MATA, REENA MAYE E.

SISON, NIKE JOY

OBJECTIVES
1. Review the history of informatics in healthcare and nursing.
2. Document the current definition of nursing informatics and its evolution.
3. Describe the national scope and standards of nursing informatics
4. Delineate the informatics competencies for all nurses and as
5. Identify the major applications of informatics within nursing practice
6. Identify some future trends in computer use in nursing practice.

KEY WORDS
• historical perspectives of documenting nursing practice
• information systems for nursing practice
• standards for nursing practice
• care planning
• outcomes management
• discharge planning

HISTORICAL PERSPECTIVES
• More than 150 years ago, Florence Nightingale spoke about the critical importance of
nursing informatics in patient care. "Decision making must be based upon the use of
accurate data," she said (Ulrich, 1992, p. 68). The nursing pioneer also spoke of frustration
from the difficulties of extracting such critical patient-related data from hospital records:
• In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely
an instance have I been able to obtain hospital records for any purposes of comparison. If
they could be obtained they would enable us to decide on many other questions besides the
ones alluded to. They would subscribers how their money was being spent, what amount of
good was really being done with it, whether the money was not doing mischief rather than
good. (Nightingale, 1859, p. 187)
• It was more than a century after Florence era that computers made their appearance on the
hospital landscape.
• The first hospital information systems arrived late 1950s to the mid-1960s, although these
systems focused primarily on financial and administrative information.
• In 1965, the Anyrican Hospital Association conferences for hospital administrators signalled
the emerging move toward more clinical adaptations of such systems in healthcare (Hannah,
Ball, and Edwards, 1994, pp. 32—33).
• In the 1970s, the advent of the silicon chip allowed them to shift from one large
supercomputer to smaller computers that could be adapted for many different applications
throughout the hospital system.
• By the 1980s, the computer was being used for diverse hospital functions such as radiology,
pharmacy, and laboratories. At this time, there emerged "a Strong drive within healthcare to
understand how clinicians would use the new tools to advance practice" (Zytkowski, 2003, p.
273).
• Throughout the 1990s, expanded uses of computers evolved as nurses in keeping with the
traditions begun 100 years before Florence Nightingale used computers to improve patient
care and conduct research by analyzing patient trends, variability in practice, and outcomes
of care. Nursing informatics at this time was characterized concerns about accessibility, and
compatibility. and overall integration of informatics efforts within nursing practice and the
entire healthcare system. That contemporary system of healthcare has been described by
Carry (2001) as new terrain that is no longer confined to "hallowed halls of brick and mortar
institutions." "Instead," said Corry. "it has become a point-and-click system with leveled
boundaries that promotes unfettered public access to healthcare information and
nontraditional communication between providers and patients" (p. 11). It is in this new point
and click system that contemporary nurses, in order to practice their profession, must build
new competencies that reflect the digital era of healthcare.

• According to Zytkowski (2003), such competencies are needed because "nursing informatics
is foundational to all areas of nursing practice" (p. 279). Snyder-Halpern and Chervany
 (2000) suggest that success with informatics is not only foundational but also key to survival
in the modern-day healthcare industry:
• The ability Of healthcare delivery networks to effectively manage and leverage clinical
information to meet strategic clinical goals is a cornerstone of their transformation and
survival as integrated information-based clinical enterprises. (p. 591)

NURSING INFORMATICS: AN EVOLVING DEFINITION

• One view of the Changing nature of nursing practice can be seen through the evolving
definition of nursing informatics.
• According to ANA (ANA, 2001), since 1980. nursing informatics has been defined broadly
either with a focus on the technological aspects, on the concept of nurses interacting with
technology to produce greater knowledge, or on the role of nurses who specialized in
developing applications of nursing practice.
• In 1989 , Graves and Corcoran set forth what had become the most widely accepted
definition
• nursing informatics is a "combination of nursing science, information science, and computer
science to manage, and process nursing data, information, and knowledge to support the
practice of nursing and the delivery of nursing care" (p. 227).
• This definition suggested that with a combination of three core sciences, nursing informatics
is a unique and distinct specialty.
• The expanding role of the informatics nurse specialist was incorporated into a new definition
published in 1992 by ANA's Computer Applications in Nursing:
• A specialty that integrates nursing science, computer science, and information science in
identifying, collecting, processing and managing data and information to support nursing
practice, administration, education, and research; and to expand nursing knowledge. The
purpose of nursing informatics is to analyse information requirements; design, implement
and evaluate information systems and data structures that support nursing, and identify and
apply computer technologies to nursing. (ANA, 1992)
• Two years later, the ANA again revised this definition by replacing specifics about the
systems life cycle with a more general description of nursing informatics which suggested
that:
• Nursing informatics supports the practice of nursing specialties in all sites and settings
whether at the basic or advanced levels. The practice includes the development of
applications, tools, processes, and structures that assist nurses with the management of
data in taking care of patients or in supporting their practice of nursing. (ANA, 1994)

Although these definitions reflect various aspects Of computer use in nursing, they did not
acknowledge and incorporate what the ANA describes as "phenomena of nursing"—the nurse,
patient, health And environment—in combination with the other critical elements which are relevant
to nursing informatics:

• Data, or the discrete entities that are described objectively without interpretation;
• Information or data that are interpreted, organized or structured;
• Knowledge, or information that is synthesized so that relationships can be identified and
• formalized;
• Nursing science, information science, and computer science
• Decision-making, or the process of choosing among alternatives;
• Information technology, which includes computer hardware, software, communication
• and network technologies derived primarily from computer science;
• Information structures, which organize data, information, and knowledge for processing
by computers; and, Information management and communication.(ANA, 2001. pp. 6-11)
As depicted in Fig. 20.1, these diverse elements are involved in the dynamic process by which
nurses use computers to make sound database and content-specific decisions about patient care. In
anticipation of a new definition of nursing informatics for the twenty-first century, the ANA suggested
that historical definitions' under emphasized the role of the patient in informatics and participatory
decision-making, neglected the importance
of both context and information communication, and focused too narrowly on data and information
within decision-making (ANA, 2001, p. 17).

Thus, the 2001 ANA Scope and Standards Of Nursing Informatics offered the newest definition

Nursing informatics is a specialty that integrates nursing science, computer science, and information
science to manage and communicate data, information, science to manage and communicate data,
information, and knowledge in nursing practice. Nursing informatics facilitates the integration of data,
information, and knowledge to support patients, nurses, and other providers in decision-making in all
roles and settings.

The goal of nursing informatics, said the ANA, is to:

• Improve the health of populations, communities, families, and individuals by optimizing

information management and communication. This includes using Technology in the direct
provision of care establishing administrative systems; managing delivering educational
experiences, supporting life-long learning and supporting nursing research (p. | 7)

This description of nursing informatics reflects the key tenets of contemporary nursing informatics
which, as identified by the ANA, include clinical and non-clinical aspects Of practice; the importance
of human factors (human-computer interaction, ergonomics, and usability ) in decision-making; the
focus on delivering the right information to the right person at the right time; concerns about and
committed to ensuring the confidentiality and security of health care data and information advocating
privacy; the central emphasis on the improvement of quality of patient care, welfare of the health
care consumer and patient outcomes and the importance of collaboration with other areas within
informatics. (ANA, 2001, pp. 22-23)

WHAT DIFFERENTIATES NURSING INFORMATICS FROM THE BROADER CATEGORY OF

HEALTHCARE INFORMATICS?

In 1997, the National Advisory Council on Nursing Education and Practice suggested that the
general field of
care informatics included

• identifying information to collect and process; creating databases;

• developing user-friendly data entry and retrieval screens;
• Educating users to work with and maximize available information resources
• installing and maintaining hospital information system
• developing distance education and telehealth systems information exchange.

STANDARDS FOR PRACTICE

In 2001, an ANA work group and revised the existing and standards of nursing informatics practice.
The new standards (ANA, 2001) built on the previous scope and standards of practice published by
the ANA Force to Develop Measurement Criteria for Standards Nursing Informatics (ANA, 1995). As
described earlier, these new ANA standards have documented the evolving definition of nursing
informatics that parallels the rapid evolution of informatics in Healthcare. These new standards
repeatedly emphasize the central role that information plays in the practice of nursing and the
importance for all nurses, beyond those who specialize in nursing informatics, to develop their skills
in managing and communicating information.

PROBLEM SOLVING AS AN ORGANIZING FRAMEWORK

• According to the ANA (2001), this "problem-solving framework supports all
• All facets of informatics practice, including those without technology and all
• Areas of nursing practice, including those without technology and all areas of nursing
practice
• And that the standards are overarching and "inherent in every aspect of practice"
• The first standard "assessment" involves using data, information, and knowledge to clarify
the presenting issue or problem. This process focuses on collecting data with different
methodologies such as structured system and different methodologies such as structured
systems and workflow analysis and from a variety of sources such as stakeholders who are
close to the problem.
• The second standard calls for identifying and evaluating possible solutions to information
issues. This includes developing functional and technical specifications based on identified
needs, designing new models for informatics solutions, considering costs and return on
investment of informatics solutions, identifying measurable outcomes and terminal objectives
and advocating for informatics solutions with key stakeholders.
• The third standard includes all activities related to the identification of an appropriate
informatics solution and planning for its application. It is at this stage that the informatics
specialist skillfully matches the capabilities and limitations of hardware and software. This
matching process involves many factors such as economic, technical, and human resources.
• Implementation is the fourth standard in which the informatics specialist acts as a process
consultant and project manager for all interventions and activities related to the informatics
application. This can involve a myriad of activities ranging from internal and external
marketing, system testing, and training.
• Finally, the sixth standard sets forth criteria to be used for the efficiency and effectiveness of
decisions, plans, activities and applications that are evaluated. This ongoing process serves
 as a means of not only evaluating the structure, process and outcome of not only evaluating
the structure, process, and outcome of the informatics solutions but also the net effects of
the informatics solution, but also the net effects of the informatics solution on nursing
practice
• In addition to standards of practice, the 2001 ANA guidelines include standards that guide
the work performance of nurses who specialize in informatics. Performance standards, while
designed for specialists in nursing informatics, provide a helpful resource for other nurses
who wish to enhance their competencies in this important and growing area of specialty
within the nursing profession.

PROBLEM SOLVING AS AN ORGANIZING FRAMEWORK

• According to the ANA (2001), this "problem-solving framework supports all
• All facets of informatics practice, including those without technology and all
• Areas of nursing practice, including those without technology and all areas of nursing
practice
• And that the standards are overarching and "inherent in every aspect of practice"
• The first standard "assessment" involves using data, information, and knowledge to clarify
the presenting issue or problem. This process focuses on collecting data with different
methodologies such as structured system and different methodologies such as structured
systems and workflow analysis and from a variety of sources such as stakeholders who are
close to the problem.
• The second standard calls for identifying and evaluating possible solutions to information
issues. This includes developing function

RECOGNIZED TERMINOLOGIES THAT SUPPORT NURSING PRACTICE

Resource Recognition date

NANDA 1992
NIC 1992
HHCC 1992
OMAHA system 1992
NOC 1997
NMMDS 1998
PCDS 1998
PNDS 1999
SNOMED CT 1999
NMDS 1999
ICNP 2000
ABC codes 2000
LOINC 2002

CARE PLANNING
• The computer-based patient record facilities the automation of the nursing care planning
process. The benefits and the challenges of integrating computerized systems with care
planning have been extensively reported in the literature during the last decade.

DECISION- MAKING WITH ADMINISTRATIVE DATA

• Although nursing leaders typically administer million dollar budgets and are held responsible
for their units budget, they often: Lack the necessary information and decision support to
manage their responsibilities effectively. Without day to day information on patient flow and
acuity, resources use, staffing levels, costs and budgetary balance, they have little support
for cost control and input into budgetary decision making.
• The desirability of cost containment in healthcare was the driving force behind the
development of CLASSICA

A DECISION SUPPORT SYSTEM FOR EFFECTIVE NURSING RESOURCE MANAGEMENT

• Improve cost containment
• Ease of use, perceived usefulness and user satisfaction
• Improve nurse managers competence in financial management
 • Provide essential information and decision support for effective financial
management, resource allocation, activity planning and staffing

DECISION MAKING WITH EXPERT SYSTEMS

Broadly defined, the term clinical decision support system (CDSS) include an array of
computer-based applications that assist healthcare clinicians in the day-to-day work of patient care.
• These may include programs that involve artificial intelligence (AI ); different types of
knowledge such as uncertainty, heuristics, and fuzzy logic; expert systems; and decision
support systems.
• According to Power (‘2004), decision support systems have been in existence since 1965,
when management decision systems first became available. Generally, two types of AI
expert systems and machine learning have been used to Al’s decision-making in nursing for
more than a decade (miller 1994;Johnston et al., 1994; Cullen, 1998).
• Solve problems by trial and error rather than using algorithms such as those used in
convention programming.

OUTCOMES MANAGEMENT
• A chapter on the use of computers in nursing practice today would be incomplete without a
description of how informatics is being used to organize and implement systems for
outcomes management.
• Martin (1999) and Martin and Scheet (1995) have written extensively about the 20 year
development of the Omaha system, with its problem classification scheme for outcomes. The
outcomes capability of the system serves as a methods for documentation and as a guide for
nursing practice .

Concept 1 2 3 4 5

Knowledge: The No Minimal Basic Adequate Superior

ability of the client knowledge knowledge knowledge knowledge knowledge
to remember and
interpret
information

Behavior: The Not Rarely Inconsistently Usually Consistently

observable appropriate appropriate appropriate appropriate appropriate
responses, actions,
or activities of the
client fitting the
purpose of the
occasion

Status: The Extreme Severe Moderate Minimal/ No signs/

condition of the signal/ signs/ signs/ symptoms symptoms
client in relation to symptoms symptoms symptoms
objective and
subjective defining
characteristics

DATA
Used both for individual care planning and for aggregate analysis. Such analyses are used to
interface with other components of an institution’s informatics systems, and to evaluate the impact of
patient care, services, meet accreditation requirements, complete reports for third party payers , plan
new programs and ultimately advance progress in nursing.
• As specific clinical example of nursing’s key involvement in outcomes management was
published in 1998 when smith described a data-based system for simplifying data
management for outcomes management of the mechanically ventilated patient population.
• In a 2000 study, Johnson and Nolan reviewed three systems that can be used for managing
patient outcome data: traditional manual data entry, automated data entry scanning system,
and a handheld device.
• In a more recent study, Larrabee and colleagues (2001) used a time series design to study
the influence of a system-wide computerized NIS on document completeness of nursing
assessment of patient outcomes, achievement of nursing outcomes, nursing interventions
 done, and routine assessments before and after implementation of a NIS in a 100-bed urban
university hospital.

DISCHARGE PLANNING
• The documentation of patient care usually begins when the admission assessments and
ends with the discharge care plan. A typical discharge plan includes five components:
➢ Summary of admission assessment
➢ Summary of learning needs that the patient had at discharge
➢ Multidisciplinary plan including problems still unresolved and outcomes
not met during hospitalization
➢ Medication and procedures that the patient must continue
➢ Summary of selected patient outcomes that a multidisciplinary team
desired as minimal criteria from the patient to have achieved during
hospitalization.
• Although the basic design of discharge plans has changed little from those used 30 years
ago (Wessling, 1972), the extent and mode of communication about patient care throughout
healthcare networks has changed dramatically.
• Healthcare professionals involved in the discharge planning process.

HEALTHCARE COLLABORATION
• Advances in technology, however have changed the ways in which members of
interdisciplinary healthcare teams are and will be communicating with each other in the
digital world of healthcare in new millennium.
• Alpay and Russell (2002) have suggested, “ the use of IT is part of the development and
delivery of health services”
• Miller and Carlton’s predictions that future healthcare practitioners such as nurses would be
“active participants in collaboratively matching wide range of telecommunications tools to the
health care application need” have become the reality for many healthcare systems in the
first years of the new century.

PROGRESS IN PRACTICE
• The inevitable integration of computers into nursing practice has been accompanied
by speculation, controversy, and research on the benefits, barriers, and real potential
of NIS’s for improving clinical practice and giving nurses a voice in the developmental
of health care policy.

IMPACT OF COMPUTERIZATION ON NURSING PRACTICE: A SAMPLE OF STUDIES

Study Year Findings Impact

(+ or -)

Hendrickson and 1990 Time saved, less paperwork, fewer telephone class,
Kovner fewer errors, more complete documentation +

Matt et al. 1993 No improvement in quality of documentation -

Pabst, Scherubel, 1996 No improvement in quality of documentation -

and Minnick

Mcdaniel 1997 Identification of outliers, documentation of interventions +

Kovnet, 1997
Schuchman, and No time savings -
Mallard

Adderley, Hyde, 1997 Faster data entry, more consistent and more available +
and Mauseth data

Goosen, Epping, 1997 Limited use and poor quality of systems -

and Dassen
 Yancey et al. 1998 More uniform reporting +

Miranda, Fields, 2001 Consisitent configuration across multiple sites, system

and Lund used for both patient care and research
+

Larrabee et.al. 2001 Improvement in bloodpresure, documentation,

completeness of nurse assessment of patient +
outcomes, and nursing intervention doene

Dumas, Dietz, 2001 Most useful applications were obtaining medical

and Connolly records, entering electronic client record informatio, +
communication with other healthcare agensies, pattern
of under use

Flynn 2001 Improved utilization of ICU beds, increased accuracy of +

documentation

SUMMARY

The nursing practice environment has changed significantly over the years, with
advances in technology, regulatory constraints, changing patient’s needs, and a shortage of
nurses. However, there are concerns about nurses' under utilization of technology and the
potential negative effects of technology on the nurse-patient relationship. To address these
issues, nurses must be proactively engaged in all phases of information.