Handbook of Informatics for Nurses and Healthcare Professionals TONI HEBDA I KATHLEEN HUNTER I PATRICIA CZAR SIXTH EDITION Handbook of Informatics for Nurses and Healthcare Professionals Sixth Edition Toni Hebda, PhD, RN-C, CNE MSIS Professor MSN Program Chamberlain College of Nursing, Downers Grove, IL 60515 Kathleen Hunter, PhD, FAAN, RN-BC, CNE Professor MSN Program Chamberlain College of Nursing, Downers Grove, IL 60515 Patricia Czar, RN Information Systems Consultant Pittsburgh, PA 330 Hudson Street, NY NY 10013 Publisher: Julie Alexander Director of Portfolio Management, Nursing: Katrin Beacom Editorial Assistant: Erin Sullivan Managing Content Producer: Melissa Bashe Content Producer: Michael Giacobbe Design Coordinator: Mary Siener Vice President of Sales and Marketing: David Gesell Vice President, Director of Marketing: Brad Parkins Director, Digital Studio: Amy Peltier Digital Project Manager: Jeff Henn Full-Service Project Management and Composition: SPi Global Full-Service Project Managers: Sreemeenakshi Raghothaman, Anitha Vijayakumar, SPi Global Editorial Project Manager: Dan Knott, SPi Global Manufacturing Buyer: Maura Zaldivar-Garcia, LSC Communications, Inc. Cover Designer: Laurie Entringer Copyright © 2019 by Pearson. All rights reserved. Manufactured in the United States of America. This publication is protected by Copyright, and permission should be obtained from thepublisher prior to any prohibited reproduction, storage in a retrieval system, or t­ ransmission in anyform or by any means, electronic, mechanical, photocopying, recording, or likewise. For informationregarding permissions, request forms and the appropriate contacts within the ­Pearson EducationGlobal Rights & Permissions Department, please visit www.pearsoned.com/ permissions/ Pearson® is a registered trademark of Pearson plc Notice: Care has been taken to confirm the accuracy of information presented in this book. Theauthors, editors, and the publisher, however, cannot accept any responsibility for errors or omissionsor for consequences from application of the information in this book and make no warranty, expressor implied, with respect to its contents. Cataloging in Publication data is available at the Library of Congress ISBN 10:    0-13-471101-7 ISBN 13: 978-0-13-471101-0 Contents Preface Acknowledgments Contributors Reviewers About the Authors 1 An Overview of Informatics in Healthcare ix xiii xv xvii xix 1 Jennifer A. Brown, Taryn Hill, Toni Hebda Big Data, Data Analytics, and Data Modeling 47 Ethical Concerns with Data and Information Use 52 Future Directions 52 Summary 53 4 Electronic Resources for Healthcare Professionals 58 Informatics 2 The Relevance of Informatics for Healthcare 3 Information Literacy 58 Creating an Informatics Culture 8 Critical Assessment of Online Information 59 Caring for the Patient Not the Computer 12 Future Directions 13 Social Media—Responsibilities and Ethical Considerations 61 Summary 14 Healthcare Information and Services 62 Online Services for Healthcare Professionals 64 Professional Organizations and Watchdog Groups 65 Healthcare Websites of Interest for Healthcare Providers 66 ELearning 67 Using Information Technology to Organize and Use Information Effectively 68 Future Directions 70 Summary 70 2 Informatics Theory and Practice 20 Maxim Topaz Overview of Theory 20 Critical Theories Supporting Informatics 22 Informatics Specialties within Healthcare 30 Informatics Competencies for Healthcare Practitioners 33 TANIC AND NICA 37 Future Directions 37 Summary 38 3 Effective and Ethical Use of Data and Information 42 Toni Hebda, Kathleen Hunter Overview of Data and Information 42 Using Data for Quality Improvement 44 Data Management 46 Brenda Kulhanek 5 Using Informatics to Support Evidence-Based Practice and Research 73 Melody Rose History 74 Levels of Evidence 75 Applying Information Literacy to Find the Highest Levels of Evidence 77 iii iv Content Integration of EBP into Clinical Systems and Documentation 78 Managing Research Data and Information 80 Creating and Maintaining the Infrastructure to Support Research 81 Ethical and Legal Principles for Handling Data and Information in Research 83 Practices for Collecting and Protecting Research Data 84 Supporting Dissemination of Research Findings 86 Effecting Practice Change 87 Future Directions 88 Summary 89 6 Healthcare Information Systems The Policy Process 95 Legislation and HIT/Informatics 98 Regulation (Rule-Making) and Implications for Informatics 101 Accreditation 104 Policy Making, Interprofessional Teams, and Informatics 106 Future Directions 108 Clinical Information Systems 136 Administrative Information Systems 139 Smart Technology 141 Current Topics in Healthcare Information Systems 143 Summary 145 9 Strategic Planning, Project Management, and Health Information Technology Selection 149 Carolyn Sipes Overview of Strategic Planning 114 Benefits of EHRSs 119 Current Status of EHRSs 121 Considerations When Implementing the EHRS 123 Future Directions Summary 152 155 Configurability 156 Interoperability 156 Ease of Use/Usefulness of Systems 156 Planning at the Project Level—The Project Management Process 157 The Informatics Nurse’s Role as Project Manager 161 Essential Skills in Other Advanced Nurse Practice Roles 162 Summary Meaningful Use 150 One Vendor versus Best of Breeds Electronic Health Record Systems 112 Future Directions Rayne Soriano, Kathleen Hunter 135 Carolyn Sipes, Jane Brokel Policy, Legislation, and Regulation Information Management Components Issues for Informatics Practice 94 Sunny Biddle, Jeri A. Milstead 7 8 10 163 164 Improving the Usability of Health Informatics Applications 167 Nancy Staggers Introduction to Usability 168 128 Definitions of Terms and Interrelationships of Concepts 169 129 The Goals of Usability 171 Content v Usability and the System Life Cycle 172 Information System Security 242 Human–Computer Interaction Frameworks 172 Security Mechanisms 249 Usability Methods 175 Administrative and Personnel Issues 256 Usability Tests 179 Levels of Access 257 Steps in Conducting Usability Tests 183 Audit Trails 260 Future Directions 185 Summary 186 Handling and Disposal of Confidential Information 260 Special Considerations with Mobile Computing 262 11 System Implementation, Maintenance, and Evaluation 191 Security for Wearable Technology/Implanted Sue Evans Devices/Bedside Technology 263 System Implementation 192 Future Directions 266 System Installation 203 Summary 266 System Evaluation 206 14 Summary 207 12 210 Workforce Development Diane Humbrecht, Brenda Kulhanek Information Networks and Information Exchange 271 Jane M. Brokel Introduction 271 Workforce Population 210 Health Information Network Models 272 Devising a Workforce Development Preparation Plan 212 Clinical Data Networks or Health Information Networks 273 Identifying the Scope of Efforts 214 Interoperability 274 Target Technology and Related Competencies 217 International Standards 278 Education Methods 219 Training Resources 225 Nationwide Health Information Network 279 Evaluating Success 226 Implications of Interoperability 280 When Information Technology Fails (Training on Backup Procedures) 228 Process and Use Cases for Health Information Exchange 280 Future Directions 229 Key Factors 281 Summary 229 Driving Forces 284 Current Status 285 13 Information Security and Confidentiality 238 Obstacles Ami Bhatt, Patricia Mulberger Privacy, Confidentiality, Security, and Consent 239 285 Future Directions 286 Summary 287 vi Content 15 The Role of Standardized Terminology and Language in Informatics Necessary Tools Simulation and Virtual Learning 293 Environments Susan Matney 346 354 Future Directions 363 Introduction to Terminology 293 Summary 363 Languages and Classification 297 Benefits of Implementing Standardized Terminologies 18 370 309 National Healthcare Reporting Requirements 312 Issues and Concerns 313 Future Directions 313 Summary 314 16 Consumer Health Informatics Melody Rose, Toni Hebda Evolution 371 Driving Forces 372 Issues 372 Consumer Health Informatics Applications 377 The Role of the Informatics Nurse Continuity Planning and with CHI Management (Disaster Recovery) 320 Carolyn S. Harmon Introduction and Background 320 What Is Continuity Planning? 321 Steps in the Developing a Preparedness Program 324 Advantages of Continuity Planning 328 Disasters Versus System Failure 329 Continuity and Recovery Options 329 Planning Pitfalls 337 Using Post-Disaster Feedback to Improve Planning 385 The Future of CHI 388 Summary 389 19 Connected Healthcare (Telehealth and Technology-Enabled Healthcare) 398 Lisa Eisele Introduction 398 History of Connected Health 399 Current State 400 Driving Forces 400 338 Connected Health Modalities 403 Legal and Accreditation Requirements 338 Implications for Practitioners 408 Future Directions 340 The Role of the INS in Connected Health 412 Summary 340 Future Directions 413 17 343 Summary 414 20 418 Using Informatics to Educate Diane A. Anderson, Julie McAfooes, Rebecca J. Sisk Public Health Informatics Why Informatics? 344 Preparing the Learner 344 Introduction 418 Educational Software Sources 344 Exploring Public Heath 419 Barriers and Benefits 345 Public Health Mandate 419 Marisa L. Wilson Content Public Health Informatics 422 Public Policy Driving Informatics Change 425 Current Public Health Informatics Systems 426 New Technological Sources of Public Health Information 428 Future Directions 430 Summary 432 Appendix A: Hardware and Software vii 435 Athena Fernandes Appendix B: The Internet and the Worldwide Web 439 Athena Fernandes Appendix C: An Overview of Tools for the Informatics Nurse 441 Carolyn Sipes Glossary Index 446 454 This page intentionally left blank A01_PERL5624_08_GE_FM.indd 24 2/12/18 2:58 PM Preface T he idea for Handbook of Informatics for Nurses & Healthcare Professionals first came from the realization that there were few resources that provided practical information about computer applications and information systems in healthcare. From its inception, this book served as a guide for nurses and other healthcare professionals who needed to learn how to adapt and use computer applications and informatics in the workplace. Over time, this text became a reliable resource for students in a variety of healthcare professions who needed to develop informatics competencies. This book serves undergraduates who need a basic understanding, as well as those who require more depth, such as informatics nurse specialists, clinical nurse leaders, doctoral students, and other healthcare professionals. After a thorough revision in response to reviewers and users of the book, the sixth edition reflects the rapid changes in healthcare information technology (HIT) and informatics. The authors endeavour to provide an understanding of the concepts, skills, and tasks that are needed for healthcare professionals today and to achieve the federal government’s national information technology goals to help transform healthcare delivery. The sixth edition builds upon the expertise provided by contributors currently involved in day-to-day informatics practice, education, and research. Both the primary editors and the contributors share an avid interest and involvement in HIT and informatics, as well as experience in the field, involvement in informatics groups, and a legacy of national and international presentations and scholarly publications. New to This Edition • New! All chapters thoroughly revised to reflect the current and evolving practice of health information technology and informatics • New! Chapter on informatics theory and practice connects theoretical concepts to applications (chapter 2) • New! Coverage of technology and caring and their symbiotic relationship • New! Content on ethical use of information lays encompasses appropriate and inappropriate behaviour and actions, and of right and wrong. • New! Information on analytics and data science that explains how Big Data applies to healthcare • New! Cutting-edge content on wearable and mobile technology security, and its impact on nursing and patient care • New! Academic electronic health record resources and the role they play in educating the next generation of healthcare providers on documentation principles • New! Hardware and software appendix (appendix A) • New! Guide to the Internet (appendix B) • New! An Overview of Tools for the Informatics Nurse (appendix C) Changes to This Edition • The sixth edition streamlines content by combining chapters with topics that fit together, and shifting hardware, software, and information on the Internet to new appendices. • This edition reworks previous content on information systems training and presents it within the context of workforce development. The content still retains the emphasis upon privacy and confidentiality, introduction of information policies, educational methods and resources. New content on evaluation models and training on backup procedures has also been added. • Former content on integration, interoperability and health information exchange is now presented within the context of information networks and information exchange. • Moves from defining evidence-based practice to a discussion of levels of evidence and using informatics to support evidence-based practice and research. • Separate chapters on policy, legislation, regulatory, reimbursement, and accreditation issues were combined to better show the connection among these ix x Preface areas and the relationship between them and information system design and use. Organization • Highlights strategic planning and project management. The book is divided into three sections: Information and Informatics, Information Systems Development Life Cycle, and Specialty Applications. The major themes of privacy, confidentiality, and information security are woven throughout the book. Likewise, project management is a concept introduced in the strategic planning chapter and carried through other chapters. Chapters include content on the role of the informatics professional, future directions relative to the topic, summary bullet points, and a case study. • Underscores the importance of patient engagement and shared decision making. Section I: Information and Informatics • Experts from various health disciplines cover the latest on the interprofessional aspects of informatics with more emphasis on interdisciplinary approaches. • Increases focus on current electronic health record issues while decreasing coverage of the historical evolution of EHRs. • Expands content on simulation and virtual learning environments. Hallmark Features Learning Objectives—Learning Objectives appear at the beginning of each chapter and identify what readers can expect to learn in the chapter. Future Directions—As the last section in each chapter, Future Directions forecasts how the topic covered in the chapter might evolve in the upcoming years. Case Study Exercises—Case studies at the end of each chapter discuss common, real-life applications, which review and reinforce the concepts presented in the chapter. Summary—The Summary at the end of each chapter highlights the key concepts and ­information from the chapter to assist in the review. References—Resources used in the chapter appear at the end. Glossary—The glossary familiarizes readers with the vocabulary used in this book and in healthcare informatics. We recognize that healthcare professionals have varying degrees of computer and informatics knowledge. This book does not assume that the reader has prior knowledge of computers. All computer terms are defined in the chapter, in the glossary at the end of the book, and on the Online Student Resources Web site. This section provides a foundation for why information and informatics are important to healthcare. It details the relationship between policy, legislation, regulation and accreditation and reimbursement and information system use. • Chapter 1: Provides a definition of informatics and its significance for healthcare, discusses healthcare professionals as knowledge workers, addresses the need for uniform data and the relationship between data, big data, and evidence. This chapter also addresses the increased prevalence of information technology in healthcare, major issues in healthcare that are driving the adoption of information technology, what is necessary to create an informatics culture, and includes a special section on caring and technology. • Chapter 2: Provides information on informatics theory and practice, and nursing informatics as a discipline. • Chapter 3: Emphasizes effective and ethical use of data and information, and includes a discussion of big data challenges and issues. Data characteristics, types, integrity, and management are covered. Clinician and informaticist roles pertaining to this area are discussed. • Chapter 4: Addresses electronic resources for healthcare professionals, basic concepts and applications of the Internet, including criteria for evaluating the quality of online information. • Chapter 5: Discusses informatics to support evidence-based practice and research. Concepts include levels of evidence, information literacy, managing research data and information, creating Preface and maintaining the infrastructure needed to support research, dissemination of evidence, and effecting practice change. • Chapter 6: Examines the relationship between policy, legislation, accreditation, reimbursement and HIT design and use. • Chapter 7: Provides information on electronic health records including definition, components, incentives for adoption, benefits, current status, selection criteria, implications for collection of meaningful data and big data, current issues, and future directions. • Chapter 8: Provides an overview of types of healthcare information systems, including clinical information systems and administrative information systems, as well as decision support, knowledge representation, and smart data. Section II: Information Systems Development Life Cycle This section covers information and issues related to the information systems development life cycle. • Chapter 9 This chapter discusses the importance of strategic planning for information management, HIT acquisition and use and provides an overview of project management and information system selection considerations. The role of informatics professionals, particularly informatics nurse specialists, in the planning process and project management are addressed, as is the process to introduce change. • Chapter 10: Addresses the concepts of usability and health informatics applications inclusive of the role that usability plays in the system life cycle and methods of usability assessment. • Chapter 11: Covers information system implementation, maintenance, and evaluation. • Chapter 12: Provides a comprehensive look at workforce development in relation to health information technology use. • Chapter 13: Discusses information security and confidentiality, including practical information on ways to protect information housed in information systems and on mobile devices and addresses security for wearable and implantable information technology. xi • Chapter 14: Provides detailed information about health information exchanges. • Chapter 15: Provides an overview of the role of standardized terminology and language in informatics. Also includes an outline of individual languages and classifications used in healthcare. • Chapter 16: Discusses the relationship between strategic planning for the organization and the significance of maintaining uninterrupted operations for patient care. Also touches on legal requirements to maintain and restore information. Much of this chapter is geared for the professional working in information services. Section III: Specialty Applications This section covers specialty applications of informatics. • Chapter 17: Details ways that information technology and informatics can support education of healthcare professionals, including sections on simulation and virtual learning environments. • Chapter 18: Emphasizes the relationship between health and information literacy, patient engagement, shared decision-making, changing healthcare delivery models, patient satisfaction, outcomes, and healthcare reform. Discusses applications of consumer health informatics. • Chapter 19: Examines telehealth and connected healthcare applications, starting with a historical perspective and including driving forces, applications, and implications for providers as well as informatics professionals. • Chapter 20: Explores public health informatics and its use to maintain and improve population health. Three appendices are included. Appendix A provides basic information on hardware and software for the reader who needs a better understanding of this area. Appendix B provides information on the Internet. Appendix C provides an overview of some tools for the informatics nurse. Instructor Resources Lecture PowerPoint showcases key points for each chapter. Test Generator offers question items, making test creation quick and simple. xii Preface Student Resources New! eText offers a rich and engaging experience with interactive exercises. Readers can access online or via the Pearson eText app. Note: Faculty can opt to package an eText access code card with the print textbook, or students can purchase access to the eText online. Notice Care has been taken to confirm the accuracy of information presented in this book. The authors, editors, and the publisher, however, cannot accept any responsibility for errors or omissions or for consequences from application of the information in this book and make no warranty, express or implied, with respect to its contents. Acknowledgments S pecial thanks to Kathy Hunter, who agreed to join me on this 6th edition, lending her knowledge, insights, and support when I most needed it and never said “no” despite her many other commitments. A special thanks to Patricia Czar, RN, without whom there would be no Handbook of Informatics for Nurses & Healthcare Professionals today. Pat actively contributed to the book from the original outline through to the present, providing her knowledge, insights, organizational skills, support, and friendship. Pat was active in informatics for more than 25 years, serving as manager of clinical systems at a major medical center where she was responsible for planning, design, implementation, and ongoing support for all of the clinical information systems. Pat was also active in several informatics groups, presented nationally and internationally, and served as a mentor for many nursing and health informatics students. She is now fully retired and enjoying time with her family. We acknowledge our gratitude to our loved ones for their support as we wrote and revised this book. We are grateful and excited to have work from our contributors who graciously shared their knowledge and expertise for this edition. We are grateful to our co-workers and professional colleagues who provided encouragement and support throughout the process of conceiving and writing this book. We appreciate the many helpful comments offered by our reviewers. Finally, we thank Lisa Rahn, Michael Giacobbe, Susan Hannahs, Daniel Knott, Taylor Scuglik, and all of the persons who worked on the production of this edition for their encouragement, suggestions, and support. Thank You T his edition brings in work from multiple contributors for a robust coverage of topics throughout the book. We thank them for their time and expertise. We would also like to thank all of the reviewers who carefully looked at the entire manuscript. You have helped shape this book to become a more useful text for everyone. xiii This page intentionally left blank A01_PERL5624_08_GE_FM.indd 24 2/12/18 2:58 PM Contributors Diane A. Anderson, DNP, MSN, RN, CNE Chapter 17: Using Informatics to Educate Associate Professor, MSN Specialty Tracks ~ Nurse ­Educator, Chamberlain College, Downers Grove, IL Ami Bhatt, DNP, MBA, RN, CHPN, CHCI Chapter 13: Information Security and Confidentiality Dr. Bhatt is currently enrolled in the DNP to PhD program at University of Nevada, Las Vegas, NV Sunny Biddle, MSN, RN Chapter 6: Policy, Legislation, and Regulation Issues for Informatics Practice Circulating Nurse in the Operating Room at Genesis Healthcare in Zanesville, OH and Clinical Instructor for Central Ohio Technical College in Newark, OH Jane M. Brokel, PhD, RN, FNI Chapter 8: Healthcare Information Systems Chapter 14: Information Networks and Information Exchange Section Instructor at Simmons College, Boston, MA Adjunct faculty for the University of Iowa College of Nursing, Iowa, City, IA Jennifer A. Brown, MSN, RN, HNB-BC Chapter 1: An Overview of Informatics in Healthcare Faculty, Bronson School of Nursing at Western ­Michigan University in Kalamazoo, Michigan in the undergraduate and RN-BSN programs. Athena Fernandes DNP, MSN, RN-BC Appendix A: Hardware and Software Appendix B: A Guide to the Internet and World Wide Web Senior Physician Systems Analyst, Penn Medicine Chester County Hospital, West Chester, PA Carolyn S. Harmon, DNP, RN-BC Chapter 16: Continuity Planning and Management Clinical Assistant Professor and Program Director for the Masters of Nursing Informatics and the Masters of Nursing Administration at University of South ­Carolina, Columbia, SC Toni Hebda, PhD, RN-BC, MSIS, CNE Chapter 3: Effective and Ethical Use of Data and Information Chapter 18: Consumer Health Informatics Professor, Chamberlain College of Nursing MSN ­Program, Downers Grove, IL Taryn Hill, PhD, RN Caring for the Patient Not the Computer in Chapter 1: An Overview of Informatics in Healthcare Dean of Academic Affairs for Chamberlain College of Nursing, Columbus, OH Diane Humbrecht, DNP, RN Chapter 12: Workforce Development Chief Nursing Informatics Officer, Abington Jefferson Health, Abington, PA Lisa Eisele, MSN, RN Chapter 19: Connected Healthcare (Telehealth and Technology-enabled healthcare) Chief - Quality, Performance & Risk Management Manchester VA Medical Center, Manchester VA Kathleen Hunter, PhD, RN-BC, CNE Chapter 3: Effective and Ethical Use of Data and Information Chapter 7: Electronic Health Record Systems Professor, Chamberlain College of Nursing MSN ­Program, Downers Grove, IL Sue Evans, MSN RN-BC Chapter 11: System Implementation, Maintenance, and Evaluation Informatics Nurse II University of Pittsburgh Medical Center East, Monroeville, PA Brenda Kulhanek, PhD, MSN, MS, RN-BC Chapter 4: Electronic Resources for Healthcare Professionals Chapter 12: Workforce Development AVP of Clinical Education for HCA in Nashville, TN xv xvi Contributors Susan Matney, PhD, RN-C, FAAN Chapter 15: The Role of Standardized Terminology and Language in Informatics Senior Medical Informaticist, Intermountain ­Healthcare, Murray, UT Julie McAfooes, MS, RN-BC, CNE, ANEF, FAAN High-fidelity simulation, software, support, and ­certification in Chapter 17: Using Informatics to Educate Web Development Manager for the online RN-to-BSN Option at the Chamberlain of Nursing, Downers Grove, IL Jeri A. Milstead, PhD, RN, NEA-BC, FAAN Chapter 6: Policy, Legislation, and Regulation Issues for Informatics Practice Professor and Dean Emerita, University of Toledo College of Nursing, Toledo, OH Patricia Mulberger, MSN, RN-BC Special Considerations with Mobile Computing in Chapter 13: Information Security and Confidentiality Clinical Informatics Quality Supervisor, Kalispell Regional Healthcare, Kalispell MT Melody Rose, DNP, RN Chapter 5: Using Informatics to Support ­Evidence-based Practice and Research Chapter 18: Consumer Health Informatics Assistant Professor of Nursing. Cumberland U ­ niversity Jeanette C. Rudy School of Nursing, L ­ ebanon, TN Carolyn Sipes, PhD, CNS, APN, PMP, RN-BC Chapter 8: Healthcare Information Systems Chapter 9: Strategic Planning, Project Management, and Health Information Technology (IT) Selection Appendix C: An Overview of Tools for the Informatics Nurse Professor, Chamberlain College, Downers Grove, IL Rebecca J Sisk, PhD, RN, CNE Virtual Learning Environment in Chapter 17: Using Informatics to Educate Professor, Chamberlain College Downers Grove, IL Rayne Soriano, PhD, RN Chapter 7: Electronic Health Record Systems Regional Director for Medicare Operations and Clinical Effectiveness. Kaiser Permanente, San Francisco, CA Nancy Staggers, PhD, RN, FAAN Chapter 10: Improving the Usability of Health ­Informatics Applications President, Summit Health Informatics and adjunct professor, Biomedical Informatics and College of Nursing University of Utah College, Salt Lake City, UT Maxim Topaz PhD, MA, RN Chapter 2: Informatics Theory and Practice Harvard Medical School & Brigham Women’s Health Hospital, Boston, MA, USA Marisa L. Wilson DNSc MHSc RN-BC CPHIMS FAAN Chapter 20: Public Health Informatics Associate Professor and Specialty Track coordinator for the MSN Nursing Informatics program at the University of Alabama at Birmingham School of Nursing. Reviewers Janet Baker DNP, APRN, ACNS-BC, CPHQ, CNE Associate Dean Graduate Nursing Programs Ursuline College, The Breen School of Nursing Pepper Pike, Ohio Theresa L. Calderone, EdD, MEd, MSN, RN-BC Assistant Professor of Nursing Indiana University of Pennsylvania Indiana, PA Vicki Evans, MSN, RN, CEN, CNE Assistant Professor of Nursing University of Mary-Hardin Baylor Belton, TX Kathleen Hirthler DNP, CRNP, FNP-BC Chair, Graduate Nursing; Associate Professor Wilkes University, Passan School of Nursing Wilkes Barre, PA Arpad Kelemen, Ph.D. Associate Professor of Informatics University of Maryland School of Nursing Baltimore, MD Michelle Rogers, PhD, MS, MA, BS Associate Professor of Information Science Drexel University Philadelphia, PA Charlotte Seckman, PhD, RN-BC, CNE, FAAN Associate Professor, Nursing Informatics Program University of Maryland School of Nursing Baltimore, MD Nadia Sultana, DNP, MBA, RN-BC Program Director and Clinical Assistant Professor, Nursing Informatics Program New York University New York, NY xvii This page intentionally left blank A01_PERL5624_08_GE_FM.indd 24 2/12/18 2:58 PM About the Authors Toni Hebda, PhD, RN-C, CNE, is a professor with the Chamberlain College of Nursing. MSN Program teaching in the nursing informatics track. She has held several academic and clinical positions over the years and worked as a system analyst. Her interest in informatics provided a focus for her dissertation, subsequently led her to help establish a regional nursing informatics group, obtain a graduate degree in information science, and conduct research related to informatics. She is a reviewer for the Online Journal of Nursing Informatics. She is a member of informatics groups and has presented and published in the field. Kathy Hunter, PhD, FAAN, RN-BC, CNE, is a professor with the Chamberlain College of Nursing MSN Program, teaching in the nursing informatics track. She has more than 40 years of experience in the fields of nursing informatics, healthcare informatics, and nursing education. After conducting clinical practice in critical care and trauma nursing for several years, she began practicing nursing informatics (NI), working with end users and with information systems design, development, testing, implementation and evaluation. She has presented nursing-informatics research in national and international meetings as well as publishing numerous articles in peer-reviewed journals. Collaborating in a community of practice with nursing-informatics faculty at Chamberlain, Dr. Hunter led the work resulting in the development of the TIGER-based Assessment of Nursing Informatics Competencies (TANIC) tool. xix This page intentionally left blank A01_PERL5624_08_GE_FM.indd 24 2/12/18 2:58 PM Hero Images/Getty Images Chapter 1 An Overview of Informatics in Healthcare Jennifer A. Brown, MSN, RN, HNB-BC Taryn Hill, PhD, RN Toni Hebda, PhD, RN-C Learning Objectives After completing this chapter, you should be able to: • Provide an overview of the current state of healthcare delivery. • Discuss the role that technology plays in healthcare. • Provide a definition for informatics. • Discuss the significance of informatics for healthcare. • Describe the process required to create an informatics culture. • Examine the relationship between technology, informatics, and caring. The healthcare delivery system today is a complex system faced with multiple, competing demands. Among these demands are: calls for increased quality, safety, and transparency; evolving roles for practitioners; a shift in consumer-provider relationships; eliminating disparities in care; adopting new models of care; the development of a learning health system (LHS); advanced technology as a means to support healthcare processes and treatment options; and providing a workforce with the skills needed to work in a highly technologyladen environment that is reliant upon data and information to function. Technology is a pervasive part of every aspect of society including healthcare delivery. Many suggest that health information technology (HIT) provides the tools to enable the delivery of safe, quality care in an effective, efficient manner while improving communication and decreasing costs (Institute of Medicine, 2012). HIT was named as one of nine levers that stakeholders could use to align their efforts with the National Strategy for Quality Improvement in Health Care, a collaborative effort also known as the National Quality Strategy, a mandate of the 2010 Affordable Care Act (ACA). The National Quality Strategy, published in 2011, represented input from more than 300 groups and organizations from various sectors of 1 2 Chapter 1 healthcare industry and the public (Agency for Healthcare Research and Quality, 2017). Yet, the healthcare sector has been slow to adopt and use technology to its full potential. Lucero (2017) noted that the failure for technology in healthcare to live up to its full promise to the present is not surprising given the complexity of healthcare delivery. So, what is information technology? Information technology (IT) is a broad term referring to the process of searching, organizing, and managing data supported by the use of computers. It has also come to include electronic communication. IT represents only a portion of the technology found in healthcare today, but is significant because data leads to information, which in turn provides knowledge. This chapter and the book as a whole will discuss the role that informatics plays to help address the multiple challenges facing healthcare today. Informatics Before we can discuss the role of informatics in healthcare, infomatics must first be defined. The American Medical Informatics Association (AMIA) (2017, Para. 1) states that informatics is an interdisciplinary field that draws from, as well as contributes to, “computer science, decision science, information science, management science, cognitive science, and organizational theory.” Informatics drives innovation in how information and knowledge management are approached. Its broad scope encompasses natural language processing, data mining, research, decision support, and genomics. Health informatics encompasses several fields that include: • Translational bioinformatics. This area deals with the storage, analysis, and interpretation of large volumes of data. It includes research into ways to integrate findings into the work of scientists, clinicians, and healthcare consumers. • Clinical research informatics. This area concentrates on discovery and management of new knowledge pertinent to health and disease from clinical trials and via secondary data use. • Clinical informatics. The concentration here is on the delivery of timely, safe, efficient, effective, evidence-based and patient-centered care (Levy, 2015). Examples include nursing informatics and medical informatics. Nursing informatics has its own scope and standards for practice as set forth by the American Nurses Association (ANA) as well as certification established by the American Nurses Credentialing Center (ANCC) (­American Nurses Association, 2015a). AMIA began the process, in 2007, of defining clinical informatics and its competencies, to lay the foundation for a credentialing process to recognize competence of clinical informaticists (Shortliffe, 2011). There is also discussion at a global level on specialty-board certification for physicians in clinical informatics (Gundlapall et al., 2015). • Consumer health informatics. The focus here is the consumer, or patient, view and the structures and processes that enable consumers to manager their own health. • Public health informatics. Efforts here include surveillance, prevention, health promotion, and preparedness. As might be surmised from a review of the above list, there are areas of overlap among the fields. Informatics and its subspecialties—including nursing informatics—continue to evolve as has the terminology used to discuss this field. For example, medical ­informatics was ­previously used as the umbrella term under which the subspecialties of health ­informatics fell. An Overview of Informatics in Healthcare The Relevance of Informatics for Healthcare Informatics is an essential component of healthcare today. The Institute of Medicine (2013a) noted its vision for the development of a continuously learning health system in which science, informatics, incentives, and culture are aligned for continuous improvement and innovation, and new knowledge is captured as a by-product of care processes. Together, HIT and informatics have been hailed as tools that can streamline processes, improve the quality of care delivered, reduce mortality, cut costs, and collect data to support learning (Institute of Medicine, 2012, 2015; Kohli & Tan, 2016; Lucero, 2017; Luo, Min, Gopukumar, & Yiqing, 2016; McCullough, Parente, & Town, 2016; Pinsonneault, Addas, Qian, Dakshinamoorthy, & ­Tamblyn, 2017). In fact, the Institute of Medicine (2013b, p. 1) stated that “digital health data are the lifeblood of a continuous learning health system.” Achieving this learning health system will require the work of many individuals and organizations. There are several factors to consider on the journey to a learning healthcare system. These include: • Healthcare professionals are knowledge workers. • Structures must be in place to support the collection, interpretation, and reuse of data in a meaningful way. • Evidence-based practices are a pre-requisite to achieving optimal outcomes. • Big data and data analytics are quickly becoming a major source of evidence, augmenting, and even replacing, other traditional forms of evidence such as clinical trials. • HIT and all forms of technology are present but best use is inconsistent. • Healthcare reform and a learning healthcare system are intricately linked. • Patient safety and the need to improve quality of care are drivers for healthcare reform. Each of these will be discussed briefly. Knowledge Work Nurses and other healthcare professionals have a long tradition of gathering data, which is then used to create information and knowledge. When previous knowledge and experience are applied appropriately to take action or intervene in some fashion, it is known as wisdom. These processes constitute a major part of the clinician’s day and, when done well, yield good outcomes. As an example, a piece of data without context has no meaning. The number 68 in isolation conveys nothing. It could be an age, a pulse rate, or even a room number, but in and of itself, there is no way to know what it means. However, if 68 is determined to be a pulse rate, the nurse can make the determination that this falls within the normal range, indicating that the patient is in no distress and requires no intervention. On the other hand, if that same number represents the rate of respirations per minute, the patient is in respiratory distress and immediate intervention is required. Gaberson and Langston (2017) noted that changes in the healthcare system, inclusive of demands for safe, accessible, quality care, have increased both the awareness of and demand for well-prepared knowledge workers. Gaberson and Langston also cited the assertion of the landmark 2010 Institute of Medicine report, The Future of Nursing: Leading Change, ­Advancing Health, that nursing is an appropriate profession to play a major role in transforming the healthcare system; yet, nursing education has not adequately prepared its graduates for this role. As a consequence, there is a need to better prepare nurses—and other healthcare ­professionals—during their basic education for this role and to provide better options to aid 3 4 Chapter 1 the new professional to assume the knowledge-worker role and to maintain essential competencies in this area. Structures to Support Meaningful Use of Data To be useful, data and information must be available when needed, to whom it is needed, and in a form that can be analyzed or used. Historically, the healthcare delivery system has collected huge amounts of data and information from different sources and in different formats, creating data silos within departments and facilities. Without organization, this data and information has limited value, even at its collection site, and is not amenable to sharing for learning purposes. The use of electronic health records (EHRs) moved data and information to a digital format, which is conducive to organization, analysis, and sharing, but differences in format still make analysis difficult. Data exists in raw and processed states and unstructured and structured forms. Examples of unstructured data include documents, email, and multimedia. Structured data fits into predetermined classifications such as that seen with a list of selectable options that can easily be quantified. Even before the widespread adoption of EHRs, there was a growing recognition that improved communication among professionals required the adoption of standardized languages and terminologies to ensure that a concept had the same meaning in all settings; this also makes generalization of research findings possible. One example of a standardized language that is familiar to most nurses is NANDA, which was created by the North American Nursing Diagnosis Association to provide standardized terms for nursing diagnoses. Standardized languages and terminologies can be integrated into EHRs. A lack of data standardization jeopardizes opportunities for learning because important data may not be available for analysis (­Auffray et al., 2016). Standardization of data and its collection in a digital format in databases facilitate ­collecting, sorting, retrieval, selection, and aggregation of data to a degree never before possible. Aggregate data can be analyzed to discover trends and, subsequently, to inform and educate. Researchers use both qualitative and quantitative methods to analyze data. Qualitative methods focus on numbers and frequencies, with the goal of finding relationships or variables specific to an outcome. Qualitative methods are variable and not focused on counting. These methods can include any data captured. This data can be in the form of questionnaires, surveys including web surveys, interviews, list serves, and email. Electronic data collection tools include personal digital assistants or laptop computers. Another important facet of information access is related to the electronic literature databases for the health sciences, business, history, government, law, and ethics that healthcare professionals and administrators use to keep up-to-date and inform their practices. Libraries purchase electronic literature databases that users can easily search using keywords, Boolean search operators, title, author, or date to find relevant information. Literature databases use key terms to index collections. Medical subject headings (MeSH) are used by the controlled vocabulary thesaurus of the National Library of Medicine (NLM) to index articles in PubMed, a free search engine maintained by the NLM. PubMed is used to access the MEDLINE bibliographic database. Some other examples of literature databases relevant for healthcare include EBSCO, Ovid, ProQuest, CINAHL, and Cochrane Library. Becoming familiar with the databases most relevant to one’s purpose or focus is important. Adept use requires time and practice. When searching a database, one should define the subject and the question; then, search for the evidence in multiple components of the literature: for example, use evidence from multiple studies (not just one random study), incorporate what was learned into practice, and evaluate the impact of what was implemented. An Overview of Informatics in Healthcare Evidence-Based Practice Evidence-based practice (EBP) entails using the current best evidence for patient-care ­decisions in order to improve the consistency and quality of patient outcomes (Mackey & Bassendowski, 2017). It requires critical thought processes. EBP provides the foundation for clinical-practice guidelines and clinical decision-support tools that are widely found in healthcare organizations today. EBP in nursing evolved from Florence Nightingale’s idea that she could improve patient outcomes through systematic observations and application of subsequent learning. EBP has been further defined by the International Council of Nurses (2012) as an approach that incorporates a search for the best available, current evidence with clinical expertise and patient preferences. Big Data and Big Data Analytics According to the National Academies of Sciences, Engineering, and Medicine (2017), a ­learning health system is one that uses real-time evidence for continuous improvement and innovation. The implications of real-time evidence are that traditional research and publication cycles where months, or even years, transpire from the time of research until dissemination of results no longer satisfy the criteria for best evidence because data may no longer be current or timely. Real-time data for analysis requires different methods, tools, and dissemination methods. Enter big data and big data analytics. Big data are very large data sets that are beyond human capability to manage, let alone analyze, without the aid of information technology. Big data has been collected for years by retailshopping organizations. As an example, consider the shopper’s card that nearly everyone has for their favorite grocery store. In exchange for special store discounts on select merchandise or points earned for discounts, the store collects information on shopper preferences every time the card is used. The aggregate data that healthcare providers collect via their EHRs is a type of big data. Another example of big data is seen when healthcare providers submit data collected for meaningful use core data (with one exemplar being smoking status) to the US Centers for Medicare and Medicaid Services (CMS) (2010), CMS analyzes the data for trends, with the intent to better allocate funds and services to improve care coordination and population health. Big data, and the technologies used to reveal the knowledge within it, provide new opportunities for healthcare to discover new insights and create new methods to improve healthcare quality (Luo, Min, Gopukumar, & Yiqing, 2016). Furthermore, the computing speed associated with big data (Kaggal et al., 2016) provides a promising development to make the LHS possible. A new science, known as data science, has emerged to deal with all aspects of big data including data format, cleaning, mining, management, and analysis. Analysis of big data, or analytics, looks for patterns in data, then uses models to ­recommend actions (Wills, 2014). Analytics can be used to forecast the likelihood of an event. Real-time analytics use current data from multiple sources to support decisions; this may result in powerful tools useful at the bedside as well as to support executive-level thought processes. Business intelligence is another term that is used when discussing best use of data, although business intelligence is a broader term that encompasses a plan, strategy, and tool sets to support decisions. Increased Prevalence of Technology in Care Settings According to recent projections, US hospital adoption of EHRs is expected to surpass 98% by the end of 2017, with adoption by physicians running slightly below that figure (Bulletin Board, 2016; Orion Market Research, 2017). EHRs are also found in long-term care settings, 5 6 Chapter 1 although adoption rates there lag behind hospital and physician-office settings (EHR Adoption, 2017) . There are also many different types of technology found at the bedside, or point of care. These range from point of care computer terminals to access patient records or literature databases to monitoring biometric measures such as pulse, heart rate and rhythm, blood pressure, oxygen saturation, and many tests that were formally only done in laboratory settings. There are also medication-dispensing cabinets, smart-technology that includes medication-administration infusion pumps that link with provider order entry, pharmacy, and medication-administration systems for greater safety. A growing number of implantable devices such as insulin pumps, pacemakers, and defibrillators, and various telehealth applications such as telestroke consultations that allow the neurologist at another site to evaluate and communicate with the stroke victim and attending family and care givers. There are also telesitter applications that allow an individual at a central location to monitor several patients at one time, observing them for attempts to get out of bed without assistance, and having the capability to verbally reorient them or call for further assistance. Many of these technologies already have the capability to communicate and input data into EHRs. There are also voiceactivated, hands-free communication devices for staff use. Technology is supplementing work once done by ancillary staff. There are robots that deliver supplies while other robots use ultraviolet light to disinfect patient rooms and operating rooms. The range of technology available in the home includes telemonitoring and care devices to track congestive heart patients, the mentally ill, and many more conditions. The number and range of mobile applications available to track wellness and manage chronic healthcare conditions is growing at an exponential rate. Patients have implantable devices to monitor their cardiac function, control seizures, control pain, and control the function of prosthetics. Robots to assist with care are expected to become commonplace in the near future. The move to a technology-laden environment has implications for informatics. Informatics specialists are prepared to design, implement, and evaluate technologies that support healthcare providers and consumers. Healthcare Reform Health reform has many drivers. The United States spends more per capital on healthcare than any other nation in the world, without commensurate results (Robert Wood Johnson Foundation, 2017). In one effort to enact change, value-based payment models reward providers for quality of care provided and efficient resource use rather than volume of services. In another effort, the enactment of the American Recovery and Reinvestment Act (ARRA) in 2009, along with its component Health Information Technology for Economic and Clinical Health (HITECH) Act, provided economic stimuli and incentives for the adoption of EHRs, in alignment with the goal that each person in the United States would have a certified digital health record by 2014. As of 2016, this goal was achieved by more than 98% of nonfederal acute care hospitals. These digital records meet the technical capabilities, functionality, and security criteria promulgated by the Center for Medicaid and Medicare Services (Office of the National Coordinator for Health Information Technology, 2017a). The push for EHRs was consistent with the thinking that a longitudinal health record would improve access to information and consequently improve care. HITECH also ensured the collection of aggregate data that could be used to improve policy decisions relative to allocation of services and population health. Digital data also facilitates collection of data needed to measure quality of healthcare delivery, as well as improving data dissemination, as digitation allows easier data sharing. Other drivers for healthcare reform include calls for improved safety and quality, transparency, the rise of consumerism with greater patient participation in planning care, and changing provider-patient relationships. An Overview of Informatics in Healthcare The Push for Patient Safety and Quality Despite life or death consequences of decisions, healthcare is not as safe as it might be. Ineffective collaboration and poor communication have led to fragmented care and potentially dangerous errors and poor patient outcomes (Titzer, Swenty, & Mustata Wilson, 2015). The World Health Organization (WHO) (2017, Para. 1) refers to patient safety as a “fundamental principle of health care,” calling for policy, leadership, data to drive improvements, patient engagement, and a skilled workforce to make healthcare safer. The Joint Commission International publishes patient safety goals that are integrated into the national accreditation process (The Joint Commission, 2017). Joint Commission International (2017) lists six patient safety goals that focus upon correct identification, effective communication, improved safety of high-alert medications, procedures that do not introduce harm, decreased risk of healthcareacquired infections, and reduced risks of harm secondary to falls. HIT can improve safety and quality through alerts and decision support that help to improve the hand-off process—a point where many errors occur—and through the use of checklists. Zikhani (2016) noted that there are active and latent errors. Active errors include mistakes, slips, and lapses made by clinicians, while latent errors occur with imperfect organization design such as those seen with incomplete procedures, poor training, and poor labeling. Zikhani outlined steps to prevent errors in healthcare that include: • Checklists that can prevent slips and lapses. • Tools that improve communication such as hand-off tools. • Automation when possible. • Simplification, organization, and standardization. • Not allowing errors to happen. An example of the latter might be the bar-code administration system that tells the nurse that it is not the correct medication during the medication administration process Clearly, these processes lend themselves well to automation, or technology. Technology can also be used to simulate clinical scenarios to educate the members of an interprofessional team (Titzer, Swenty, & Mustata Wilson, 2015). Nurse leaders have recognized the importance of integrating nursing informatics into undergraduate curricula by adding an informatics-competency category to the quality and safety curriculum developed by the Quality and Safety Education for Nurses (QSEN) project (QSEN Institute, 2017a). Many hospitals have elearning systems or use their intranets to provide ongoing education for personnel (Chuo, Liu, & Tsai, 2015). Another effort to improve the coordination of care has led to new care models such as accountable care organizations (ACOs) and patient medical homes (PMHs). ACOs bring together primary care providers, specialists, and hospitals to share information and coordinate care and payment plans with the aims of greater efficiency and quality at a lower cost and, ideally, with less aggravation for the patient (Dewey, 2016). PMHs also bring together an interdisciplinary team that networks with other practices and networks to deliver or improve access to services (Hefford, 2017). Hefford (2017) noted that PMHs represent a move towards an integrated system of care. Team-based healthcare delivery models require great levels of collaboration (Rajamani et al., 2015). All models are dependent upon data, particularly shared data, for success. Another model of care is seen with the changing dynamics of the provider-patient relationship. In the past, patients relied upon the judgment of their provider, often without question. However, with the rise in consumerism and widespread recognition that healthcare reform requires input from everyone, including consumers, patients are encouraged to be involved in their healthcare decisions. The transition from passive recipient to active 7 8 Chapter 1 participant requires several skills that include language literacy, health literacy, digital literacy, and transparency. The latter—transparency—requires access to information. The digitization process—making information available in electronic format—makes it easier to post and share information needed to make health decisions. Provider roles are also changing and evolving. In addition to traditional roles, providers serve as gatekeeper to services, coach, navigator, and, sometimes, informatician (Johnson, 2015). And at a time where not every local practitioner has privileges at local hospitals, or patients are transported to other facilities, the hospitalist fills that void—a role that is still new to many healthcare consumers. Creating an Informatics Culture While informatics is much more than data management, knowledge that is derived from data and information is a central tenet. Creating a knowledge strategy and the infrastructure, expertise, and tools required to discover new learning and knowledge in data, particularly big data, fits well within the scope of informatics (Dulin, Lovin, & Wright, 2016; Kabir & Carayannis, 2013) . An informatics culture requires a vision to develop the policies, funding, infrastructure, and education to instill the knowledge and skills needed by all healthcare executives, clinicians, and informaticists, and the tools to gather and analyze amassed data. The process to do this takes time. The first step in the process is assessing the current state to determine gaps (How ­Informatics can reshape healthcare, 2016). A highly innovative culture provides a solid foundation with the EHR playing a key role, because it provides a view of what is going on within an organization and beyond as data from healthcare exchanges and national data sets are examined. Foundational Skills There are foundational skills that are required for an information-driven culture. These include computer literacy, information literacy, and (for the consumer), health literacy. Computer literacy is a term used to refer to the basic understanding and use of computers, software tools, spreadsheets, databases, presentation graphics, social media, and communication via email. The fundamentals of basic literacy—the ability to read, write, and comprehend—are prerequisite. Without a basic understanding of literacy, barriers to other forms of literacy cannot be addressed (Nelson & Staggers, 2018). Health informatics is built on overlapping layers of literacies. Information literacy is the ability to read and understand the written word and numbers as well as the ability to recognize when information is needed. One of the biggest challenges today is making health information accessible to all without regard to background, education, or level of literacy. Health literacy is the ability to understand and act upon basic healthcare information. A simple example would be how a person acts upon a change in diet in relation to a new medical diagnosis. Clearly each type of literacy is important for both healthcare consumer and healthcare worker. Creating a Policy, Legal, and Reimbursement Framework Professional organizations and informaticists have been working to create an informatics culture for some time through their involvement in national and organizational policy-setting. As an example, the American Nurses Association (2014) position statement Standardization and Interoperability of Health Information Technology: Supporting Nursing and the National Quality An Overview of Informatics in Healthcare Strategy for Better Patient Outcomes called for standard representation and interoperability of data collected in EHRs and other HIT. The National Association of Clinical Nurse Specialists (2017) set two goals relative to HIT for their 2016–2018 public policy agenda that included representing the role of the clinical nurse specialist in relevant legislative, policy, and ­advocacy efforts for increased access to healthcare via the use of technology. The US Office of the National ­Coordinator for Health Information Technology (ONCHIT), the federal entity charged with coordinating national efforts to implement and use HIT and electronic exchange of health information, invites input from healthcare professionals and consumers (HealthIT.gov, 2016). ONCHIT also has many committees with healthcare professions representation. Informatics groups, inclusive of the American Medical Informatics Association, American Nursing Informatics Association, Health Information Management Systems Society (HIMSS), and the ­Alliance for Nursing Informatics (ANI), include public policy related to HIT-enabled care among their goals (Collins, Sensmeier, Weaver, & Murphy, 2016; Health Information Systems Society, 2017a). Ethical Framework Ethics is the formal study of values, character, and/or conduct of individuals or collections of individuals from a variety of perspectives or viewpoints (American Nurses Association, 2015b). The field of health informatics focuses on using computers to enhance the way health information is processed. Today, the Internet opens up multiple avenues for obtaining information. Most links on the information highway do not have an overseer or monitor screening for good ethical decision making. This process is individual and personal, based on standards and the ability to differentiate right from wrong. Ethical decision making is the basis for this process. There are also issues related to how information collected for one purpose may be used for another. In a work that remains relevant today Beauchamp and Childress (1994) proposed four simple guiding principles for moral action. First is autonomy. Autonomy is the individual’s freedom to control interferences by others, retaining a personal capacity for intentional action. Second is nonmaleficence: the obligation for doing no intentional harm, Third is beneficence, which refers to actions that result in positive outcomes in which benefits and utility are balanced. Finally, fourth is justice, which refers to the standards practiced by healthcare professionals. Professional associations for informatics also have codes of ethics that provide guidance for ethical use of data and information. Workforce Preparation Fox, Flynn, Clauson, Seaton, & Breeden, (2017, p. 1) noted that “informatics education for clinicians is a national priority,” particularly since there is a lack of consistency in teaching informatics competencies. Informatics competencies are needed to help healthcare professionals manage and use technology effectively. The Institute of Medicine (2012) recognized the need for a workforce prepared to work with technology. The Technology Informatics Guiding Education Reform (TIGER) Initiative is another effort that grew out of the need to develop informatics skills among an interprofessional workforce (Healthcare Information and Management Systems Society, 2017). Informatics competencies are delineated for nursing graduates by the American Association of Colleges of Nursing, National League for Nursing, and the QSEN Institute, among others. QSEN Institute identified quality and safety competencies for nurses that fit well with an informatics culture. These competencies include: patient-centered care, teamwork, evidencebased practice, quality improvement, safety, and informatics. Educators can use the QSEN framework as a guide. Teaching strategies can start with incorporating the QSEN competencies into curricula via classroom, simulation lab, and clinical strategies. The goal of the competencies is to use information and technology to communicate, manage knowledge, 9 10 Chapter 1 mitigate error, and support decision making (QSEN Institute, 2017b). The institute recommends incorporating the competencies beginning in the first semester of education and continuing throughout the nursing program. The competencies are formatted into three categories: knowledge, skill, and attitude. An example of knowledge would be the ability to contrast benefits and limitations, understand the value of databases for patient care monitoring, and establish a good understanding of terminology and interoperability of systems. An example of skills is for the nurse to play an active role in the design, promotion and modeling of standard practice. Nurses are an important member of the healthcare informatics team that can bring a clinical lens to the development table. Attitude incorporates nursing values whether it is in the realm of reporting or preventing errors, improving patient safety in a noblame environment, and acting as a sentry for self, patients, and family. QSEN (2017c) also lists competencies for nurses prepared at the graduate level. Hersh et al. (2014) spoke to the need for physicians needing informatics competencies because of their interaction with EHRs, clinical decision support, quality measures and improvement, personalized medicine, personal health records, and telehealth. Obviously, physicians are not the only healthcare professionals who use EHRs, decision support, telehealth, personal health records, or have concerns related to quality measurement and improvement, so all clinicians are impacted. The Office of the National Coordinator for Health Information Technology (2017b) funded curriculum development centers to develop curricula and education in response to the mandate by the HITECH Act of 2009 to aid institutions of higher learning to establish or expand medical-informatics education programs. Twenty topics were developed originally, and more recently, five additional topics were developed in population health, care coordination and interoperability, value-based care, analytics, and patient-centered care. Materials developed through this effort are available for use at no cost. Workforce preparation is under review in other areas of the world as well. One exemplar is the collaborative effort between the United States and European Union, which yielded an extensive list of competencies, including an informatics category. The workforce published the list of competencies as a tool for self-assessment. The Health Information Technology Competencies (HITCOMP) tool may be accessed without charge at http://hitcomp.org/ Technical Infrastructure The technical infrastructure for healthcare informatics and exchange of information is the result of policy, legislation, funding, a multitude of agencies that are working to advance HIT for the benefit of healthcare, and technical standards. Policy and legislation and the relationship with funding will be discussed later in the book. One of the most important US agencies to advance HIT is the Agency for Healthcare Research and Quality (AHRQ). AHRQ is a division of the US Health and Human Services committed to research and evidence to improve the safety and quality of healthcare and to providing education for healthcare professionals that will enable them to improve care (Agency for Healthcare Research and Quality, n.d.). Another agency that is a division of the US Health and Human Services is the National Institutes of Health (NIH). While NIH does not focus on technology to the same extent as AHRQ, it does provide funding for research to improve health (NIH, n.d.). The third notable US government agency is the Office of the National Coordinator for Health Information Technology (ONCHIT). This office was funded with money granted by the Public Health Service Act (PHSA) as defined by the Health Information Technology for Economic and Clinical Health Act (HITECH). ONCHIT provides EHR certification, and its structure includes multiple offices that are relevant for HIT as may be seen in Figure 1-1 (HealthIT.gov, 2017). An Overview of Informatics in Healthcare Office of the chief privacy officer Office of clinical quality and safety Office of the chief operating officer Office of planning, evaluation, and analysis Office of the chief scientist Office of public affairs and communications Office of standards and technology Office of policy Office of the National Coordinator Office of care transformation Office of budget Office of procurement and grants Office of programs and engagement Office of ethics and compliance Office of operational services Office of planning oversight and data Office of human capital Figure 1-1 • ONC Organization. SOURCE: From Office of the National Coordinator for Health Information Technology (ONC), Published by U.S. Department of Health and Human Services. Technical standards provide specific directions to ensure that data and information can be exchanged in a fashion so that uniform meaning is maintained on both sides of the exchange. Health-information data standards may be grouped into the following four categories: content, transport, vocabulary, and privacy/security standards (Health Information Management ­Systems Society, 2017b). Content standards establish the structure and organization of the content. Transport standards set forth the format for exchange. Terminology standards improve communication through the use of structured terms and facilitate organization of data. (More will be said on terminology standards later). Privacy standards protect personal health information, while security standards provide administrative, physical, and technical actions that provide patient confidentiality as well as the availability and integrity of health information. It is important to dispel the idea that computers are taking nurses away from the bedside. As nursing practice evolves, technology evolves in tandem. Technology supports all aspects of nursing practice, which include direct care, administration, education, and research (McGonigle, Hunter, Sipes, & Hebda, 2014). In order to create an informatics culture, there must be harmonious interaction between people and technology. While technology changes rapidly, so do the needs of the user. Informaticists play a key role in both system design and nurturing the user’s abilities. 11 12 Chapter 1 EHRs bring a meaningful medium to enhance continuity of care, care coordination, access to information, and satisfaction for both patient and provider, while decreasing costs. Various studies have reported mixed reviews. A study published by Gomes, Hash, Orsolini, Watkins, and Mazzoccoli (2016) intended to determine the effects of implementing an EHR and the direct relationship to patient-centered activities, attitudes, and beliefs. A wellknown EHR was implemented, with the study taking place six months post implementation. Data from nurses’ self-reports showed that post-implementation, nurses spent more time in patient rooms and more time engaged in purposeful interaction. Nursing documentation time decreased by 4%, which may be related to increased skill in doing documentation via computer. Although time spent in the patients’ rooms had increased, that increase did not always equate to higher quality care if interactions were not patient-focused. Caring for the Patient Not the Computer There is currently a gap in the research related to integrating technology within the caring nurse-patient relationship. In our current digital world, reliance on technology is high. In healthcare, some may argue that this reliance is even higher. Nurses and other healthcare workers rely on machines to obtain vital signs that were previously assessed manually. The change from manual to automated blood pressures has the ability to change the focus of the healthcare system from person to machine. Using the machines as extensions of nursing care, rather than as replacements for it, can allow for continued relationship building, progress toward optimal health, and reduction in medical errors. The notable expectation regarding the use of technology is using it as a tool to gather data about a patient’s health status. We must always remember that these devices are tools to be used for this purpose and not to replace assessment skills. There is currently a gap in the literature regarding effective ways to integrate the concept of caring with the use of today’s health information technology. Let’s take, for example, the concept of alarm fatigue. Alarms on medical equipment are designed to alert the healthcare team of an existing or impending change in the patient’s healthcare status. However, it is estimated that “While defects of devices threatened patient safety in the past, alarms indiscriminately generated by the explosive increase in the number of medical devices now threaten their safety. Reports on safety accidents related to the diversity of medical device alarms have raised awareness of the clinical alarm hazard” (Cho, Hwasoon, Lee, & Insook, 2016, p. 46). This alarm fatigue is compounded by the number of potential false alarms during a nurses’ work shift. It is important that we visit the reason for the alarm fatigue and the importance of using technology as a means to improve patient outcomes. Cho et al. (2016) noted that when The Joint Commission introduced the latest patient safety goals in 2013, hospitals were asked to identify ways to manage alarms. This included a deep dive into the most important alarms and what type of signals could be identified to improve alarm safety. Hospitals began the task to create policies and procedures to address this issue. As the primary caregiver at the bedside, nurses are empowered to identify ways to improve the safety of patient care through the management of alarm fatigue. Nurse informaticists are especially equipped to identify ways to highlight important alarms and reduce the number of non-actionable alarms. Nurses need to be equipped with the resources needed to make this happen. Part of this process includes the realization that the alarm-generating technology is paramount in providing data to nurses that allows them to make critical decisions about the care of their patients. The electronic health record provides the nurse with the opportunity to use technology in a caring way that provides direct one-on-one interactions with the patient, using the An Overview of Informatics in Healthcare computer as a tool to gather and store data that is important to patient care. Nurse informaticists can be on the cutting edge in devising technology that focuses on decreasing the frequency of monitor alarms so that the alarms become more actionable to the nurse. Through a systematic review of research articles on physiologic-monitor alarms and alarm fatigue, Paine et al. (2016) identified that the proportion of actionable alarms ranged from less than 1% to 36% across hospital settings. Some studies showed that the amount of alarm exposure affected nurse response time to the alarm. Longer response times may lead to poorer patient outcomes. The findings of this systematic review are further support that nurses need to be well versed in the reasons they use technology as a support. When nurses do not utilize technology to support the care of the patient, but, instead, use it as a substitute for assessing the patient, part of the nurse-patient relationship is lost. Nursing education is at a pivotal time to be able to educate current and future nurses on the importance of utilizing information technology as a tool for safe patient care. Nursing faculty and nursing staff need to be able to minimize barriers to both training and implementation of tools within a technology-rich environment. Understanding how to use technology for patient intake and assessment, while still creating a trusting nurse-patient relationship, can provide an environment that enhances both quality and safety in nursing. An important way to assist in creating this type of environment is to ensure that all patients are aware of the type of technology that is used for data collection and communication. It is important that they have the perception that the nurse cares about them. Instilling this value in the relationship is difficult when nurses are so heavily reliant on technology such as computers, specialized communication devices, and telephones that they carry with them during the course of patient care. Limitations to building a trusting, caring relationship come when patients perceive the nurse does not care, or is distracted during interactions—as can be the case when nurses stop to answer the phone or other communication devices during the course of a nurse-patient interaction. Patients need to be able to see the relevance of technology to the quality and safety of the care they receive. A collaborative approach to the use of technology between the patient and the nurse may assist in increasing caring relationships and decreasing patient events related to alarm fatigue. Future Directions Over the last few years, the focus has been on health information exchange for care d ­ elivery and quality. Over the next ten years, the infrastructure to support interoperability of ­systems and data exchange must be completed. The Office of Health and Human Services is responsible for increasing the amount of electronic health information and interoperability of HIT. This coincides with the ONC mission to protect the health of all Americans and provide essential human services, especially for those least able to help themselves (Office of the National Coordinator for Health Information Technology, 2015). The ONC roadmap for interoperability is written for both public and private stakeholders who will advance health IT interoperability for the betterment of patient care, smarter spending, and a healthier people. The document is intended to be dynamic as goals are met and new ones created. In order to achieve interoperability and ensure electronic health information security, the ONC proposed the following pathways: • Improved technical standards and implementation guidance. In short, this means use of commonly known standards and consistency in application of standards. • A shift in alignment of federal, state, and commercial payment policies away from feefor-service to a value-based model. • Coordination among stakeholders to promote and align policies and business practices. 13 14 Chapter 1 Individuals access and share health information HIT for quality and safety in care delivery Quality measures Population health management and regional information exchange Public health Big data and analytics Clinical research Technical standards and services Certification of HIT to accelerate interoperability Privacy and security protections Practice Patient Population Public Supportive business, clinical, and regulatory environments Rules of engagement and governance Clinical decision support Public health policy Clinical guidelines Figure 1-2 • Health IT Ecosystem. SOURCE: From Office of the National Coordinator for Health Information Technology (ONC), Published by U.S. Department of Health and Human Services. The IT ecosystem is important as new technology enters the market. At the core of the ecosystem are the patient, practice, population, and public. Surrounding the core of stakeholders are the products and services that allow interoperability to happen. Figure 1-2 depicts the health IT ecosystem. Nursing informatics will continue to evolve as a specialty, particularly as its visibility increases and the need for all healthcare professionals to develop their own informatics competencies becomes increasingly apparent. Nursing informatics will continue its journey by staying current with technology trends, building strong collaborative teams, promoting standardization, and being proactive. As clients demand more health information and quicker access to it, information research using the tools of technology is a basic must-have skill for the nurse. Just as nurses face the challenges of patient care through competencies, the same approach should be incorporated into practice while facing the future of technology. New technologies afford the opportunity to create new tools or to use them in new ways. As one example consider the growing use of virtual reality for education. Virtual worlds are found in computerized settings that simulate environments without typical boundaries. Second Life (http://secondlife.com) is one example of a virtual application that allows for creativity although it can be time-intensive, costly, and unable to provide feedback from a sense of smell and touch. Summary • The healthcare delivery system faces many demands that include calls for increased ­quality, safety, and transparency; evolving roles for practitioners; a shift in consumerprovider relationships; eliminating disparities in care; adopting new models of care; the need to develop a learning health system; increased technology; and workforce preparation. An Overview of Informatics in Healthcare • HIT has the potential to facilitate delivery of safe, quality care in an effective, efficient manner while improving communication and decreasing costs. • Informatics in healthcare provides the knowledge and skills to harness the potential of HIT. • Healthcare professionals are knowledge workers, and their work is supported via wellused HIT; but educational preparation for knowledge work has been inconsistent. • Structures are needed to support meaningful use of data. These include digital formats using standardized languages and terminologies to ensure consistent meanings across all settings. • Large data sets, known as big data, increasingly provide evidence to support learning and new practices—often supplementing or replacing traditional research findings. • Healthcare delivery needs to become a learning health system, which is defined as one that uses real-time evidence for continuous improvement and innovation. This realtime evidence can be supplied through big data and analytics or business intelligence. • Technology is pervasive throughout healthcare delivery inclusive of point of care devices, wearable, implantable, monitoring, as well as information systems and EHRs. Informatics professionals play a role in the design, implementation, and evaluation of that same technology. • Economic incentives for the adoption of EHRs provides means to measure quality of care and provided learning that can be used for improved allocation of resources. • Patient safety is a global initiative. HIT can provide or enhance safety through the provision of checklists, improved communication, and prevention of errors, as well as simplification and standardization. • New care models are reliant upon data to better coordinate patient care. • The move to consumerism, with care as a partnership, drives the need for available quality data for consumers to facilitate informed decision-making. • An informatics culture recognizes the value of data, establishes a knowledge strategy, and the infrastructure, expertise, and tools required to discover new learning and knowledge in data. • An infrastructure conducive to an informatics culture fosters legislative, policy, and advocacy efforts to increase access to information and quality care. Professional groups and government agencies, including the US Office of the National Coordinator for Health Information Technology, have demonstrated efforts to foster an informatics culture. • Informatics and healthcare professionals have ethical codes to guide the use of data and information. • All healthcare professionals need informatics knowledge and skills to ensure appropriate use of technology and data, information, and knowledge. Informatics professionals need to provide leadership and informatics to ensure that all healthcare professionals receive these competencies. • Technology provides a tool to augment, not replace, the care. Informaticists must consider the needs of healthcare professionals and consumers when technology is deployed. • HIT is not deployed in isolation; instead, it is part of the health IT ecosystem that brings together patients, provider practices, populations, and the public in a system designed to support each through research, policy, guidelines, and decision support, while measuring quality and outcomes. • The development of new technologies and informatics competencies is a given over time. 15 16 Chapter 1 Case Study The community member on your hospital’s advisory body has asked you to provide an overview of the relationship between informatics, technology in healthcare, and the status of healthcare delivery today. In your efforts to provide a short answer what would be four points that you would make? About the Authors Jennifer A. Brown has been a nurse educator for over eighteen years and has spent the last five years teaching Health Informatics to students in nursing, health information management, interdisciplinary health sciences, and computer science. Board Certified in Holistic Nursing, her passion for holism is threaded throughout each course that Professor Brown teaches. She is a tenured full-time faculty and teaches in the Bronson School of Nursing at Western Michigan University in Kalamazoo, Michigan in the undergraduate and RN-BSN programs. Taryn Hill serves as Dean of Academic Affairs for Chamberlain College of Nursing. She contributed the content Caring for the Patient Not the Computer. She has authored and presented on nursing informatics topics. Toni Hebda teaches graduate-level informatics courses at Chamberlain College of Nursing. References Agency for Healthcare Research and Quality. (2017). About the national quality strategy. 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Journal of Healthcare Management, 61(4), 271–281. 19 Hero Images/Getty Images Chapter 2 Informatics Theory and Practice Maxim Topaz, PhD, MA, RN Learning Objectives After completing this chapter, you should be able to: • Discuss the relevance of theory for informatics research and practice. • Apply the DIKW framework to a situation in your lived experience. • Examine ways that informatics may use the wisdom-in-action framework to support clinical care. • Compare and contrast the different informatics subdisciplines found within healthcare. • Weigh how the scope of informatics practice determines the types and levels of competencies needed. • Discuss future needs and directions for nursing informatics. Overview of Theory Theory Definition In general, theory is defined as a scientifically acceptable general principle—or constellation of principles—offered to explain phenomena (Meleis, 2015). Scientific disciplines are often based on some central theories that define the general school of thought accepted within a discipline. For example, a theory of evolution formalized by Darwin (1859) states that through a process called natural selection, live organisms are changing over time while passing their new traits to the next generations. This process results in evolution of simple creatures to complex organisms. Eventually, the changes accumulate and produce an entirely different organism. This theory is fundamental to several fields, for example, biology, where a common assumption st...
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