document information in client EHRs, such as having computers in every room, providing mobile, laptop, or tablet computers, or placing computers in strategic locations throughout the work setting. computer and Informatics competencies for Professional nurses Computer use in health care delivery became prevalent in the early 21st century. In their pioneering efforts to determine professional nurse knowledge and skills in informatics, Staggers, Gassert and Curan (2001, 2002) conducted a Delphi study that serves as the basis for today’s competencies. The 2003 Institute of Medicine report, Health Professions Education: A Bridge to Quality, noted deficits in current education of all health professionals, including the following six core areas that needed vast improvement: patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics (these are also the six key areas for Quality Safety Education for Nurses [QSEN] competencies). In 2004, President Bush issued a mandate that required all American health organizations providing direct client care to use EHRs by 2014. To meet this challenge, professional nurse leaders, educators, and informatics experts recognized the need to develop a vision for integrating informatics into practice, education, and research (Sherwood & Barnsteiner, 2012). In 2006, the Technology Information Guiding Education Reform (TIGER) Initiative established seven “pillars” or key areas for nursing workforce development: management and leadership, education, communication and collaboration, informatics design, information technology, policy, and culture. The final report resulted in the TIGER Nursing Informatics Competencies Model, which addresses the basic computer competencies, information literacy, and information management skills nurses need. Listed competencies from the model have become part of most baccalaureate and higher degree nursing pro- grams (TIGER Summit, 2007).

In 2008, the American Association of Colleges of Nursing (AACN) revised its criteria for program accreditation to include informatics competences. The current AACN recommendations for professional nurse generalists outline the following informatics skills that nurses are expected to have. • Use information and communication technology to document and evaluate patient care, advance patient education, and enhance the accessibility of care. • Use appropriate technologies in the process of assessing and monitoring patients. • Work in an interdisciplinary team to make ethical decisions regarding the application of technologies and the acquisition of data. • Adapt the use of technologies to meet patient needs. •Teach patients about health care technologies. • Protect the safety and privacy of patients in relation to the use of health care and information technologies. • Use information technologies to enhance one’s own knowledge base. In 2009, QSEN established specific knowledge, skills, and attitudes for all professional nurses to achieve to display competency in nursing informatics (and in the aforementioned key areas). The experienced nurse must be able to use applications for diagnostic coding, evaluate computer-assisted instruction as a teaching method, and integrate selected resources into a client file. The experienced professional should also be able to define how computerized information affects the nurse’s role, assess the accuracy of health information posted on the internet, and serve as an advocate for client system users. Box 15.1, Professional Building Blocks “Check- list for Professional Nurse Competencies in the Use of Technology and Informatics” provides a tool for nurses to verify their level of competence with informatics and technology for general clinical practice. Nurses who specialize in nursing informatics have additional advanced competencies such as developing backup systems in the event of a computer systems failure, designing software programs applicable to clinical care settings, and troubleshooting software and computer system problems as they arise.

EVERYDAY INFORMATICS Why Nurses Need to Understand Nursing Informatics DEE McGONIGLE, PhD, RN, CNE, FAAN, ANEF; KATHY HUNTER, PhD, RN-BC, CNE; CAROLYN SIPES, PhD, RN-BC, CNS, APN, PMP; TONI HEBDA, PhD, RN-BC, MSIS, CNE N ursing informatics is an exciting nursing specialtydit affects learning environments, meaningful use, interprofessional collaboration, patient care settings, strategic planning, patient satisfaction, and, ultimately, patient outcomes. Simply put, nursing informatics is the practice of using nursing science and technology to enhance the pathway that data take to become knowledge to improve patient care. Furthermore, nursing informatics “is the synthesis of nursing science, information science, computer science, and cognitive science for the purpose of managing and enhancing health care data, information, knowledge, and wisdom to improve patient care and the nursing profession.”1(p90) According to Hebda and Czar, it is “broadly defined as the use of information and computer technology to support all aspects of nursing practice, including direct delivery of care, administration, education, and research. The definition of nursing informatics is evolving as advances occur in nursing practice and technology.”2(p6) Nursing informatics is important to all nursing specialty areas. It is important for nurses to understand the relevance of nursing informatics to their practice.

In clinical practice, for example, nursing informatics can be used to track patient outcomes, find data trends, and assess workload and interventions. It also can help develop technologies, such as apps, to help health care workers virtually monitor and stay in touch with patients, improve workflows, and help patients deal with their diseases. The use of nursing informatics in nursing education supports virtual teaching and learning, assessment, analytics associated with educational outcomes, and the paradigm shift of bringing the library to the student virtually. Nurse executives use nursing informatics to help them with cost containment, improved workflows, decision support, budgeting tools, and trending costs and savings. Nursing informatics also can facilitate and support nursing research by evaluating patient outcomes, evidence-based practice, standardized terminologies, and virtual knowledge bases. As nurses learn nursing informatics, they must learn to use all information technologies effectively, recognize the benefits and limitations of this technology, and integrate them into how they implement these technologies. In this era of large amounts of data, nursing informatics competencies are key to safe, efficient, and quality practice, and good use of nursing informatics can result in enhanced patient care outcomes. THE DATA, INFORMATION, KNOWLEDGE, AND WISDOM PATHWAY The principles and practices of nursing informatics allow nurses to understand the process they use to convert raw data into the wisdom they need to care for patients. This process is called the data, information, knowledge, and wisdom pathway. The data, information, knowledge, and wisdom Informatics in nursing http://dx.doi.org/10.1016/j.aorn.2014.06.012 324 j AORN Journal  September 2014 Vol 100 No 3 Ó AORN, Inc, 2014 EVERYDAY INFORMATICS www.aornjournal.org are not synonymous, because knowledge includes pathway is used in all levels of nursing practice. As others’ thoughts and information, whereas wisdom nurses access data and process it into information is focused on one’s own mind and the synthesis of and knowledge, they build the wisdom necessary one’s own experience, insight, intuition, underto positively affect the lives of their patients. standing, and knowledge. Wisdom could be Nursing informatics provides the tools and capathought of as the foundation of the art of nursing. bilities necessary to enrich the data, information, knowledge, and wisdom pathway and, therefore, literally puts the information and knowledge nurses PERSONAL IMPORTANCE need at their fingertips.

The focus of this new “Everyday Informatics” The pathway begins with data. Data are raw column is to help nurses understand and implement facts that do not have meaning without context. the concepts of nursing informatics and optimize After data have been processed to have meaning, patient care by using health care technology. Exthey become information. For information to be amples of concepts and topics that will fit within valuable, it must be accessible, accurate, timely, this column include electronic health records (EHR) complete, cost effective, flexible, reliable, relevant, personal health records, electronic access to simple, verifiable, care (eg, telehealth), and secure. terminologies and The next step is taxonomies (eg, the Nursing informatics provides the tools and for information to capabilities necessary to enrich the data, Perioperative Nursing information, knowledge, and wisdom pathway become knowledge, Data Set3 language), and, therefore, literally puts the information which is information virtual environments, and knowledge nurses need at their fingertips. that the user can relate social networking and to other information professional boundand can apply to a task aries, simulation, or use to reach an informed decision. As nurses robotics, databases and database management, acquire important knowledge and skills and hone analytics, dashboards and benchmarking, accessitheir ability to observe patients and their environbility, privacy, meaningful use, and optimization. ments (ie, acquiring more data), they learn to place Innovative ideas and questions of how perioperatheir observations in proper contexts to generate tive nurses embrace the rapid advancement of information. As their knowledge grows, nurses technology and retain the art of the practice at can assess the information they have acquired, the same time generates content for this column.

communicate applicable findings, and take approThe team members who will be writing this priate actions based on these assessments. Nursing column with me are Kathy Hunter, Toni Hebda, informatics informs and supports these activities. and Carolyn Sipes. I asked them each to say why Wisdom, the final step on the pathway, is the they believe nursing informatics is important. Their application of knowledge to appropriate situations responses are included here. by using insight or intuition while being thoughtful, judicious, and practical. Nurses need to apply their Monitoring Patients knowledge to patients’ situations and rely on their Kathy Hunter: Years ago, when I was working knowledge, integrated with evidence-based practice, full time nights in the Maryland Shock-Trauma to enhance patient care. Wisdom uses knowledge Unit, we had computer display units in every paand experience to heighten common sense, pertient cubicle that were connected to patient moniceptions, and the ability to think critically and use toring equipment. Laboratory data were provided sound clinical judgment.

Knowledge and wisdom directly from the trauma laboratory. Vital signs AORN Journal j 325 September 2014 Vol 100 No 3 EVERYDAY INFORMATICS work. Today, the informaticist functions in the role data were collected from the monitors. Critical of a facilitator for information technology and parameters could be automatically calculated or clinical staff members as well as performs many requested as needed. Any paramet …