Ch. 23 Nursing Informatics
Eight Core Functions of the Electronic Health Record
1. Health information and data 2. Result management 3. Order management 4. Decision support 5. Electronic communication and connectivity 6. Patient support 7. Administrative processes and reporting 8. Reporting and population health
Few doctors currently communicate with their patients through e-mail Could help to avoid "phone tag" with clients and improve efficiency Drug-refill requests and educational information could be accessed
Nurses in both IN and INS roles
"support nurses, consumers, patients, the interprofessional health care team, and other stakeholders in their decision-making in all roles and settings to achieve desired outcomes. This support is accomplished through the use of information structures, information processes, and information technology"
Health care experts picked the top 12 ways AI will revolutionize the delivery and science of health care (Bresnick, 2018):
1. Unifying mind and machine through brain-computer interfaces 2. Developing the next generation of radiology tools—without the need for biopsies 3. Expanding access to care in underserved or developing regions 4. Reducing the burdens of electronic health record use 5. Containing the risks of antibiotic resistance 6. Creating more precise analytics for pathology images 7. Bringing intelligence to medical devices and machines 8. Advancing the use of immunotherapy for cancer treatment 9. Turning the electronic health record into a reliable risk predictor 10. Monitoring health through wearables and personal devices 11. Making smartphone selfies into powerful diagnostic tools 12. Revolutionizing clinical decision-making with AI at the bedside
Patient Digital Assistant (PDA)
Allows bedside data collection and charting Conserves time and reduces steps to and from nurses' station Offers easier information transmission between workers Portability and information at your fingertips Can use to monitor: Blood glucose levels Blood pressure Diet Activity Calculate dosages Analyze lab results Access reference materials Check for drug interactions Schedule procedures Order prescriptions "Beam" assignments
Computerized Provider Order Entry
CPOE is a technology-enabled process that allows providers such as physicians, nurse practitioners, and pharmacists to enter patient care orders directly into a computer system that transmits these orders directly to the receiving department (pharmacy, radiology, dietary, etc.) without intervening steps such as RN review for clarity and completeness. The true benefits of CPOE come with implementing clinical decision support systems (CDSSs) at the same time
Privacy and Confidentiality
Confidentiality agreements should be reviewed and signed when starting employment and yearly thereafter. Breaches of security, confidentiality, or privacy should be addressed and resolved quickly, and the offender should be charged accordingly. Every lapse should be treated openly and used as an example for others to take note of. The IN may be involved in the investigation process and the writing of the policies and procedures.
Electronic Health Records
EHRs are essential for health care to leverage state-of-the-art technology to deliver the highest-quality, lowest-cost patient care. Two other terms coming into vogue are the comprehensive health record and the connected health record. These terms describe two different visions of the next generation of the EHR. These visions include social determinants of health and more into nontraditional sources of data, including families/caregivers, school clinics, senior centers, and community health facilities. Other experts see the next step in EHR development to include shared care planning, genomics and personalized medicine, population health and public health, and remote monitoring and sensors
Robotics in Patient Care
From robots who greet and respond to verbal responses, to direct care robots, which can lift patients or lead patients in exercise activities to therapeutic robots—robotics are becoming part of the health care environment. Therapeutic robots built to look like cute animals such as a dog or baby harp seal deliver emotional responses based on sensors and produce the benefits of animal therapy without the problems live animals bring
NI education
INs who want to hold leadership roles in NI will need graduate-level preparation. A student who held a leadership role in NI and was enrolled in a NI master's program once said that she thought she knew all about NI, but she learned that she only knew about it at her own organizational level. Her graduate-school education had broadened her perspectives and introduced her to new concepts and ways of thinking (C. Parker, 2011, personal communication).
The Joint Commission
TJC wrote the IM standards in the mid-1990s. These 10 standards outline the need for IM regulation. Since then, IM has been woven throughout various standards and the National Patient Safety Goals. An example of this is noted in Standard IM.02.01.03 of the revised requirements for the Laboratory Accreditation Program, where the lab must have a "written policy addressing the integrity of health information against loss, damage, unauthorized alteration, unintentional change, and accidental destruction" (TJC, 2014, p. 1).
Patient Engagement
To be engaged, patients must use the resources available to maximize their health. When we add health information technology to the concept of patient engagement, we get the definition from the Office of the National Coordinator for Health Information Technology, "The ability of individuals to easily and securely access and use their health information electronically serves as one of the cornerstones of nationwide efforts to increase patient and family engagement and advance person-centered health" (HealthIt.gov, 2018b).
Telemedicine, Telehealth, and Health Monitoring
Today, the use of telecommunication technologies to provide health care is expanding at a phenomenal rate. Surprisingly, it's not just the under-30 population who is embracing this technology. Long labeled as technology-adverse, the senior population is proving just the opposite, especially since telemedicine visits via two-way video reduces the burden of travel to a provider's office.
What is the ultimate goal of healthcare organizations?
With the advent of both specialty and integrated clinical information systems (CIS), the longitudinal electronic health record (EHR) has become the goal of health care organizations and is now supported by federal mandate
What Are Regulatory and Accreditation Requirements?
the Health Insurance Portability and Accountability Act (HIPAA) and The Joint Commission (TJC) impact the daily work of every clinician and organization. The nurse must have a clear understanding of HIPAA regulations and of TJC requirements to be able to provide safe nursing care.
two distinct roles in NI:
the IN and the informatics nurse specialist (INS) The IN has experience in NI but does not have an advanced degree in the specialty. The INS has graduate-level education in informatics or a related field
Internet Resources
the US Surgeon General's Family History Initiative is a great place to start with promoting the importance of a well-documented family health history. In addition to the Office of the Surgeon General, other US Department of Health and Human Services (USDHHS) agencies involved in this project include the National Human Genome Research Institute (NHGRI), the Centers for Disease Control and Prevention (CDC), the Agency for Healthcare Research and Quality (AHRQ), and the Health Resources and Services Administration (HRSA). A downloadable free tool entitled "My Family Health Portrait" is available at http://www.genome.gov/27527640. This tool helps patients organize their family trees and identify common diseases that may run in their families. After completing the required information, the tool will create and print out a graphic representation of the patient's family generations and the health disorders that may have moved from one generation to the next. This is a powerful tool for predicting illnesses (USDHHS, 2016) and can be brought by the patient to a health care provider appointment.
Advantages of Electronic Health Records
• Simultaneous, remote access to patient from many locations • Legibility of record—no handwriting • Safer data—backup and disaster recovery system, so less prone to data loss • Patient data confidentiality—authorized use can be restricted and monitored automatically • Flexible data layout—can recall data in any order (chronologically or in reverse chronological order) • Integration with other information resources • Incorporation of electronic data—can automatically capture physiological data from bedside monitors, laboratory analyzers, and imaging devices • Continuous data processing—check and filter the data for errors, summarize and interpret data, and issue alerts and/or reminders • Assisted search—can search free-text or structured data to find a specific data value or to determine whether a particular item has been recorded previously • Greater range of data output modalities—data can be presented to users via computer-generated voice, two-way pagers, e-mail, and smartphones • Tailored paper output—data can be printed using a variety of fonts, colors, and sizes to help focus the clinician's attention on the most important data; images can be included to help see a more complete "picture" of the patient's condition • Always up-to-date
CAFE internet research
▪ Challenge the information and demand accountability. ▪ Adapt and require more credibility and evidence for stronger claims—it is okay to be skeptical of the information. ▪ File new information in your mind rather than immediately believing or disbelieving it. ▪ Evaluate and reevaluate regularly. Recognize the dynamic, fluid nature of the information.
Although there are multiple theories that are applicable to NI practice, the three most common are as follows:
▪ General systems theory—This theory organizes interdependent parts working together to produce a product that none used alone could produce. Key elements are input, process, output, control, and feedback. ▪ Rogers' diffusion of innovation theory—A five-step process of an individual's decision to adopt an innovation, which includes knowledge, persuasion, decision, implementation, and confirmation (Rogers, 2003). ▪ Change theory—Kurt Lewin's change theory
The following is a list of some simple precautions to take to help secure patient information that may be stored on a mobile device. These recommendations should be followed as standard practice:
▪ Keep careful physical control of the device at all times. ▪ Use a password or other user authentication and a time-out to reactivate the authentication. ▪ Install and enable encryption. ▪ Install and activate remote wiping and/or remote disabling. ▪ Disable and do not install or use file-sharing applications. ▪ Disable the infrared ports and Wi-Fi except when they are actually being used. ▪ Do not send infrared or Wi-Fi transmissions in public locations. ▪ Keep your security software up-to-date. ▪ Research mobile applications (apps) before downloading. ▪ Use adequate security to send or receive health information using public Wi-Fi networks. ▪ Delete all stored health information before discarding or reusing the mobile device.
Watson is being used in several areas of health care already, including the following:
▪ Managing care of complex patients ▪ Accelerating drug discovery by being able to manage the volume of drug research data far better than humans can ▪ Identifying appropriate cancer treatments in studies ▪ Matching patients with clinical trials (Speights, 2018)
Cyberthreats include the following:
▪ Unpatched software—out-of-date software, which has not had updates and patches applied ▪ Ransomware—malware that prevents authorized users from accessing data until ransom is paid ▪ Phishing (pronounced "fishing")—using e-mail, telephone, or text message posing as a legitimate institution to lure individuals into providing sensitive and usable data ▪ Loss of data stored on mobile device ▪ Insider fraud and misuse of data
The CARS Checklist
✓ Credibility—An authoritative source, which includes author's credentials and evidence of quality control such as peer review. ✓ Accuracy—A source that is correct today (not yesterday) and is comprehensive. ✓ Reasonableness—Look at the information for fairness, objectivity, moderateness, consistency, and worldview. ✓ Support—A source that provides convincing evidence for the claims made and which can be triangulated (find at least two other sources that support it).
WHO (2018b) goes on to define mHealth as
"a component of eHealth and involves the provision of health services and information via mobile technologies, such as mobile phones, tablet computers, and Personal Digital Assistants (PDAs)."
HealthIT.gov defines EMR as
"a digital version of the paper charts.... An EMR contains the medical and treatment history of the patients in that office, clinic, or hospital"
Personal Health Record
"is an electronic record of an individual's health information by which the individual controls access to the information and may have the ability to manage, track, and participate in his or her own health care"
Cloud Computing
"the delivery of computing services—servers, storage, databases, networking, software, analytics, and intelligence and more—over the Internet ('the cloud') to offer faster innovation, flexible resources, and economies of scale" (Microsoft Azure, 2018).
The World Health Organization (WHO) provides the following definition for eHealth
"the use of information and communication technologies (ICT) for health"
The 10 E's in "E-Health"
1. Efficiency leading to decreasing costs by avoiding duplicate or unnecessary diagnostic or therapeutic interventions, through enhanced communication possibilities among health care establishments, and through patient involvement. 2. Enhancing quality of care by allowing comparisons among different providers, involving consumers as additional power for quality assurance, and directing patient streams to the best quality providers. 3. Evidence-based intervention effectiveness and efficiency should not be assumed but proven by rigorous scientific evaluation. 4. Empowerment of consumers and patients by making the knowledge bases of medicine and personal electronic records accessible to consumers over the Internet; e-health opens new avenues for patient-centered medicine and enables evidence-based patient choice. 5. Encouragement of a new relationship between the patient and health professional, toward a true partnership where decisions are made in a shared manner. 6. Education of physicians and health care providers through online sources (continuing education) and consumers (health education, tailored preventive information for consumers). 7. Enabling information exchange and communication in a standardized way among health care establishments. 8. Extending the scope of health care beyond its conventional boundaries. 9. Ethics e-health involves new forms of patient-physician interaction and poses new challenges and threats to ethical issues such as online professional practice, informed consent, privacy, and equity issues. 10. Equity to make health care more equitable is one of the promises of e-health, but at the same time there is a considerable threat that e-health may deepen the gap between the "haves" and "have nots," deepening the "digital divide."
The ANA recognized terminologies/data sets as listed in the 2018 revised position statement continue to include the following:
1. NANDA—Nursing Diagnoses, Definitions, and Classification 2. Nursing Interventions Classification System (NIC) 3. Nursing Outcomes Classification System (NOC) 4. Nursing Management Minimum Data Set (NMMDS) 5. Clinical Care Classification (CCC) (formerly Home Health Care Classification [HHCC]) 6. Omaha System 7. Perioperative Nursing Dataset (PNDS) 8. SNOMED CT 9. Nursing Minimum Data Set (NMDS) 10. International Classification of Nursing Practice (ICNP) 11. ABC Codes for billing 12. LOINC
Relevant websites and online Resources
American Health Information Management Association (AHIMA) What Is a Personal Health Record (PHR)? http://www.myphr.com/StartaPHR/what_is_a_phr.aspx American Medical Informatics Association (AMIA) AMIA NI Working Group. http://www.amia.org/programs/working-groups/nursing-informatics American Nursing Informatics Association (ANIA) https://www.ania.org/ Centers for Medicare & Medicaid Services (CMS) Promoting Interoperability (PI). http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/ HealthIT.gov Privacy, Security, and HIPAA. http://www.healthit.gov/providers-professionals/ehr-privacy-security HIMSS Impact of the Informatics Nurse Survey Final Report https://www.himss.org/library/2017-nursing-informatics-workforce-survey-full-results Nursing Informatics https://www.himss.org/library/nursing-informatics/%3FnavItemNumber%3D16520 Medicare.gov Manage Your Health. https://www.medicare.gov/manage-your-health/ Microsoft Microsoft Health Vault. https://www.healthvault.com/en-us/ U.S. Department of Health & Human Services (HHS) Health Information Privacy (2018). http://www.hhs.gov/ocr/privacy/ WebMD WebMD Personal Health Record. http://www.webmd.com/phr Your Mobile Device and Health Information Privacy and Security http://www.healthit.gov/providers-professionals/your-mobile-device-and-health-information-privacy-and-security
Clinical decision support (CDS)
Clinical decision support (CDS) is a type of health information technology that provides health care providers, nurses, patients, and other individuals with relevant person-specific information that is presented at the right time for the health care provider to make a clinical decision about the patient's plan of care. Computerized alerts, reminders, diagnostic support, potential drug interactions, and clinical guidelines are a few CDS tools that assist health care providers and nurses with clinical decision-making and improving workflow
Further description of EHRs
Further description of EHRs focuses on the total health of the patient—going beyond standard clinical data collected in a single event such as a provider's visit or hospitalization. They provide a broader view on a patient's care. EHRs are designed to reach out beyond the health organization that originally collects and compiles the information. They are built to share information with other health care providers so they contain information from all the clinicians involved in the patient's care
Patient Portals
HealthIT.gov (2017) defines a patient portal as a secure online website that gives patients convenient, 24-hour access to personal health information from anywhere with an Internet connection. Using a secure username and password, patients can view health information such as the following: ▪ Recent doctor visits ▪ Discharge summaries ▪ Medications ▪ Immunizations ▪ Allergies ▪ Lab results Some patient portals also allow you to: ▪ Securely message your doctor ▪ Request prescription refills ▪ Schedule non-urgent appointments ▪ Check benefits and coverage ▪ Update contact information ▪ Make payments ▪ Download and complete forms ▪ View educational materials
What Is Nursing Informatics?
In 1994, the American Nurses Association (ANA) recognized the field of NI. In 2015, the ANA updated the definition of NI as "the specialty that integrates nursing science with multiple information management and analytical sciences to identify, define, manage, and communicate data, information, knowledge, and wisdom in nursing practice" (ANA, 2015, p. 1).
The Certification Process
In 1994, the American Nursing Credentialing Center (ANCC) provided a method for nurses to become certified in this specialty. The baccalaureate degree is the minimum requirement needed to take the certification exam. Nurses can obtain RN-BC certification in informatics nursing through the ANCC.
The following is an excerpt from the 2019 NCLEX-RN Test Plan regarding the content area of Information Technology on the NCLEX-RN exam:
Information Technology • Receive and transcribe health care provider ordersa • Apply knowledge of facility regulations when accessing client records • Access data for client through online databases and journals • Enter computer documentation accurately, completely and in a timely manner • Utilize resources to enhance client care (e.g., evidenced-based research, information technology, policies, and procedures)a Confidentiality/Information Security • Assess staff member and client understanding of confidentiality requirements • Maintain client confidentiality and privacya • Intervene appropriately when confidentiality has been breached by staff members
NI Conclusion
Nursing informatics is a specialty grounded in the present while planning for the future. Nursing informatics nurses face many challenges in their daily activities, because they are in a position to wear many hats and bear many responsibilities. The next challenge after EHR implementation will be using the data in a meaningful way to improve patient care and lower costs. Computing devices and applications will continue to evolve and improve point-of-care access. Touch screens and voice input are already beginning to have an impact. Change is the only constant. At the end of this chapter are relevant websites and online resources on the concepts that have been presented. The challenge will be for informatic nurses and informatics nurse specialists to assume leadership roles in informatics, while the nurse educator, manager, and practicing nurse prepare to embrace the generalized applications of working within a computerized environment. No longer will it be sufficient to turn on a computer and complete a simple task. A nurse will need to be able to use technology in all the forms found in health care organizations, access information, as well as access and use data and evaluate the content of the information provided to the patient population. Wishing will not make technology go away, so savvy nurses will focus on the benefits that technology brings to patient care, learn the skills they need, and embrace the future with all the changes it will bring.
How to Evaluate Websites
Step 1: Authority Who is/are the author(s)? Describe each author's authority or expertise. Are professional qualifications listed? How can you contact the author(s)? Who is the site's sponsor? What does the URL tell you? What type of domain does it come from (.gov, .mil, .edu, .org)? Is the site copyright protected? If the website is offering medical information, is the website HONcode certified? To learn more about Health on the Net Foundation Code of Conduct (HONcode), visit: https://www.hon.ch/HONcode/Pro/. Step 2: Timeliness and Currency When were the site materials created? When did it become active on the Web? When was it last updated/revised? Are the links up-to-date? Are the links functional? When were data gathered? What version/edition is it? Step 3: Purpose Who is the targeted audience? What is the purpose of the website? Are the goals/aims/objectives clearly stated? Does the website present facts or opinions? Does the website offer an area for consumers and another one for health care professionals? Step 4: Content Accuracy and Objectivity Does the information provided meet the purpose? Who is accountable for accuracy? Are the cited sources verifiable and published within the last 5 years? What is the value of the content of this site related to your topical needs? How complete and accurate are the content information and links? Is the site biased? Does it agree with other expert sources? Does it contain advertisements? Step 5: Structure, Design, and Access What is the appearance of the site? Does the site load quickly? Do multimedia, graphics, and art used on the page serve a purpose, or are they just decorative or fun? Is there an element of creativity? Is there appropriate interactivity? Is the navigation intuitive? Are there icons? Is it a secured site? Is an index with links available?
Role of the Informatics Nurse/Informatics Nurse Specialist (IN/INS)
The IN/INS must have a basic knowledge of how computers and networks work as well as an understanding of system analysis, design principles, and information management (IM). It is important for the IN/INS to converse with both the clinical staff and the technology staff regarding hardware, software, communications, data representation, and security. An IN/INS will be comfortable with software and hardware implementation, training, testing, presenting, and facilitating knowledge Typical job responsibilities consist of (1) product evaluation; (2) system implementation, including preparing users, training, and providing support; (3) system development and quality initiatives, including system evaluations/problem solving and quality improvement/patient safety; and (4) other duties as assigned It is important to note that not all nurses in IN/INS roles work on implementation of the EMR/EHR. Some work for health care product vendors in both the hardware and software areas. They help inform the next generation of existing products, and they work with engineers/design teams to create new products, always bringing the patient care viewpoint and the needs of the end user to the design process. Others work for consulting firms and specialize in workflow improvement using technology, whereas others still work for government, third-party payers, and educational
Websites for Health Information
The US National Library of Medicine and National Institutes of Health provides an excellent website on Evaluating Health Information at http://www.nlm.nih.gov/medlineplus/evaluatinghealthinformation.html, including some resources in Spanish. As nurses, we need to have a better understanding of how consumers find health information on the Internet, how to evaluate the quality of this information, and how to help our patients critically evaluate and manage the information
"sweeping change" to the HIPAA Privacy, Security, Enforcement, and Breach Notification Rules
The changes in the final rulemaking provide the public with increased protection and control of personal health information. The HIPAA Privacy and Security Rules have focused on health care providers, health plans and other entities that process health insurance claims. The changes announced today expand many of the requirements to business associates of these entities that receive protected health information, such as contractors and subcontractors. Some of the largest breaches reported to HHS have involved business associates. Penalties are increased for noncompliance based on the level of negligence, with a maximum penalty of $1.5 million per violation. The changes also strengthen the Health Information Technology for Economic and Clinical Health (HITECH) Breach Notification requirements by clarifying when breaches of unsecured health information must be reported to HHS. Individual rights are expanded in important ways. Patients can ask for a copy of their electronic medical record in an electronic form. When individuals pay by cash they can instruct their provider not to share information about their treatment with their health plan. The final omnibus rule sets new limits on how information is used and disclosed for marketing and fundraising purposes and prohibits the sale of an individual's health information without their permission.
Health Insurance Portability and Accountability Act of 1996
The major impact from this regulatory legislation is in these areas are as follows: ▪ Health information privacy law ▪ Data security standards ▪ Electronic transaction standards
Big Data
Think about all the data we collect on a single patient during a 4-day hospital stay. Now add all the data we collect on all the patients in that hospital during that same 4 days. Now add to that all the data we collect on all the patients in all the hospitals in the United States during those 4 days—that is a lot of data (i.e., Big Data!). All of this data is too much to do anything with using traditional data management. So people working in informatics have developed and continue to develop ways of using the massive amounts of data to look for patterns and trends that may help us identify early warning signs, predisposing factors, and other patterns to improve health and health care.
4 Nurse Informaticist (NI)
the extensive clinical background of the IN/INS is invaluable to the success of the implementation of the hardware and software applications needed to transform health care. Nurses have a unique understanding of workflow, the hospital and clinical environment, and the specific procedures that are necessary for effective health care information infrastructure. Moreover, the IN/INS roles are critical members of the team when translating information into practical models that can be applied to improve the health care systems and patient outcomes.
There still remain major barriers to the complete integration of health information technology. These barriers include the following:
▪ Lack of standardization across care areas—the need for laboratory data and pharmacy systems to be integrated with the patient's EHR, and the ED systems need to share data with the inpatient systems. ▪ Siloed data—hospital data, provider practice data, and long-term care facility data may all be in separate systems with steep fees for building interfaces to allow for exchange of data. ▪ Cost and funding—information technology is costly, and often the major costs are borne by hospitals rather than shared by other providers, payers, and employers. ▪ Privacy and security concerns—a single set of privacy laws is needed to simplify the task of communicating across facilities, agencies, and local, state, and federal governments. ▪ Lack of a uniform approach (number) to match patients to their record—a single authentication number is needed to reduce safety risks and provide a uniform access to patient data
In 2018, the ANA updated its position statement on the inclusion of recognized terminologies to support nursing practice within health care information technology (HIT) systems to recommend the following:
▪ When exchanging data with another setting for problems and care plans, Systematized Nomenclature of Medicine—Clinical Terms (SNOMED CT) and Logical Observation Identifiers Names and Codes (LOINC) should be used for exchange. LOINC should be used for coding nursing assessments and outcomes and SNOMED CT for problems, interventions, and observation findings (ONC, 2018). ▪ Health information exchange between providers using the same terminology does not require conversion of the data to SNOMED CT or LOINC codes. ▪ Development of a clinical data repository that includes multiple recognized terminologies should be based on the national recognized terminologies of ICD-10, CPT, RxNorm, SNOMED CT, and LOINC (American Nurses Association, 2018).
