Trends in Nursing Informatics
Trends in Nursing Informatics
science to manage and communicate data, information, and knowledge in nursing practice. Nursing informatics facilitates the integration of data and knowledge to support patients, nurses, and other providers in their decision making in all roles and settings. This support is accomplished through the use of information structures, information processes and information technology. TRENDS IN NURSING INFORMATICS CLINICAL INFORMATION SYSTEM Clinical information system (CIS) is a computer based system used to inform clinicians about tests, procedures and treatment in an effort to improve the quality of care through real-time assistance in decision-making and to increase efficiency and effectiveness of care delivery. Computerized patient records A computerized patient record or electric patient record (CPR) or electric patient record will include all information about an individuals lifetime health status and health care. The CPR is a replacement for the paper medical record as the primary source of information for health care, meeting all clinical, legal na d administrative requirements. However, CPR is more than the todays medical record. Information technology permits much more data to be captured, processed and integrated, which results in information than that found in a linear paper record. The CPR is not a record in the traditional sense of the term. The term traditionally has suggested that the sole purpose for maintaining health data is to document events. Although this is an important purpose, the CPR permits health information to be used to support the generation and communication of knowledge. The health care delivery system is dramatically changing, with a strong emphasis on improving outcomes of care and maintaining health. The CPR needs to be considered in a broader context and is not applicable only to patients, that is, individuals with the presence of an illness or disease. Rather, in the CPR, the focus is on the individuals health, encompassing both wellness and illness. As a result of this focus on the individual, the CPR is a virtual compilation of nonredundant health data about the person across her lifetime including facts, observations, interpretations, plans, actions, and outcomes. Health data include information on allergies, history of illness and injury, functional status, diagnostic
studies, assessments, orders, consultation reports and treatment records. Health data also include wellness information such as immunization history, behavioral data environmental information, demographics, health insurance, administrative data for care delivery processes, and legal data such as consents. The structure of data includes text, numbers, sounds, images, and full- motion video. These are thoroughly integrated so that any given view of health data may incorporate one or more structural elements. Within a CPR, an individuals health data are maintained and distributed over different systems in different locations, such as hospital, clinic, practitioners office and pharmacy. Intelligent software agents with appropriate security measures are necessary to access data across theses distributed systems. The nurse or other user who is retrieving these data must be able to assemble the data in such a way as to provide a chronology of health information about the individual. The CPR is maintained in a system that captures, processes, communicates, secures and presents the data about the patient. This system may include the CIS (Clinical Information System). Other components of CPR system include clinical rules, literature for patient education, expert opinions, and payer rules related to reimbursement. When these elements work together in an integrated fashion, the CPR becomes much more than a patient record- it becomes a knowledge tool. The system is able to integrate information from multiple sources and provides decision support; thus, the CPR serves as primary source for patient information for patient care. A fully functional CPR is a complex system. Consider a single data element (datum), such as a persons weight. The system must be able to record the weight, store it, process it, communicate it to others, and present it in a different format, such as a bar graph or chart. It may also be necessary to convert a weight in pounds to kilograms or vice-versa. All of this must be done in a secure environment that protects the patients confidentiality and privacy. The complexity of these issues and the development of the necessary systems help to explain why few fully functional CPR systems are in place today. Data capture Data capture refers to the collection and entry of data into a computer system. The origin of the data may be local or remote, with the data coming from patientmonitoring devices, from telemedicine applications, directly from the individual recipient of health care, and even from others who have information about the recipients health or environment, such as relatives, friends an d public health agencies. Data may be captured by multiple means, including entry, pattern recognition (voice, handwriting, or biological characteristics), and medical device transmission.
All data entered into a computer are not necessarily structured for subsequent processing. Document imaging systems, for example, provide for creation of electronically stored text but have limitations on the ability to process that text. Data capture includes the use of controlled vocabularies and code systems to ensure common meaning for terminology and the ability to process units of information. Data capture also encompasses authentication to identify the author of an entry and to ensure that the author has been granted permission to access the system and change the CPR. Storage Storage refers to the physical location of the data. In the CPR systems, health data are distributed across multiple systems at different sites. For this reason, there needs to be common access protocols, retention schedules, and universal identification. Access protocols permit only authorized users to obtain data for legitimate uses. The systems must have backup and recovery mechanisms in the event of failure. Retention schedules address the maintenance of the data in active and inactive form and the permanence of the storage medium. A persons identity can be determined by many types of data in addition to common identifiers such as name and number. Universal identifiers or other method are required for integrating health data of an individual distributed across multiple systems at different sites. Information Processing Computer processing functions provide for effective retrieval and processing of data into useful information. These include decision-support tools such as alerts and alarms for drug interactions, allergies, and abnormal laboratory results. Reminders can be provided for appointments, critical path actions, medication administration, and other activities. The systems may also provide access to consensus-driven and evidencedriven diagnostic and treatment guidelines and protocols. The nurse could integrate a standard guideline, protocol, or critical path into a specific individuals CPR, modify it to meet unique circumstances, and use it as a basis for managing and documenting care. Outcome data communicated form various caregivers and health care recipients themselves also may be analyzed and used for continual improvement of the guidelines and protocols. Information communication Information communication refers to the interoperability of systems and linkages for the exchange of data across disparate. To integrate health data across multiple systems at different sites, identifier systems (unique numbers or other methodology) for health
care recipients, caregivers, providers, payers and sites are essential. Local, regional, and national health information infrastructures that tie all participants together using standard data communication protocols are key to the linkage function. Hundreds of types of transactions or messages must be defined and agreed to by the participating stakeholders. V0ocabulary and code systems must permit the exchange and processing of data into meaningful information. CPR systems must provide access to point-of-care information databases and knowledge sources, such as pharmaceutical formularies, referral databases and reference literature. Electronic data sharing of any kind of data as described previously raises concerns of security and confidentiality. Existing challenges in protecting security while allowing for increased ease of data retrieval have been significantly complicated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Specific legal and ethical issues vary from state to state, from specialty to specialty and from caregiver to caregiver. Incorporating these variations into a cohesive, comprehensive CIS presents a considerable challenge. Security Computer-based patient record systems provide better protection of confidential health information than paper-based systems because they support controls that ensure that only authorized users with legitimate uses have access to health information and the integrity of the data. Security functions must be designed to ensure compliance with applicable laws, regulations and standards. Security systems must ensure that access to data is provided only to those who are authorized and have a legitimate purpose fro using the data. Security functions also must provide a means to audit for inappropriate access. Three important terms are used when discussing security: privacy, confidentiality and security. It is important to understand the differences among these concepts. o Privacy refers to the right of individuals to keep information about them from being disclosed to anyone. If a patient had an abortion and chose not to tell a health care provider this fact, the patient would be keeping that information private. o Confidentiality refers to the act of limiting disclosure of private matters. After a patient has disclosed private information to a health care provider, that provider has a responsibility to maintain the confidentiality of that information. o Security refers to the means to control access and protect information from accidental or intentional disclosure to unauthorized persons and from alteration, destruction or loss. When private information is placed in a confidential CPR, the
system must have controls in place to maintain the security system and not allow unauthorized persons access to the data. Information Presentation The wealth of information available through CPR systems must be managed to ensure that authorized caregivers, including nurses and others with legitimate uses, have the information they need in their preferred presentation form. A nurse for example, may like to see data organized by source, caregiver, encounter, problem or date. Data can be presents in detailed or summary form. Tables, graphs, narrative and other forms of information presentation must be accommodated. Some users many need to know only of the presence or absence of the data, not the nature of the data itself. For example, Blood donation centers test the blood for HIV, hepatitis and other conditions. If a donor has a positive test result, the center may not be given the specific information regarding the test but just general information that a test result was abnormal and that the patient should be referred to an appropriate health care provider. INTERFACE BETWEEN THE INFORMATICS NURSE AND THE CLINICAL INFORMATION SYSTEM Information demands in health care systems are pushing the development of CISs and CPRs. The ongoing development of computer technology- smaller, faster machines with extensive storage capabilities and the ability for cross- platform communication-is making the goal of an integrated electronic system a realistic option, not just a longterm dream. As these systems evolve, informatics nurses will play an important role in their development, implementation, and evaluation. Informatics nurses, because of their expertise, are in an ideal position to assist with the development, implementation and evaluation of CISs. Their knowledge of policies, procedures and clinical care is essential as work-flow systems are redesigned within a CIS. It is not unusual for nurses within an institution to have more hands-on interaction with and knowledge of different departments than any other group of employees in an institution. TRENDS IN COMPUTING Computers have moved from the realm of a nice to know luxury item to a need to know essential resource for professional practice. Nurses are knowledge workers who require accurate and up-to-date information for their professional work. The explosion in information-some estimate that all information is replaced every 9 to 12 monthsrequires nurses to be on the cutting edge of knowledge to practice ethically and safely. Trends in computing will also affect the work of professional nurses and not just
through the development of CISs and CPRs. Research advances, new devices, monitoring equipment, sensors, and smart body parts will all change the way that health care is conceptualized, practices and delivered.
Ubiquitous Computing In this phase, computers will be everywhere- in walls, chairs, clothing, light switches, cars, appliances, and so on. Computers will become so fundamental to our human experience that they will disappear, and we will cease to be aware of them. The result will be calm technology, in which computers do not cause stress and anxiety for the user but rather recede into background of life. Another dimension of UC is the Internet. Each time we connect to the internet, we are being connected to millions of information resources and hundreds of information delivery systems. Virtual Reality Virtual Reality (VR) puts people inside a computer-generated world. Virtual Reality, while still somewhat limited in its development, does have enormous potential in health care applications. With a VR a person can see, move through and react to computer-simulated items and environments. It has allowed the practitioners to develop minimally invasive surgical techniques. Recent innovations in video technology allow direct viewing of internal body cavities through natural orifices or small incisions. Te surgeon operates on a virtual image. Applications in health education also exist. It allows the information visualization through the display of enormous amounts of information contained in large databases. Through 3-D visualization, students can understand important physiological principles or basic anatomy. For students learning clinical procedures, VR gives them opportunity to practice invasive and less commonly occurring procedures in the laboratory so they have both the skill and confidence necessary when encountering a patient requiring the procedure for the first time. THE INTERNET Through internet information can be presented in different forms and in different languages. It also provides different organizational structures for information storage and access to accommodate the users preference and need. Even though computer stored and displayed information resources are potentially very useful in relation to patient education, their integration into nursing practice is rather inconsistent. Using Internet for Clinical Practice
A major use of the internet is to obtain information. In clinical practice, this dimension of the Internet is becoming essential to ensure that you have accurate and up-to-date information for your nursing work. To use information that exists on the internet, it is important to develop skills for searching quickly and efficiently. No one research strategy is going to work all the time, nor is any one search engine more effective than any other. Here are some strategies and tactics to render internet searches more efficient and reduce search time: Use websites published by governmental or professional organizations such as the American Heart Association (www.americanheart.org) or the National Heart, Lung and Blood institute (www.nhlbi.nih.gov) for questions related to cardiac diseases; CancerNet (http://cancer-net.nci.nih.gov) for cancer information; and the National Institute of Diabetes an Digestive and Kidney Diseases (http://digestive.niddk.nih.gov) for information on diabetes and digestive disorders. The Center for Disease Control and Prevention (www.cdc.gov) is a primary resource for developing and applying disease prevention and control, environmental health and health promotion activities; the National Institute on Aging (www.nia.nih.gov) focuses on well-being and health of older adults. Also helpful is the American Dietetic Association (www.eatright.org) offering information related to food and diet. The American Medical Associations consumer health information site (www.ama-assn.org) is a valuable source for general health information. Use reputable health care organizations Websites such as www.mayoclinic.com from the Mayo Clinics and www.intelihealth.com form HAVARD Medical School. Use consumer health sites organized by medical librarians. These offer a wealth of organized information on disease management. Examples are MEDLINE plus (www.medlineplus.gov) maintained by the National Library of Medicine and New York Online Access to Health (NOAH) (www.noah-health.org), a multilingual website organized and maintained by medical librarians in New York City. Use precise terms, such as Diabetes Type 1 instead of just Diabetes, to reduce the number of hits when searching for very specific information. Draw on search engines, such as Mayo Clinic (www.mayoclinic.com); WebMD (www.webmd.com); and so forth that collect information from reliable online health resources rather than relying on the bots or robots typically used by search engines to crawl the web such as Google. Refine your internet searches with filters. Filtering is mechanically blocking internet content from being retrieved through the identification of key words and phrases. For example, you can narrow your search by the type of medical viewpoint (traditional or alternative), reading level (easy, moderate or complex), and type of site
(commercial, non-commercial, government or non-profit) that you use in your key words to filter your search. The P-F-A Assessment One strategy to develop your search is to conduct a purpose-focus-approach (P-F-A) assessment. To determine your purpose, ask yourself why you are doing the search and why you need the information. Consider questions such as the following: Is it for personal interest? Do you want to obtain information to share with co-workers or a client? Are you verifying information given to you by someone else? Are you preparing a report or writing a paper for a class or project?
Based on your purpose, your focus may be as follows: Broad and general (basic information for yourself) Lay oriented (to give information to a patient) or professionally oriented (for colleagues) Narrow and technical with a research orientation Purpose combined with focus determines your approach. For example, information that is broad and general can be found using brute force methods or quick and dirty searching. Lay information can be quickly accessed at a few key sites, including MEDLINEplus and consumer health organizations. Similarly, professional associations and societies are a good starting point for professionally oriented information. Scientific and research information usually requires literature resources that can be found in databases such as MEDLINE and CINAHL (Cumulative Index to Nursing and Allied Health Literature). Quick and Dirty Searching Quick and dirty searching is a very simple but surprisingly effective search strategy. First, start with a search engine, such as AltaVista (www.altavista.com). Next, type in the term of interest. At this point, do not worry about being overly broad or general. You will retrieve an enormous number of found references (called hits), but you are interested only in the first 10 to 20. Look at the universal resource locators (URLs). Brute Force Brute force searching is another alternative. To do this, type in an address in the URL box (the address box at the top of the browser window) and see what happens. The worst outcome is an annoying error message, but you may land on a site that is exactly
what you want. To be effective, think how URLs work: they usually start with www. Then there is a thing in the middle followed by a domain. Perhaps you are trying to find a school of nursing at a certain university. www.unh.edu is the very logical URL for the University of Hampshire. RIGHTS OF CHILDREN One of the most encouraging sign of our time is the awakening of the public to the needs and rights of our children. The needs of children and our duties towards them are enshrined in our constitution. The relevant articles are: 1. Article 24 prohibits employment of children between ages of 14 in factories. 2. Article 39 prevents abuse of children of tender age. 3. Article 45 provides for free and compulsory education for all children until they complete the age of 14 years. UNITED NATIONS DECLARATION OF THE RIGHTS OF CHILDREN: All children need the following rights: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. To be free from discrimination. To develop physically and mentally in freedom and dignity. To have name and nationality. To have adequate nutrition, hosing, recreation and medical services. To receive special treatment if handicapped. To receive love, understanding and material security. To receive an education and develop his/her abilities. To be the first to receive protection in disaster. To be protected from neglect, cruelty and exploitation. To be brought up in a spirit of friendship among people.