H E A LT H I N F O R M AT I C S S E R I E S HI

Edwards
Hannah Ball
Kathryn J. Hannah Marion J. Ball
Margaret J.A. Edwards
Building on two previous editions, Introduction to Nursing Informatics, Third
Edition, is a beginner’s guide through the vital healthcare field of nursing
informatics. From basic terms and concepts to cutting-edge developments
in information technology, this book illustrates and explores each concept
fundamental to the successful use of information systems in nursing.
This book combines the best of the two earlier editions with the most cur-
rent thought in nursing informatics to create a comprehensive resource for
Introduction to

Introduction to Nursing Informatics

Nursing
practicing nurses, educators, and students alike. In addition to new chap-
ters that cover nursing data standards and defining information manage-
ment requirements, this book contains a revised and updated discussion
of the following topics:

Informatics
• The Anatomy and Physiology of Computers
• Telecommunications and Informatics
• Nursing Aspects of Health Information Systems
• Selection of Software and Hardware
• Implementation Concerns
Complete with several appendices full of nursing informatics resources,
Introduction to Nursing Informatics, Third Edition, is the most comprehen-
sive primer for any reader searching for basic information on how to select
and successfully incorporate information technology into nursing practice.
Kathryn J. Hannah, PhD, RN, is President of Hannah Educational &
Consulting Services, Inc.; and Professor, Department of Community Health
Sciences, Faculty of Medicine, at the University of Calgary, both in Calgary,
Alberta, Canada. Dr. Hannah is the Senior Editor of Springer’s Health
Informatics Series.
Marion J. Ball, EdD, is Vice President of Clinical Informatics Strategies at
Healthlink, an IBM company; and Professor at Johns Hopkins University
School of Nursing, both in Baltimore, Maryland, USA. Dr. Ball is the Co-
Editor of Springer’s Health Informatics Series.
Margaret J.A. Edwards, PhD, RN, is Professor and Coordinator, Graduate
Programs, Centre for Nursing and Health Studies, at Athabasca University
in Athabasca, Alberta; and President of Margaret J.A. Edwards &
Associates, Inc., in Calgary, Alberta, Canada.
Third Edition

Third Edition
springeronline.com H E A LT H I N F O R M A T I C S S E R I E S
 Health Informatics
(formerly Computers in Health Care)

Kathryn J. Hannah Marion J. Ball

Series Editors
 Health Informatics Series
(formerly Computers in Health Care)

Series Editors
Kathryn J. Hannah Marion J. Ball

Dental Informatics
Integrating Technology into the Dental Environment
L.M. Abbey and J. Zimmerman

Ethics and Information Technology

A Case-Based Approach to a Health Care System in Transition
J.G. Anderson and K.W. Goodman

Aspects of the Computer-Based Patient Record

M.J. Ball and M.F. Collen

Performance Improvement Through Information Management

Health Care’s Bridge to Success
M.J. Ball and J.V. Douglas

Strategies and Technologies for Healthcare Information

Theory into Practice
M.J. Ball, J.V. Douglas, and D.E. Garets

Nursing Informatics
Where Caring and Technology Meet, Third Edition
M.J. Ball, K.J. Hannah, S.K. Newbold, and J.V. Douglas

Healthcare Information Management Systems

A Practical Guide, Second Edition
M.J. Ball, D.W. Simborg, J.W. Albright, and J.V. Douglas

Clinical Decision Support Systems

Theory and Practice
E.S. Berner

Strategy and Architecture of Health Care Information Systems

M.K. Bourke

Information Networks for Community Health

P.F. Brennan, S.J. Schneider, and E. Tornquist

Informatics for the Clinical Laboratory

A Practical Guide
D.F. Cowan

Introduction to Clinical Informatics

P. Degoulet and M. Fieschi

Behavioral Healthcare Informatics

N.A. Dewan, N.M. Lorenzi, R.T. Riley, and S.R. Bhattacharya

(continued after Index)

Kathryn J. Hannah Marion J. Ball
Margaret J.A. Edwards

Introduction to
Nursing Informatics
Third Edition

With 45 Figures
Kathryn J. Hannah, PhD, RN Marion J. Ball, EdD
President, Hannah Educational Vice President, Clinical
& Consulting Services, Inc. Informatics Strategies
Calgary, Alberta, T3B 4ZB Healthlink, an IBM company
Canada Baltimore, Maryland 21210
and USA
Professor, Department of and
Community Health Sciences Professor, Johns Hopkins University
Faculty of Medicine School of Nursing
University of Calgary Baltimore, Maryland, 21205
Calgary, Alberta T2N 4N1 USA
Canada

Margaret J.A. Edwards, PhD, RN

Professor and Coordinator,
Graduate Programs
Centre for Nursing and Health Studies
Athabasca University
Athabasca, Alberta T9S 3A3
Canada
and
President, Margaret J.A. Edwards
& Associates, Inc.
Calgary, Alberta T2W 2A6
Canada

Library of Congress Control Number: 2005929460

ISBN -10: 0-387-26096-X

ISBN -13: 978-0387-26096-9

Printed on acid-free paper.


C 2006 Springer Science+Business Media, Inc.
All rights reserved. This work may not be translated or copied in whole or in part without the
written permission of the publisher (Springer Science+Business Media, Inc., 233 Spring Street,
New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly
analysis. Use in connection with any form of information storage and retrieval, electronic
adaptation, computer software, or by similar or dissimilar methodology now known or hereafter
developed is forbidden.
The use in this publication of trade names, trademarks, service marks, and similar terms, even
if they are not identified as such, is not to be taken as an expression of opinion as to whether
or not they are subject to proprietary rights.

Printed in the United States of America. (TB/SBA)

9 8 7 6 5 4 3 2 1

springeronline.com
The three authors of this book share many experiences, interests, and
values. The strongest of these shared values is a firm belief in marriage
and family. We dedicate this book to our husbands, Richard Hannah,
John Ball, and Craig Edwards, who are our respective life partners,
our friends, and our greatest individual sources of support. We also
dedicate this book to our families, especially the youngest generation,
which represents the future: Richard Steven Hannah, Cameron Robert
Hannah, Kyle James Hannah, Alexis Marion Concordia, Michael John
Concordia, Erica Adelaide Concordia, Alexander John Ball, Ryan Jokl
Ball, Maryn Joy Edwards, and John Kurt Edwards.
Series Preface

This series is directed to healthcare professionals who are leading the trans-
formation of healthcare by using information and knowledge. Launched in
1998 as Computers in Health Care, the series offers a broad range of ti-
tles: some addressed to specific professions such as nursing, medicine, and
health administration; others to special areas of practice such as trauma and
radiology. Still other books in the series focus on interdisciplinary issues,
such as the computer-based patient record, electronic health records, and
networked healthcare systems.
Renamed Health Informatics in 1998 to reflect the rapid evolution in the
discipline now known as health informatics, the series will continue to add
titles that contribute to the evolution of the field. In the series, eminent
experts, as editors or authors, offer their accounts of innovations in health
informatics. Increasingly, these accounts go beyond hardware and software
to address the role of information in influencing the transformation of health-
care delivery systems around the world. The series also will increasingly focus
on “peopleware” and the organizational, behavioral, and societal changes
that accompany the diffusion of information technology in health services
environments.
These changes will shape health services in the new millennium. By mak-
ing full and creative use of the technology to tame data and to transform
information, health informatics will foster the development of the knowl-
edge age in health care. As coeditors, we pledge to support our professional
colleagues and the series readers as they share advances in the emerging and
exciting field of Health Informatics.

Kathryn J. Hannah
Marion J. Ball

vii
Preface

The first book in the Computers in Health Care series, Introduction to Nurs-
ing Informatics, was published more than a decade ago. The third edition of
this book is intended to be a primer for those just beginning to study nursing
informatics, providing a thorough introduction to basic terms and concepts.
We have listened to feedback about the two earlier editions from readers.
The book has been reorganized and restructured. New material has been
added and new information incorporated. The book introduces terms and
concepts foundational to nursing informatics and provides an introduction
to the Internet. An overview of nursing use of information systems is pro-
vided. The book includes an exploration of the most common applications of
nursing informatics in clinical nursing practice (both community and facility
settings), nursing education, nursing administration, and nursing research.
It also provides insight into practical aspects of the infrastructure elements
of the informatics environment. An overview of professional nursing infor-
matics education and the future for nurses in health informatics concludes
the book.
Although readers will no doubt find diverse uses for this book, we have
written it with three principal uses in mind:
University and College Baccalaureate Nursing Programs and Health Infor-
mation Science Programs: to acquaint undergraduate students in nursing and
health information science with the field of nursing informatics. This book
provides students with a fundamental understanding of the field of nursing
informatics necessary for them to be able to use computers and information
management strategies in their practices, to make informed choices related
to software/hardware selection and implementation strategies, and to use
the more advanced volumes in the Springer series.
Nursing Administrators: to familiarize themselves with the field of nurs-
ing informatics in preparation for implementing computerized solutions
for information management in their institutions. Practical guidelines will
assist the manager in making informed decisions regarding system selec-
tion/development, implementation, and use.

ix
x Preface

Reference: to involve nursing unit managers and staff in the implemen-

tation of computer applications and automated information management
strategies in their workplaces. This book would be used to familiarize staff
with the field of nursing informatics. In addition, the practical information
facilitates implementation and use of computer applications.
We believe that this book, Introduction to Nursing Informatics, Third Ed-
dition, and the companion volume, Nursing Informatics: Where Caring and
Technology Meet, provide comprehensive coverage of nursing informatics.
We hope that through this book we can introduce newcomers to the ex-
citement of nursing informatics and share our enthusiasm for this rapidly
evolving field.

Calgary, Alberta, Canada Kathryn J. Hannah

Baltimore, Maryland, USA Marion J. Ball
Calgary, Alberta, Canada Margaret J.A. Edwards
Contents

Series Preface v
Preface vii
Contributors xiii

PART I FOUNDATIONS OF NURSING

INFORMATICS
Chapter 1 Nurses and Informatics 3
Chapter 2 Anatomy and Physiology of Computers 12
Chapter 3 History of Healthcare Computing 27
Chapter 4 Telecommunications and Informatics 41

PART II NURSING USE OF INFORMATION

SYSTEMS
Chapter 5 Enterprise Health Information Systems 57
Chapter 6 Nursing Aspects of Health Information Systems 84

PART III APPLICATIONS OF NURSING

INFORMATICS
Chapter 7 Clinical Practice Applications: Facility Based 105
Chapter 8 Clinical Practice Applications: Community Based 118
Chapter 9 Administration Applications 129
Chapter 10 Education Applications 142
Chapter 11 Research Applications 155

xi
xii Contents

PART IV INFRASTRUCTURE ELEMENTS OF

THE INFORMATICS ENVIRONMENT
Chapter 12 Nursing Data Standards 171
Chapter 13 Defining Information Management Requirements 189
Chapter 14 Selection of Software and Hardware 199
Chapter 15 Data Protection 218
Chapter 16 Ergonomics 234
Chapter 17 Disaster Recovery Planning 243
Chapter 18 Implementation Concerns 254
Chapter 19 A Process Redesign Approach to Successful IT
Implementation 267

PART V PROFESSIONAL NURSING

INFORMATICS
Chapter 20 Nursing Informatics Education: Past, Present,
and Future 280
Chapter 21 The Future for Nurses in Health Informatics 292

APPENDICES
Appendix A Generic Request for Proposal 307
Appendix B Nursing Informatics Special Interest Groups 310
Appendix C Sources of Additional Healthcare Informatics
Information 313
Appendix D Professional Societies 316
Appendix E Academic Informatics Programs Worldwide 318
Appendix F Transforming Clinical Documentation: Preparing Nursing
for Change 327
Appendix G Research Databases of Interest to Nurses 333

Glossary 340
Index 357
Contributors

James Cato
Chief Nursing Officer, Eclipsys Corporation, Boca Raton, FL 33487, USA

Ann Casebeer, BA, MPA, PhD

Associate Professor, Department of Community Health Sciences;
Associate Director, Centre for Health and Policy Studies; Faculty Director,
AHFMR SEARCH Program, University of Calgary, Calgary, Alberta T2N
1N4, Canada

Hélène Clément, RN, BScN, MHA

Vice President, Canadian Operations, GRASP Systems International
Companies, Richmond Hill, Ontario L4C 9Y5, Canada

Jane Curry
Information Architect, Health Information Strategies, Inc., St. Albert,
Alberta T8N 6M5, Canada

Linda Dietrich, MSN, RN

Director, Practice Transformation, Clinical Practice Model Resource
Center, a Subsidiary of Eclipsys Corporation, Grand Rapids, MI 49509,
USA

Diana Domonkos
Healthlink, an IBM company, Houston, TX 77098, USA

Judith V. Douglas, MA, MHS

Adjunct Faculty, Johns Hopkins University School of Nursing,
Baltimore, MD 21205, USA

Craig Edwards, CIO

Margaret J.A. Edwards & Associates, Calgary, Alberta T2W 2A6, Canada

xiii
xiv Contributors

Richard S. Hannah, PhD

Professor Emeritus, Faculty of Medicine, University of Calgary, Calgary,
Alberta T2N 1N4, Canada

Eleanor Callahan Hunt, RN, MSN, BC

Clinical Informatics, EMR Solutions R&D, Misys Healthcare Systems,
Raleigh, NC 27615, USA

Rebecca Rutherford Kitzmiller, RN, MSN, MHR, BC

Director of Nursing Informatics, Duke University Health System, Durham,
NC 27710, USA

Jo Ann Klein, MS, RN-C

Forum Manager, The Nursing Network Forum; Member, Curriculum
Committee, Johns Hopkins University School of Nursing, Baltimore, MD
21205, USA

Susan K. Newbold, MS, RNBC, FAAN, FHIMSS

Lecturer in Nursing, Vanderbilt University School of Nursing, Nashville,
TN 37203, USA

Paul E. Pancoast, MD
Senior Manager, Clinical Specialist, Deloitte Consulting LLC, Austin, TX
78701, USA

Helen Lee Robertson, MLIS

Document Delivery/Liaison Librarian, University of Calgary, Calgary,
Alberta T2N 1N4, Canada

Joyce Sensmeier
Vice President of Informatics, HIMSS, Chicago, IL 60611, USA

Sara Breckenridge Sproat, RN, MSN, BC

Lieutenant Colonel, US Army Nurse Corps, Deputy Director, Division of
Regulated Activities, Walter Reed Army Institute of Research, Silver
Spring, MD 20910, USA

Carole Stephens
Coustal Physician Services, Durham, NC 27705, USA

Lorraine Toews, MLIS

Head, Public Services, Health Sciences Library, University of Calgary,
Calgary, Alberta T2N 1N4, Canada
Part I
Foundations of Nursing
Informatics
1
Nurses and Informatics

We have entered the information age. Home computers, laptops, handheld

computers, and iPODs are pervasive. Banks and stock markets move and
track billions of dollars around the world every day through information
systems. Factories and stores buy, build, sell, and account for the products in
our lives through information systems. In schools, computers are being used
as teaching tools and as instructional resources for students in such varied
disciplines as astronomy, Chinese, and chemistry. The airline industry uses
information systems to book seats, calculate loads, order meals, determine
flight plans, determine fuel requirements, and even fly the planes and control
air traffic.
The information age has not left the health industry untouched. Mov-
ing beyond standard data processing for administrative functions common
to all organizations such as human resources, payroll, and financial infor-
mation systems now play an important role in patient care by interpret-
ing electrocardiograms, scheduling, entering orders, reporting results, and
preventing drug interactions (by cross-referencing drug compatibility and
warning appropriate staff). We are beginning to see the advent of life-
time electronic health records in many countries. In addition, informa-
tion systems are now being more widely used in support of population
health and public health activities related to health protection (e.g., im-
munization), health promotion (e.g., well baby clinics), disease prevention
(e.g., smoking cessation or needle exchange programs), and health mon-
itoring or surveillance (e.g., restaurant inspection or air quality monitor-
ing).
Nurses have always had a major communication role at the interface
between the patient/client and the health system. This role is now labeled
information management, and nurses are increasingly using information sys-
tems to assist them to fulfill this role in clinical practice, administration,
research, and education. Before attempting to talk about the role of nurs-
ing in informatics, let us first establish definitions of nursing and “nursing
informatics.”

3
4 Foundations of Nursing Informatics

What Is Nursing?
Nursing is emerging as a professional practice discipline. Based on the work
of theorists, nursing practitioners see its goals as the promotion of adapta-
tion in health and illness and the facilitation of achievement of the highest
possible individual state of health (Rogers, 1970; Roy, 1976). These early
theoretical models have provided the impetus for the development of cur-
rent approaches to the classification of phenomena of concern to nursing
care (see Chapter 12 for a detailed discussion of nursing classification and
nomenclature systems).
The practitioner of nursing has many roles and responsibilities. Among
these roles are those of an interface between the client and the healthcare
system and that of client advocate in the healthcare system. Nursing functions
can be considered under three major categories.
r Managerial, which includes establishing nursing care plans, keeping charts,
transcribing orders and requisitions, and scheduling patient appointments
for diagnostic procedures or therapy
r Delegated tasks, which include physical treatments and administration of
medications under the direction of a physician
r Autonomous nursing functions, which include interpersonal communica-
tion skills, application of the psychological principles of client care, and
providing physical care to patients.

It is the third category of nursing activities that is the core of nursing

practice. In this category of autonomous activity nurses use their knowledge,
skills, judgment, and experience to exercise independent decision making re-
lated to the phenomena for which nurses provide care and the nursing inter-
ventions that effect those phenomena and influence patient care outcomes.

What Is “Medical/Healthcare Informatics?”

Before we explore the nature of hospital and nursing information systems, we
need to review the definitions of health, medical, and nursing informatics.
Francois Gremy of France is widely credited with coining the term infor-
matique medical, which was translated into English as medical informatics.
Early on, the term medical informatics was used to describe “those collected
informational technologies which concern themselves with the patient care,
medical decision making process” (Greenburg, 1975). Another early defini-
tion, in the first issue of the Journal of Medical Informatics, proposed that
medical informatics was “the complex processing of data by a computer to
produce new kinds of information” (Anderson, 1976). As our understanding
of this discipline developed, Greenes and Shortliffe (1990) redefined medical
informatics as “the field that concerns itself with the cognitive, information
processing and communication tasks of medical practice, education, and
 Nurses and Informatics 5

research, including the information science and the technology to support

these tasks. An intrinsically interdisciplinary field . . . [with] an applied fo-
cus, . . . [addressing] a number of fundamental research problems as well as
planning and policy issues.” More recently, Shortliffe et al. (2001) defined
medical informatics as “the scientific field that deals with biomedical infor-
mation, data, and knowledge—their storage, retrieval and optimal use for
problem-solving and decision-making.”
One question consistently arose: “Does the word medical refer only to
physicians, or does it refer to all healthcare professions?” In the first edition
of this book, the premise was that medical referred to all healthcare profes-
sions and that a parallel definition of medical informatics might be “those
collected informational technologies that concern themselves with the pa-
tient care decision-making process performed by healthcare practitioners.”
Thus, because nurses are healthcare practitioners who are involved in the
patient care and the decision-making process that uses information cap-
tured by and extracted from the information technologies, there clearly was
a place for nursing in medical informatics. Increasingly, as research was con-
ducted and medical informatics evolved, nurses realized there was a discrete
body of knowledge related to nursing and the use of informatics. During the
early 1990s, other health professions began to explore the use of informatics
in their disciplines. Mandil (1989) coined the phrase “health informatics,”
which he defined as the use of information technology (including both hard-
ware and software) in combination with information management concepts
and methods to support the delivery of healthcare. Thus, health informatics
has become the umbrella term encompassing medical, nursing, dental, and
pharmacy informatics among others. Health informatics focuses attention
on the recipient of care rather than on the discipline of the caregiver.

Nursing’s Early Role in Medical Informatics

The nurse’s early role in medical informatics was that of a consumer. The
literature clearly shows the contributions of medical informatics to the prac-
tice of nursing and patient care. Early developments in medical informatics
and their advantages to nursing have been thoroughly documented (Hannah,
1976; see also Chapter 3, this volume). These initial developments were
fragmentary and generally restricted to automating existing functions or
activities such as automated charting of nurses’ notes, automated nursing
care plans, automated patient monitoring, automated personnel time as-
signment, and the gathering of epidemiological and administrative statis-
tics. Subsequently, an integrated approach to medical informatics resulted
in the development and marketing of sophisticated hospital information
systems that included nursing applications or modules. As models of health
services delivery have shifted toward integrated care delivery across the
entire spectrum of health services, integrated information systems have de-
veloped. These enterprise systems provided an integrated clinical record
6 Foundations of Nursing Informatics

within a complex integrated healthcare organization. Such systems support

evidence-based nursing practice, facilitate nurses’ participation in the health-
care team, and document nurses’ contribution to patient care outcomes. They
have failed, however, to meet the challenge of providing a nationwide com-
prehensive, lifelong, electronic health record that integrates the information
generated by all of a person’s contacts with the healthcare system.

Development of Nursing Informatics

Nursing informatics, as originally defined (Hannah, 1985, p. 181) referred
to the use of information technologies in relation to those functions within
the purview of nursing that are carried out by nurses when performing their
duties. Therefore, any use of information technologies by nurses in relation
to the care of patients, the administration of healthcare facilities, or the
educational preparation of individuals to practice the discipline is considered
nursing informatics. For example, nursing informatics would include, but not
be limited to the following.
r Use of artificial intelligence or decision-making systems to support the use
of the nursing process
r Use of a computer-based scheduling package to allocate staff in a hospital
or healthcare organization
r Use of computers for patient education
r Use of computer-assisted learning in nursing education
r Nursing use of a hospital information system
r Research related to what information nurses use when making patient
care decisions and how those decisions are made

As the field of nursing informatics has evolved, the definition of nursing

informatics has been elaborated and refined. Graves and Corcoran (1989)
suggested that nursing informatics is “a combination of computer science,
information science, and nursing science designed to assist in the manage-
ment and processing of nursing data, information and knowledge to support
the practice of nursing and the delivery of nursing care.” An Expert Panel of
the American Nurses Association (2001) promoted nursing informatics as

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

In an extensive review and analysis of the evolution of definitions of nurs-

ing informatics, Staggers and Thompson (2002, p. 259) concluded that after
three decades as a specialty there was still a proliferation of definitions for
 Nurses and Informatics 7

nursing informatics. Staggers and Thompson (2002) modified the ANA def-
inition and proposed a revised definition of nursing informatics as
a specialty that integrates nursing science, computer science, and information science
to manage and communicate data, information 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 pro-
cesses and information technology.
Furthermore, Staggers and Thompson (2002, p. 259–260) built on the ANA
work to propose that the goal of nursing informatics is
to improve the health of populations, communities, families and individuals by op-
timizing information management and communication. This includes the use of in-
formation and technology in the direct provision of care, in establishing effective
administrative systems, in managing and delivering educational experiences, in sup-
porting lifelong learning, and in supporting nursing research.

Impact of Informatics on Nursing

As we mentioned earlier, nursing informatics has moved beyond merely the
use of computers and is increasingly referring to the impact of information
and information management on the discipline of nursing. Staggers and
Thompson (2002) affirmed our long-held position that nurses are “infor-
mation integrators at the patient level.” Nurses form the largest group of
healthcare professionals in any setting to have a health information system.
Therefore, when providing patient care, nurses make use of information
management more often than any other group of healthcare professionals.
(The advantages to the practice of nursing that come from information
systems and information management are described in detail in Chapters 7
and 8.)
The nursing profession is recognizing the potential of informatics to im-
prove nursing practice and the quality of patient care. New roles are evolv-
ing for nurses. The American Nurses Association (2001) recognized nursing
informatics as a nursing specialty in 2001. Hospitals and other healthcare
organizations are now hiring informatics nurse specialists and informatics
nurse consultants to help in the design and implementation of information
systems. Nurse educators are using information systems to manage the edu-
cational environment. Computer-based information systems are used to in-
struct, evaluate, and identify problem areas of specific students; gather data
on how each student learns; process data for research purposes; and carry
out continued education. Nurse researchers, who have been using comput-
erized software for data manipulation for years, are turning their attention
to the problems of identifying variables for data sets essential to the diag-
nosing of nursing problems, choosing nursing actions, and evaluating patient
care. As Figures 1.1 and 1.2 illustrate, there is no doubt that we have reached
the information age in nursing. We must now prepare for the full impact of
informatics on nursing.
8 Foundations of Nursing Informatics

FIGURE 1.1. Nursing informatics at the bedside. (Photograph courtesy of Aironet

Wireless Communications, Inc.)

FIGURE 1.2. Nursing informatics at the nursing station. (Photograph courtesy of

Clinicare Corporation.)
 Nurses and Informatics 9

Future Implications
Technology has historically relieved people of backbreaking drudgery and
dreary monotony, providing them with more free time to pursue personal
relations and creative activities. Nurses, too, when relieved of routine and
time-consuming clerical or managerial paper handling chores, can devote
more time to the unique problems and needs of individual patients or clients.
Increasingly, across the world, the managerial and clerical paper-handling
tasks of nursing are being performed by information systems. In addition,
robotics (e.g., lifting and turning patients, delivering medications or meals,
and recording temperature, pulse, and other physiological measurements)
might assist with the physical care category of nursing tasks. Similarly, deci-
sion support systems may actively assist with nursing judgments.
Relieved of routine and less complex chores, the professional nurse hav-
ing enhanced information management skills and working in an environ-
ment enhanced by information systems will be expected to carry out higher
level, more complex activities that cannot be programmed. Nurses are be-
ing held responsible and accountable for the systematic planning of holis-
tic and humanistic nursing care for patients and their families. Nurses are
also increasingly responsible for the continual review and examination of
nursing practice (using innovative, continuous quality improvement ap-
proaches), as well as applying basic research to finding creative solutions
for patient care problems and the development of new models for the de-
livery of nursing care. Increasingly, nurses will provide more primary care
through community-based programs providing health promotion and early
recognition and prevention of illness. Nurses’ role as patient educator is
being extended by means of multimedia programs and the Internet. At
the same time nurses must assume greater responsibility for assisting the
public to become discriminating users of information as they select, sort,
interpret, evaluate, and use the vast volumes of facts available across the
Internet.
Nurses still must assess, plan, carry out, and evaluate patient care, but ad-
vances in the use of information management, information processes, and
technology will continue to create a more scientific, complex approach to
the nursing care process. They will have to be better equipped by their edu-
cation and preparation to have a more inquiring and investigative approach
to patient care. Evidence-based nursing practice is becoming the standard.
As information systems assume more routine clerical functions, nurses will
have more time for direct patient care. Accordingly, nursing must be part
of future developments in nursing informatics with strong input regarding
such decisions as the following.

1. Which patient care-related nursing functions could be accomplished by

nursing informatics?
2. What information do nurses require to make patient care decisions?
10 Nurses and Informatics

3. What information do caregivers from other health professions require

from nursing?
4. To what extent can nursing informatics support improvements in the qual-
ity of nursing care received by patients?
5. How can the financial and emotional costs of care to patients be reduced
using nursing informatics?
6. What is the impact of nursing on client outcomes?
7. What do nursing interventions contribute to patient outcomes?

The implication is that nursing must continually reassess its status and
reward systems. Presently, a nurse gains status and financial reward by
moving away from the bedside into supervisory and managerial roles. If
more of these coordinating functions are taken over by the computer, nurs-
ing must reappraise its value system and reward quality of care at the
bedside with prestige and money. Some movement in this direction is al-
ready beginning: for example, the movement toward employment of clin-
ical nurse specialists prepared at the master’s degree level to work at the
bedside. However, currently this movement seems to be too little and too
slow.

Summary
The role of the nurse will intensify and diversify with the widespread in-
tegration of computer technology and information science into healthcare
agencies and institutions. Redefinition, refinement, and modification of the
practice of nursing will intensify the nurse’s role in the delivery of patient
care. At the same time, nurses will have greater diversity by virtue of em-
ployment opportunities in the nursing informatics field.
Nursing’s contributions can and will influence the evolution of healthcare
informatics. Nursing will also be influenced by informatics, resulting in a
better understanding of our knowledge and a closer link of that knowledge
to nursing practice (Turley, 1997). As a profession, nursing must anticipate
the expansion and development of nursing informatics. Leadership and di-
rection must be provided to ensure that nursing informatics expands and
improves the quality of healthcare received by patients within the collabo-
rative interdisciplinary venue of health informatics.

References
American Nurses Association. (2001). Scope and Standards of Nursing Informatics
Practice. Washington, D.C., ANA.
Anderson, J. (1976). Editorial. Journal of Medical Informatics 1:1.
Graves, J.R., & Corcoran, S. (1989). The study of nursing informatics. Image; 21:227–
231.
 Nurses and Informatics 11

Greenburg, A.B. (1975). Medical informatics: Science or science fiction. unpublished.

Greenes, R.A., & Shortliffe, E.H. (1990). Medical informatics: an emerging aca-
demic discipline and institutional priority. Journal of American Medical Associa-
tion 263(8):1114–1120.
Hannah, K.J. (1976). The computer and nursing practice. Nursing Outlook 24(9):
555–558.
Hannah, Kathryn J., Guillemin, Evelyn J., & Conklin, Dorothy, N. (eds.) (1985).
Nursing Use of Computers and Information Science. Amsterdam: North Holland.
Mandil, S. (1989). Health informatics: New solutions to old challenges. World Health
2 (Aug/Sept):5.
Rogers, M.E. (1970). An Introduction to the Theoretical Base of Nursing Practice.
Philadelphia: Davis.
Roy, C. (1976). Introduction to Nursing: An Adaptation Model. Englewood Cliffs,
N.J.: Prentice-Hall.
Shortliffe, E.H., Perreault, L.E., Wiederhold, G., & Fagan, L.M. (eds.) (2001). Medical
Informatics: Computer Applications in healthcare and Biomedicine, 2nd Edition.
New York: Springer-Verlag, p. 21.
Staggers, N., & Thompson, C.B. (2002). The evolution of definitions for nursing infor-
matics: a critical analysis and revised definition. Journal of the American Medical
Informatics Association 9(May/June):255–261.
Turley, J.P. (1997). Developing informatics as a discipline. In: Gerdin, U., Tallberg,
M., Wainwright, P. (eds.) Nursing Informatics: The Impact of Nursing Knowledge
on healthcare Informatics. Amsterdam: IOS Press, pp. 69–74.
2
Anatomy and Physiology
of Computers
Craig Edwards

Basic Computer Ideas

For most people the inner workings of a television are a mystery, but that
does not stop them from using and enjoying television. In the same way, it
is not necessary to understand all the details of computer technology be-
fore it can be used to great advantage. This chapter is intended to give
an adequate but not exhaustive understanding of computers, thus enabling
the reader to take confident advantage of whatever computer technology is
available.
There are generally two main parts to any computer system.

1. Hardware is the term that describes the physical pieces of the computer,
commonly grouped in five categories.
r Input: Data must be placed into the computer before the computer can
be useful.
r Memory: All data processing takes place in memory.
r Central processing unit (CPU): This is the “brain” of the computer,
which coordinates all the activities and does the actual data processing.
r Storage: The data and programs can be saved for future use.
r Output: Processed data are of little value to people unless they can see
the data in some form.
Hardware can be considered the anatomy of a computer, its physical,
mechanical portion.
2. Software is the term that describes the nonphysical pieces. It can be
grouped into two categories.
r Operating system: This is the collection of standard computer activities
that need to be done consistently and reliably. These processes are the
building blocks for computer functions and programs.
r Application programs: These are packages of instructions that com-
bine logic and mathematical processing using the building blocks of the
computer. Programs are what make computers valuable to people by
transforming raw data into information.

12
 Anatomy and Physiology of Computers 13

Software can be considered the physiology of a computer, the instructions

that make its anatomy function properly. These pieces of a computer are
described later in more detail, but it is important to have a mental picture
of a “computer” before we proceed. It is also helpful to understand some
computer terminology (or jargon) that often overwhelms or confuses.

Common Computer Terms

r Chip refers to a small piece of silicon that has electronic logic circuits built
into it. A chip can hold thousands of circuits in something that is about
one-quarter of an inch on each side (Fig. 2.1). The chip is the fundamental
physical piece used for computer memory and central processing units (see
later in the chapter).
r RAM and ROM are the two types of memory that a computer uses. ROM
standsforRead-OnlyMemory.Thismemoryhasinformationalreadystored
in it by the computer manufacturer, and nothing is allowed to change that
information. RAM stands for Random-Access Memory. This memory has
no information in it but is available for any program to store information.
r Bit is the smallest part of computer memory. It can hold exactly one piece
of information that has only two possible values, either a one (1) or a zero
(0). This “two-value” system is called a binary system.
r Byte is the fundamental grouping of bits used to make up computer mem-
ory. By grouping bits together and setting these bits to either 0 or 1 in
different combinations, a coding scheme can be built to represent informa-
tion. The byte is the basic measuring unit for memory capacity or storage
capacity.
r Kilo, mega, and giga are prefixes that represent certain multipliers. Al-
though “kilo” in scientific notation means “1000” (103 ), its value is changed
to “1024” (210 ) when talking about computer memory or storage. Numbers
that are powers of 2 (e.g., 4 is a power of 2, being 22 ) are chosen because the

FIGURE 2.1. Silicon wafer.

14 Foundations of Nursing Informatics

computer uses a binary system. Thus, one kilobyte of computer memory

represents 1024 (1 × 1024) bytes, two kilobytes represent 2048 (2 × 1024)
bytes, and so on. One megabyte represents 1,048,576 (1024 × 1024) bytes,
and one gigabyte represents 1,073,741,824 bytes (1024 × 1024 × 1024).
Although it is not accurate, most people tend to still give kilo, mega, and
giga their normal values of 103 ,106 , and 109 when referring to computers.
r Megahertz (MHz) and gigahertz (GHz) describe the frequency that the
central processing unit’s internal clock uses for its timing control (see later
in the chapter).

Computer technology has had an explosive growth during the past several
decades. The large computers that used to fill their own special-purpose
rooms have in many cases been replaced by computers small enough to fit
on a desk (“desktop” model), on one’s lap (“laptop” model), or in the palm
of one’s hand (“palmtop” computers). This trend is expected to continue. It
is probable that what is described next will be considered obsolete within
just a few years.

Hardware
Input
r Keyboard is the most common way a person gives information and com-
mands to a computer. It looks like a typewriter; its surface is filled with
keys that are either numbers, letters, or control functions (such as “Home”
and “Delete”).
r Touchscreen is a technique that lets people do what comes naturally—point
with a finger. When a special sensing device is fitted around the perimeter of
a monitor, the computer can calculate where someone’s finger has touched
the screen.
r Light pen is another pointing technique. Using special types of monitors,
an attached pen (Fig. 2.2.) can be used (instead of a finger) to point to
places on the screen.
r Mouse is yet another pointing device and perhaps the most common
one. By moving a mouse around on a flat surface, a person also causes
a marker (called the “cursor”) on the computer screen to move. When
that marker is resting on the desired place on the screen, a button on
the mouse is pressed to signal the computer that something has been
“pointed to.”
r Voice is a technology that is evolving rapidly. Using a microphone and
some special application programs, a person can speak in a natural way
and have that speech recognized by the computer. The words could be
numbers (i.e., “One”), commands (i.e., “Print”), or just text (e.g., “The”
“dog,” “was” . . .).
 Anatomy and Physiology of Computers 15

FIGURE 2.2. Light pen.

r Pen-based technology translates the normal model of pen and paper for
use with a computer system. With special computer screens and pens, a
person can print or write on the screen with the pen and have the computer
recognize what is written. Nothing is physically marked on the screen by
the pen, but the computer senses and traces out the pen’s movements.
It then tries to recognize letters or numbers from those traces or it can
just store what has been traced out as an image file, a picture of the pen’s
movements.

Memory
The two basic types of memory, ROM and RAM, were defined earlier. Gen-
erally, a computer has a sufficient amount of ROM built in by the manufac-
turer. ROM is preloaded with the low-level logic and processes needed to
start the computer when its power is turned on (a process called “booting
up”). Most computers also have a starting amount of RAM preinstalled.
RAM can be purchased separately, though, and installed as needed. Ap-
plication programs are loaded, when called for, into RAM. The program
executes there and stores information in other parts of RAM as is needed.
Today, application programs have growing RAM requirements as more logic
and functions are packed in them.

Central Processing Unit

There are several types of CPU chips. In the personal computer world, the
Intel Corporation is probably the most recognized manufacturer with, first,
16 Foundations of Nursing Informatics

its 80 × 86 series of CPU chips (i.e., 80386, 80486, . . .) and then its PentiumTM
chip (i.e., Pentium 4 or P4) series. In the large computer world, IBM (Inter-
national Business Machines) is probably the most recognized name.
One measure of CPU processing capacity is called MIPS (“millions of
instructions per second.”) Although not a totally accurate measure, it is
useful to see the growth of processing capacity over time. Intel’s 80386 chip,
produced in 1985, was rated at 5 MIPS. Intel’s Pentium chip, introduced
8 years later in 1993, was rated at 100 MIPS—about 20 times faster. Intel’s
Pentium 4 chip, made 7 years later in 2000, was rated at 1700 MIPS.
All CPUs have three basic elements: a control unit, an arithmetic logic
unit (ALU), and an internal memory unit. The ALU performs all the math-
ematical operations, the control unit determines where and when to send
information being used by the ALU, and the internal memory is used to
hold and store information for those operations. The CPU has an inter-
nal system clock that it uses to keep everything in synchronized order. The
clock’s speed is described in terms of frequency, using megahertz (MHz) or
gigahertz (GHz), so a CPU might be described as having a clock speed of
450 MHz or 2.4 GHz. Generally, the faster the clock, the faster the CPU can
process information.

Storage
The memory of a computer is not the place to store information and programs
for a long time. ROM is read-only (unwriteable) and therefore not of any
use. RAM holds programs and information but only so long as the computer
is turned on; once turned off, all information in RAM is gone. Therefore
other means are used for long-term storage, the most common technologies
being magnetic, optical, and special nonvolatile memory.

r Floppy Disk (or “floppy”) is the term that describes a material that can
be magnetically encoded to store information and programs. This mate-
rial is housed in a protective case. Floppy disks most commonly are 3.5
inches (“three and a half”) in size. The computer has a specially sized
slot or opening where these floppy disks can be inserted as needed. The
amount of information these disks can hold varies. The 3.5 inch floppy disk
holds 1.44 megabytes of data. Some manufacturers have experimented
with floppy drives and disks that can store 120 megabytes of information.
Floppies are reusable; old information on the floppy can be erased and new
information stored in its place. Floppies are removable from the computer.
r Hard Disk Drive (or simply “Hard Drive”) is the term that describes a
device that magnetically encodes much more information than a floppy
can but is not removable from the computer. A typical hard drive size on
personal computers, for example, is 40 to 80 gigabytes of capacity. Most
often, a person does not see a hard drive; the drives are usually inside a
computer and not removable. Hard disks are reusable.
 Anatomy and Physiology of Computers 17

r Removable Disk Drive is the same kind of device as a hard disk drive with
similar storage capabilities. The difference is that the magnetic storage
media can be removed and replaced, just as with a floppy disk.
r Tape describes a medium that can magnetically encode a lot of informa-
tion. In many ways, tape in a computer system is used like audio tape.
Computer tape is typically used to store a copy of important information,
to be recovered in case of a major problem with the computer. Tape is
packaged in various ways, from large reels to small cartridges. Tape is
reusable.
r Optical Storage is a term that covers several devices that store informa-
tion optically, not magnetically. Common examples are CD-R (Compact
Disc-Recordable) and CD-RW (Compact Disc-Rewritable). Capacities of
500 megabytes or more are available. Reusable optical storage is becoming
more common as manufacturers agree on storage standards.
r Flash Drive is a removable device that uses special nonvolatile memory to
hold information. Unlike RAM, this memory retains its information when
the device is removed from the computer. When the device is connected,
the computer sees and uses it as a removable hard drive. Flash drives can
store gigabytes of information.

Output
r Monitor is the most common way a person sees the information and in-
structions on a computer. Historically, on desktop computers the mon-
itor looks like a television screen and uses the same display technol-
ogy as a television. On laptop computers (“small enough to fit in your
lap”), the monitor is a flat screen that uses liquid crystal display (LCD)
technology. This LCD technology is increasingly being used in desktop
monitors as well. Some other names for the monitor are VDT (video
display terminal), CRT (cathode ray tube), screen, and display. Illus-
trations of what a monitor and keyboard may look like are shown in
Figure 2.3.
r Printers and plotters are two ways by which the computer can put the
processed information, such as a report or a chart, onto paper for people.
The most common output device in offices is the laser printer, capable of
putting either text (e.g., a report) or graphics (e.g., a chart) onto standard-
size paper.

Software
Operating Systems
Operating systems are the basic control programs for a computer. All the
basic logic required for using a computer’s hardware, such as the monitor, the
18 Foundations of Nursing Informatics

FIGURE 2.3. A. Monitor, keyboard, and mouse.

printer, and the hard drive, is contained in the operating system. Because
the operating system handles those computer parts, it is unnecessary for
application programs to do so. An example in the personal computer world
is Microsoft Corporation’s WindowsTM operating system.

FIGURE 2.3. B. Another type of monitor and keyboard. (Photograph courtesy of

Franklin Electronic Publishing.)
 Anatomy and Physiology of Computers 19

Application Programs
Application programs are packages of instructions and operations that take
raw data and process them into information. Applications focus on work-
ing with people to produce information that is important to them. Some
examples of applications are word processing, spreadsheets, and desktop
publishing.

Graphical User Interface (GUI) Software

The graphical user interface (GUI) is a special type of software in common
use today. It can be part of the operating system software, or it can be a com-
plete application program on its own; at times, a GUI (pronounced “gooey”)
seems to straddle the line between operating and application software. The
basic design of any GUI is that it stands between the operator of the com-
puter and the computer itself and acts as the go-between. Any GUI has
two primary goals: (1) to shield the operator from needing a great amount
of technical knowledge to use the computer effectively and correctly; and
(2) to give a consistent “look-and-feel” to application programs (if they are
designed for it).
Accomplishing the first goal means that an operator can perform all nec-
essary technical tasks (e.g., copying data files between disks, backing up
information) by pointing at icons (small pictures) on the screen. These icons
represent the tasks that can be done. For example, by pointing to an icon that
represents a desired data file and then dragging that icon over onto another
icon that represents a printer, a person can print the file. Note that because of
the GUI’s capabilities, the person did not have to know the correct operating
system commands to print the file.
Accomplishing the second goal means that any application program can be
designed so it is less difficult for a person to learn how to use it. Basically, the
GUI defines a standard set of functions that it can provide (e.g., open a data
file, save a data file, print a data file) and gives standard ways for application
programs to use these functions. If application programs are designed and
built to use these functions, a person has to learn only once how to open a
data file. Any other program that uses the GUI functions has the same “look-
and-feel”; that is, a person can open a data file in the same manner. Doing
things in a consistent, predictable way not only reduces a person’s learning
time but increases a person’s comfort level and productivity. Figure 2.4 is an
example of a main menu for a nursing software package.

Databases and Relational Database

Management Systems
A database is a data file whose information is stored and organized so it can
be easily searched and retrieved. A simple analogy is a filing cabinet drawer.
20 Foundations of Nursing Informatics

FIGURE 2.4. Graphical user interface (GUI)-type menu.

The difference between a file and a database is the same difference between
a file drawer that has reports dumped into it in any old way and a drawer that
has neatly labeled file folders, arranged in meaningful order, with an index
that shows where to store a report. In both cases, we know the information
we need is in the file drawer—only in the second case (i.e., the database) we
are confident that we can find that information quickly and easily.
A database management system (DBMS) is a set of functions that appli-
cation programs use to store and retrieve information in an organized way.
Over the years, various ways to organize information have been used (e.g.,
hierarchical, network, indexed). The way it is used most frequently now is
called relational. A relational DBMS stores information in tables (i.e., rows
and columns of information). This approach allows powerful searches to be
done quite easily.

Terminals, Workstations, Stand-alone, Networks

Terminals
In the early days of computer technology, an organization usually required
only a single large-capacity computer to handle its information needs. These
computers were called “mainframes.” They required a trained staff to main-
tain and run them and were quite expensive to purchase and upgrade (e.g.,
add more memory, more disk storage). People gave information and com-
mands to the mainframe through a “terminal,” essentially just a keyboard
and monitor; the terminal had no processing capability of its own. The
 Anatomy and Physiology of Computers 21

number of terminals a mainframe could handle was limited, which created

lineups of people waiting their turn to submit computer requests.

Workstations
Advances in computer technology, such as IBM’s personal computer intro-
duced in 1981, dramatically changed this situation. Now it was possible to
have a powerful computer right in the office and for far less money. What
is more, all its resources and power were under the control of, and totally
available to, its user. As people began to move toward personal comput-
ing, computer manufacturers built more powerful workstations. Soon, these
powerful workstations became small enough to be easily moved, promoting
the idea of “mobile computing.” Today, laptop computers easily allow com-
puter technology to be available at the point of care (Fig. 2.5) (see Chapter 7
for more discussion).

FIGURE 2.5. Portable terminal. (Photograph courtesy of Prologix.)

22 Foundations of Nursing Informatics

Stand-alone
By “stand-alone” we mean that all the pieces of a computer that are needed
to gather, process, display, possibly store, and provide an output of the infor-
mation are physically connected; moreover, if needed, they can be moved as
a complete unit to another location. This is the usual setup for most home
and small business computer systems. Such a setup is inexpensive and quite
simple to manage. Although it makes sense to use a “stand-alone” computer,
it is often better for a computer to be part of a network.

Local Area Networks

Definition
A network is a way to connect computers so several benefits can be realized.
Local Area Networks (LANs) connect computers that are physically close
together (i.e., in the same local area). This means not only in the same room
but also in the same building, or in several buildings that are close together.
LANs use three things to connect computers: a physical connection (e.g.,
wire), a network operating system, and a communication scheme.
There are several ways to connect computers physically. The most common
method is to use coaxial cable, similar to the kind used by cable television.
Another way is to use wire similar to telephone cable (“twisted pair”), and
the latest way uses fiberoptic cable (light is used in place of electricity).
The very latest methods are wireless; they use either radio transmission
or infrared light for the connection. Each method is suited for different
situations and is part of the consideration when a network is built.
There are several network operating systems available today that pro-
vide the necessary processes to allow computers to talk with each other
and to share information and programs. The communication schemes are
properly called protocols. This is a standard method by which the computers
in a network to talk with each other and pass information around. There
are three main ways to connect computers in a network: star, ring, and bus

FIGURE 2.6. Network typologies.

 Anatomy and Physiology of Computers 23

FIGURE 2.7. Example of resource sharing on a network.

configurations. These are called network topologies and represent different

physical arrangements of the computers (Fig. 2.6). As with the physical con-
necting medium (i.e., coaxial cable vs. twisted pair), each topology has its
strengths and weaknesses, which must be considered when a network is built.

Benefits of a Network
The important benefits of a network are shared information, shared pro-
grams, shared equipment, and easier administration. It is technically possi-
ble for any computer on a network to read and write information that an-
other computer has in its storage (i.e., its hard disk). Whether that computer
is allowed to do so is an administrative matter. This means, though, that
information can be shared among the computers on the network. Pro-
grams can also be used by computers on the network, regardless of where
those programs are physically stored. It is also possible (and usually desir-
able) for computers on a network to share equipment such as printers. A
diagram of how a system might be connected is shown in Figure 2.7. Tech-
nically, any computer on the network can print its information on a printer
that is physically connected to another computer somewhere else. By shar-
ing expensive office equipment, an organization reduces its expenses. Fi-
nally, administration of computers on a network is simplified because all
the other computers can be examined, helped, and maintained from one
computer.

Wide Area Networks

Wide Area Networks (WANs) are extensions of Local Area Networks. There
are two kinds of WAN. The first one attaches or connects a single computer to
a preexisting LAN; this kind is called “remote LAN attachment.” The second
one connects, or “bridges,” two or more preexisting LANs. Both WANs
24 Foundations of Nursing Informatics

allow a computer to use information or equipment no matter where they are

located in the organization. An interesting point about WANs is the options
that can be used to connect the LANs. Instead of being limited by the length
of cable that can be placed between computers, WANs can communicate via
satellite and earth stations. This literally means that a person could be using
a computer in Africa and working with information that is on a computer
in Iceland—without knowing or caring about its origin. To that person, the
information appears to be on his or her computer.

Open Systems
“Open systems” is the idea that it should be possible to do two things: run a
particular program on any brand of computer and connect any collection of
computers together in a network. However, because of the development of
computer technology, this is difficult to accomplish.
Most computers were initially developed as “closed” systems; that is, a
manufacturer built the computer, wrote the operating system, and wrote the
application programs to run on the computer. Each computer manufacturer
saw tremendous sales advantage from this strategy. The result was several
computers that were similar in function but very different in how those
functions were executed. It was not easy to buy an application program from
a vendor and run it on two different brands of computers. It was a torturous
exercise to get any two computer brands to “talk” with each other.
For people who simply want to buy and use computer technology, “plug
and play” is the ideal mode. This means that a computer could be purchased
from vendor X, a second computer from vendor Y, a program from vendor Z,
and a printer from vendor A, and all these parts could be connected and used
with the same ease that people expect with stereo system components. The
way to achieve this ideal is through standards. Just as stereo components are
built to use a standard voltage, produce or use a standard type of signal, and
connect with standard plugs and cables, computers and application programs
need to use certain standards for communication protocols and file access.
This “plug and play” mode is getting closer today because of vendors’ and
manufacturers’ support and adoption of standards.

Client/Server Computing
As we have seen, computers come in a variety of sizes and with various
processing capacities. Some computers are better suited than others for dif-
ferent tasks. For example, personal computers, because of the physical size
of their hard drives, have a limit to their storage capacity. On the other hand,
the large, mainframe-type computer was designed to handle tremendous
amounts of information and therefore has large storage capacity. Where
does it make more sense to store a large data set?
 Anatomy and Physiology of Computers 25

This brings us to client/server computing. The essence of “client/server

computing” is to assign to each computer the tasks for which it is best qual-
ified or, in other words, to use the right tool for the job. Capitalize on the
strengths of one computer for task A and use a different computer more
suited for task B. A personal computer works well with people; it is fast and
has color and good graphics display capability. It could be the primary inter-
face device for people and computer systems. Mainframe computers have
huge storage capacity, great speed, and large processing power. This could
be the place to store, process, and retrieve information from the vast amount
of data accumulated by a large organization. In a network, client/server com-
puting makes sense.

Remote Access Computing

Computers can be connected together in a network; but, increasingly, mo-
bile computing requires that computers be able to access and connect to
other computers from almost anywhere. This is possible through the use of
telephone or cable systems and special computer communication devices
called “modems” (Fig. 2.8.) “Modem” is short for “modulate-demodulate.”
The computer that, at the moment, is sending information uses its modem
to “modulate” its electronic signal into a form that can be carried over the
telephone or cable system; the computer receiving that information uses its
modem to “demodulate” the signal. Information can be exchanged at speeds
that allow effective long-distance computing.

FIGURE 2.8. Remote access from clinic office. (Photograph courtesy of Clinicare
Corporation and Health Plus Medical Clinic, Calgary, Alberta, Canada.)
26 Foundations of Nursing Informatics

Computing Hygiene for E-mail

The advent of the Internet and of “E-mail” (electronic mail; see Chapter
4) has allowed us to exchange ideas and information remotely, easily, and
to great advantage. Unfortunately, there are those who try to introduce
problems into this situation.
“Spam” refers to e-mail containing information on products and services
that are sent out to many people at the same time. The problem is that
the people rarely asked for this information. These recipients then spend
significant time reviewing their incoming electronic mail, discarding the un-
requested e-mails and keeping the valuable ones. Most e-mail programs have
some kind of filtering tool that can be used to reduce the number of “junk”
e-mails a person sees.
In addition, e-mails can have files attached to them. This is one way in-
formation can be exchanged electronically. The problem is that when an
attached file is opened, it can run a program called a “virus” or a “worm”
without notifying the operator of the computer. If the creator of the attached
file intends harm, opening that file can cause problems for the computer op-
erator. There are several antivirus programs available that can scan e-mails
as they are received and try to remove any attached files that carry viruses
or worms.
There are some general rules of computing hygiene for handling e-mail.
r Purchase an antivirus program and use it. Make sure it is scanning the
incoming mail. Keep its “virus recognition” files up-to-date.
r Do not open an e-mail message if you do not recognize the sender—just
delete the e-mail.
r Even if the sender is known, do not open or run any attached files until
you know the purpose or content of the file.

Summary
As promised, we have not gone into great detail about computer technology.
We have also not included a bibliography because technology is changing
every day. We recommend that the interested reader visit any library or local
bookstore to find up-to-date information on computer technology. For the
very latest information, the Internet is the place to search.
3
History of Healthcare Computing

Since the beginning of time, people have invented tools to help them. Trac-
ing the evolution of computers gives us a clearer historical vantage point
from which to view our rapidly changing world. This approach also identi-
fies informatics as a tool that can advance the goal of high quality nursing
care. From a historical perspective, however, it is difficult to identify the true
origin of computers. For instance, we could go back in time to the devices
introduced by Moslem scientists and to the mathematicians of the fifteenth
century. An example is Al-Kashi, who designed his plate of conjunctions to
calculate the exact hour at which two planets would have the same longitude
(De and Price, 1959; Goldstine, 1972). A more familiar example is the first
rudimentary calculating tool, the Chinese abacus. This is still a rapid and
efficient method of handling addition and subtraction.

Historical Development of Computers

Before 1950
The early nineteenth century had its share of men and women whose ideas
were far ahead of the engineering, technological, and tooling abilities neces-
sary to build calculating or computing machines. The groundwork for com-
puterization was laid by Boole (1815–1864), who expanded the Leibnitz
mathematic logic (binary numbers), and by Babbage (1791–1871), who in-
vented the analytical machine in 1842.
It was not until the twentieth century that manufacturing made it possible
to carry out those ideas. Differential analyzers were developed in Germany
and Russia during the 1930s. By 1940 there were about seven of these prim-
itive analog computers in operation throughout the world. In 1939, Howard
H. Aiken of Harvard University and Claire D. Lake of IBM developed an au-
tomatic sequence-controlled calculator. In 1944 they developed the Harvard
Mark I. The Mark I was an electromechanical digital machine that would
do arithmetic computations (using punched cards) and store results. One

27
28 Foundations of Nursing Informatics

hundred times faster than any manual operation, it could run 24 hours per
day and accomplish 6 months’ work during those 24 hours.
George R. Stibitz, at the Bell Telephone Laboratories, set up yet another
type of electromechanical computer using relay machines. It was possible,
using this device, to calculate and produce firing and bombing tables and re-
lated gun control data. This prompted the Ordnance Department of the U.S.
War Department to underwrite a development program at the Moore School
of Electrical Engineering, University of Pennsylvania, which resulted in the
production of the ENIAC in 1946. The ENIAC, using vacuum tubes and elec-
tronic circuits, received much publicity as the first electrical computer with
no moving parts. However, it has subsequently been revealed that Konrad
Zuse, an aircraft engineer, had built the world’s programmable binary based
electric computer in Germany in 1941 (Lee, 1994). Similarly, the English
code breakers at Bletchley Park developed and built the COLOSSUS Mark
I computer that began breaking code in January 1944 (Sale, 2004).
Augusta, Lady Lovelace, daughter of Lord Byron, is known as the “mother
of programming” because of her pioneering work on the mathematic logic
for Babbage’s difference engine, his analytic machine (Fig. 3.1). John von
Neumann is widely credited with the concept of the stored computer pro-
gram that revolutionized programming techniques based on his theoreti-
cal paper in 1945 (Lee, 2002). However, Tom Kilburn at the University of
Manchester in England wrote the first computer program that first worked
on June 21, 1948 on the first electronic stored-program computer (affection-
ately called “Baby”) (University of Manchester, 2001).
The invention of the general purpose, high speed electronic computer
and the work by von Neumann and Kilburn mark the close of the early
development of the computer. These first-generation computers, although

FIGURE 3.1. Augusta, Lady Lovelace, the mother of programming.

 History of Healthcare Computing 29

bulky, expensive, and less than totally reliable, provided useful results and
excellent experience for both users and developers of the computer.

The 1950s
The transistor, invented by Shockley in 1947 (WGBH, 2004), was used to de-
velop a second generation of computers and ultimately the transistor lead to
the silicon chip. Second-generation computers were smaller, produced less
heat, were more reliable, and were much easier to operate and maintain.
Second-generation computers moved into the business and industrial world
where they were used for data-processing functions such as payroll and ac-
counting. The rapidly expanding healthcare industry began using computers
to track patient charges, calculate payrolls, control inventory, and analyze
medical statistics.
During the 1950s, Blumberg (1958) foresaw the possibilities of automating
selected nursing activities and records. Little action was taken then because
the existing computer programs were inflexible, computer manufacturers
had a general lack of interest in the healthcare market, and hospital ad-
ministrators and nursing management had a general lack of interest and
knowledge about such equipment.

The 1960s
During the 1960s, universities were bursting at the seams as members of the
post-World War II baby boom entered college. The philosophy of “education
for all” left educators searching for a way to provide more individualized
and self-paced instruction. The computer seemed to hold great promise.
At the University of Illinois, Dr. Donald Bitzer was working on a display
screen that would increase the graphics resolution available on the PLATO
(programmed logic for automated teaching operations) computer system he
developed.
During 1965 and 1966, the “third generation” of computers was intro-
duced. These third-generation computers were identifiable by their mod-
ular components, increased speed, ability to service multiple users simul-
taneously, inexpensive bulk storage devices that allowed more data to be
immediately accessible, and rapid development of systems.

The 1970s
The development of the silicon chip paved the way for the development
of minicomputers and personal computers. The silicon chip allowed large
amounts of data to be stored in an extremely small space. This development
allowed the total size of computers to be significantly reduced. The first
mass-market personal computer, the MITS Altair 8800, was sold in 1975
30 Foundations of Nursing Informatics

as a hobbyist kit; the Apple I, another personal computer kit marketed to

hobbyists by Stephen Wozniak and Steve Jobs, followed in 1976.
Soon the vision of connecting computers to share information began to
spread, and many computer networks were being developed all over the
world, but they could not communicate with one another because they used
different protocols, or standards, for transmitting data. In 1974, Vint Cerf
(sometimes known as the “father of the Internet”), along with Bob Kahn,
wrote a new protocol, TCP (transmission control protocol), which became
the accepted international standard. The implementation of TCP allowed
the various networks to connect and become the Internet as we know it.

The 1980s
Personal computer technology augmented and replaced the large, cumber-
some hardware of the 1970s. In 1981 IBM debuted the PC with an Intel
8088 microprocessor, 16K of RAM, and a 5.25 disk drive with two choices
of operating system. The Apple Mac was launched in 1984, and in 1986
Intel introduced the 486 Processor. Research and development in computer
technology was aimed at “open systems.” This additional technological ad-
vance served the nursing profession because it systematized and simplified
the process of data entry, storage, and retrieval.

The 1990s
During the 1990s, information technologies, including personal comput-
ers and workstations, combined with telecommunications technologies
such as local and wide area networks to create client/server architectures.
Client/server architecture integrated and capitalized on the strengths of the
hardware, software, and telecommunications capacities, allowing users to
navigate through data across many systems. These linkages were vital to
breaking the barriers between different systems. The open flow of informa-
tion among systems (see Chapter 2 for details) contributed to many devel-
opments in nursing informatics.
In 1990 Tim Berners-Lee created a new way to interact with the Internet—
the World Wide Web. His system made it much easier to share and find data
on the Internet. Others augmented the World Wide Web by creating new
software and technologies to make it more functional. For example, Marc
Andreesen led the team that created Netscape Navigator (Griffin, 2000).

The New Millennium (2000)

The dawning of the twenty-first century saw pervasive digital prolifera-
tion. Digital cameras, music players, and videos became widely available.
Handheld devices of all sorts and for highly diverse purposes multiplied and
became widely available and affordable. Handheld wireless communication
 History of Healthcare Computing 31

devices such as Blackberry are bringing convergence of digital telecommu-

nications.

Introduction of Computers into Healthcare

Healthcare trailed government and industry in the initial exploration of the
feasibility of computer usage and in installation of computers. One reason
for the delay was that first- and second-generation computers were not well
suited for the data processing needs of hospitals. A second reason was that
only about 250 of the largest hospitals had in-hospital punch card installa-
tions. These hospitals were usually the first targets of computer salesmen.
The computer manufacturers simply did not understand the potential of the
hospital market or ultimately the healthcare market.
When focusing on the use of computers in healthcare, computers tradition-
ally gained entry through the accounting area, where most hospital computer
systems still have their roots. Patient care requires continuous and instan-
taneous response in contrast to the fiscal methodology where timing is less
critical. To achieve successful utilization of computers in healthcare, both
needs must be addressed.

The 1950s
During the late 1950s a few pioneering hospitals installed computers and
began to develop their application software. Some hospitals had help from
computer manufacturers, especially IBM. Then, in 1958–1959, John Diebold
and Associates undertook an in-depth feasibility study of hospital computing
at Baylor University Medical Center. The final report identified two major
hospital wide needs for computerization: (1) a set of business and financial
applications, and (2) a set of hospital–medical applications that would re-
quire on-line terminals at nursing stations and departments throughout the
hospital. Such a system could be used for the following purposes.
r As a communications and message-switching device to route physicians’
orders and test results to their proper destinations
r As a data-gathering device to capture charges and patient medical infor-
mation
r As a scheduler to prepare such items as nursing station medication sched-
ules
r As a database manager with report preparation and inquiry capabilities

These functions are often collectively called hospital information systems

(HISs), medical information systems (MISs), and sometimes hospital–
medical information systems (HMISs). The first term (or its acronym, HIS)
is used in this book.
32 Foundations of Nursing Informatics

The 1960s
Although a few hardware manufacturers offered some business and financial
application packages for in-hospital processing during the early 1960s, it was
not until the mid-1960s that other vendors began to see the potential of the
hospital data-processing market. The hardware vendors during the 1960s
(e.g., IBM, Burroughs, Honeywell, UNIVAC, NCR, CDC) were commit-
ted primarily to selling large general-purpose computers to support clinical,
administrative, communication, and financial systems of the hospitals.
The 200 to 400 bed hospitals that installed computers during the late 1960s
for accounting applications found their environments growing more com-
plex, which resulted in a constant battle just to maintain and update existing
systems to keep pace with regulating agencies. Many hospitals of this size
turned to shared computer services.
In 1966, Honeywell announced the availability of a business and financial
package for a shared hospital data-processing center. IBM followed quickly
the next year with SHAS (shared hospital accounting system). The avail-
ability of this software was an important factor in establishing not-for-profit
and for-profit shared centers during the next 5 years. There are still many
shared-service companies (e.g., SMS, McAuto) specializing in hospital data
processing. These companies continue to provide useful services, particu-
larly to smaller hospitals. The companies prospered not only because of
their computer and systems products and services but because smaller, sin-
gle hospitals were unable to justify, employ, and retain the varied technical
and management skills required for this complex and constantly changing
environment.
The first hospital computer systems for other than accounting services
were developed during the late 1960s. The technology that attempted to
address clinical applications was unsuccessful. Terminal devices such as key-
board overlays, early cathode-ray tubes, and a variety of keyboard and card
systems were expensive, unreliable, and unwieldy. Also, hardware and soft-
ware were scarce, expensive, and inflexible. Database management systems,
which are at the heart of good information software today, had not yet ap-
peared. During this period, some hospitals installed computers in offices
to do specific jobs (Ball and Jacobs, 1980). The most successful of these
early clinical systems were installed in the clinical pathology laboratory
(Ball, 1973). Most of the hospitals that embarked on these dedicated clinical
programs were large teaching institutions with access to federal funding or
foundation research money. Limited attempts were made to integrate the
accounting computer with these stand-alone systems.
During the mid-1960s, Lockheed Missile and Space Company and Na-
tional Data Communications (then known as Reach) began the development
of HISs that would require little or no modification by individual hospitals.
This was the forerunner to the product that is now marketed by Eclipsys.
 History of Healthcare Computing 33

About 1965, the American Hospital Association (AHA) began to conduct

four or five conferences per year to acquaint hospital executives with the po-
tential the computer holds for improving hospital administration. The AHA
also devoted two issues of its journal solely to data processing. These AHA
activities served to crystallize a market (i.e., hospitals ready for data pro-
cessing) and to encourage existing and new firms to enter the marketplace.

The 1970s
During the early 1970s, with inflation problems and with cost reimburse-
ment becoming stricter, some large hospitals that had installed their own
computers with marginal success changed to the shared service. By this time
the shared companies had improved earlier accounting software and could
carry out tighter audit controls. Most importantly, however, the companies
developed personnel who understood hospital operations and could com-
municate and translate the use of computer systems into results in their client
hospitals. This added a dimension of service that is seldom offered or under-
stood by the major hardware vendors. As a result, the business opportunities
for the service companies increased. Over time, these companies have ex-
panded their scope of services from fiscal applications and administrative
services to clinical and communication applications.
Major hardware changes took place as the minicomputer entered the
scene. This was quickly followed by the introduction of the personal com-
puter during the late 1970s. Technologic developments have resulted in a
steady trend toward microminiaturization of computers. Personal computers
are now more powerful than the original ENIAC. These personalcomputers
have invaded homes, schools, offices, nursing stations, and administrative
offices to a degree never dreamed possible. The linking of these personal
computers, using local area networking technology, provided a better alter-
native to many of the processes formerly carried out by one large general-
purpose computer.
Many major mainframe hardware companies moved rapidly into the per-
sonal computer field as well. Simultaneously, the service companies began to
develop on-site networking systems to handle data communications and spe-
cialized nonfinancial applications. They began to expand their scope of data
retention to support clinical applications that required a historical patient
database.

The 1980s
During the 1980s, specific personal computer-based systems were developed.
These systems did not replace but, instead, complemented a variety of al-
ternatives in various healthcare environments. Thus, awareness of computer
concepts by healthcare professionals became even more essential.
34 Foundations of Nursing Informatics

The 1990s
During the 1990s, the advent of powerful, affordable, portable personal com-
puters made information management tools accessible to support highly mo-
bile, remote activities, especially in community health. At the same time, the
power of networks and database technology has made possible linkages of
health data in widely separated locations. There also was a growing emphasis
on information management across health enterprises. Accompanying this
was recognition of the importance of patient/client-centered, integrated data
in contrast to departmental focused data. Such linkages and shift in focus
created the possibility of a longitudinal, lifelong health record encompass-
ing healthcare encounters by individuals with all sectors of the healthcare
system.

History of Nursing Use of Computers

Nursing Education
The seminal work in the use of computers in nursing education was con-
ducted by Maryann Drost Bitzer. During the early 1960s, Bitzer wrote a
program that was used to teach obstetric nursing. Her program was a sim-
ulation exercise. It was the first simulation in nursing and one of the first
in the healthcare field. (Bitzer’s 1963) master’s thesis showed that students
learned and retained the same amount of material using the computer sim-
ulation in one-third the time it would take using the classic lecture method.
This thesis (Bitzer, 1963) has become a classic model for subsequent work by
her and many others, including two of the authors (K.J.H. and M.J.E.) of this
volume. Bitzer’s early findings have been consistently confirmed. She was
later project director on two Department of Health Education and Welfare
(HEW)-funded research projects. These projects undertook evaluative
studies that documented the efficacy of teaching nursing content using a com-
puter. Until 1976 Bitzer was associated with the Computer-Based Education
Research Laboratory at the University of Illinois in Urbana, where
she continued to develop computer-assisted instruction lessons to teach
nursing.
During the 1970s many individual nursing faculties, schools, and units de-
veloped and evaluated computer-assisted instruction (CAI) lessons to meet
specific institutional student needs. Most of the software created was used
solely by the developing institution.
The use of computers to teach nursing content has been a focal point of in-
formatics activity in nursing education. However, the need to prepare nurses
to use informatics in nursing practice is just as important. This aspect was pio-
neered in 1975 by Judith Ronald of the School of Nursing, State University of
New York at Buffalo. Ronald developed the course that served as a model
and inspiration for courses developed later. Ronald’s enthusiasm and her
 History of Healthcare Computing 35

willingness to share her course materials and experiences have greatly facili-
tated the implementation of other such courses throughout North America.
In Scotland, Christine Henney of the University of Dundee undertook sim-
ilar activities aimed at promoting computer literacy among nurses.

Nursing Administration
The use of computers to provide management information to nurse man-
agers in hospitals has been promoted on both sides of the Atlantic. Marilyn
Plomann of the Hospital Research and Educational Trust (an affiliate of
the American Hospital Association) in Chicago was actively involved for
many years in the design, development, and demonstration of a planning,
budgeting, and control system (PB CS) for use by hospital managers. In
Glasgow (Scotland) Catherine Cunningham was actively involved in the de-
velopment of nurse-manpower planning projects on microcomputers. Simi-
larly, Elly Pluyter-Wenting (from 1976 to 1983 in Leiden, Holland), Christine
Henney (from 1974 to 1983 in Dundee, Scotland), Phyllis Giovanetti (from
1978 to the time of writing in Edmonton, Canada), and Elizabeth Butler
(from 1973 to 1983 in London, England) have been instrumental in devel-
oping and implementing nurse scheduling and staffing systems for hospitals
in their areas.
In the public health area of nursing practice, Virginia Saba (a nurse con-
sultant to the Division of Nursing, Bureau of Health Manpower, Health
Resources Administration, Public Health Service, Department of Health
and Human Services) was instrumental in promoting the use of manage-
ment information systems for public health nursing services. The objective
of all these projects has been to use computers to provide management in-
formation to help in decision-making by nurse administrators.

Nursing Care
Much research on the development of computer applications for use in pa-
tient care was conducted during the 1960s. Projects were designed to provide
justification for the initial costs of automation and to show improved patient
care. Hospital administrators became aware of the possibilities of automat-
ing healthcare activities other than business office procedures. Equipment
became more refined and sophisticated. Healthcare professionals began to
develop patient care applications, and the manufacturers recognized the
sales potential in the healthcare market.
Nurse pioneers who have contributed to the use of computers in patient
care activities have been active on both sides of the Atlantic. In the United
Kingdom, Maureen Scholes, chief nursing officer at The London Hospital
(Whitechapel), began her involvement with computers and nursing in 1967
as the nurse member of the steering team that directed and monitored The
London Hospital Real-Time Computer Project. This project resulted in a
36 Foundations of Nursing Informatics

hospital communication system that provided patient administration ser-

vices, laboratory services, and radiography services using 105 visual display
units in all hospital wards and departments.
Elizabeth Butler was associated with the Kings College Hospital from
1970 to 1973. As the nursing officer on a medical unit, Butler was involved
in developing and implementing the computerized nursing care plan system
for the Professional Medical Unit and for the nursing care plan system for all
wards and specialties in the 500-bed general area of the hospital. In Dundee,
Scotland, Christine Henney worked with James Crooks (from 1974) on the
design and implementation of a real-time nursing system at Ninewells Hos-
pital.
In the United States, Carol Ostrowski and Donna Gane McNeill were
both associated with the development of the Problem Oriented Medical In-
formation System (PROMIS) at Medical Center Hospital of Vermont under
the direction of Lawrence Weed. From 1969 to 1979, Donna Gane McNeill
was a nurse clinician on the PROMIS project. As such, McNeill managed
the first computerized nursing unit, developed content for PROMIS, and de-
veloped functions and tasks for the computer. She also conducted a compar-
ison between computerized and noncomputerized units. From June 1976 to
December 1977, Carol Ostrowski served as director of audit for the PROMIS
system. She was responsible for implementing the components that sup-
ported concurrent audit of medical and nursing care and the environment
that guided and evaluated patient care.
In the United States, Margo Cook also began her association with com-
puters in nursing in 1970 when she was employed at El Camino Hospital,
Mountain View, California. Cook participated as the nursing representa-
tive on the team that developed and implemented the Medical Information
System (still marketed by Elipsys). As nursing implementation coordina-
tor, Cook was responsible for identifying and addressing the needs of all
nursing units at El Camino. Often she functioned as interpreter between the
computer analysts and nurses. Eventually she assumed senior level respon-
sibility for the MIS maintenance and development. In 1983 Cook left El
Camino to become senior consultant of Hospital Productivity Management
Services.
In 1976 Dickey Johnson became computer coordinator at Latter Day
Saints Hospital in Salt Lake City, Utah. Johnson’s responsibilities involved
coordination between the computer department and other hospital users in
planning, development, implementation, and maintenance of all programs
either used by, or affecting, nursing personnel. In 1983, Johnson was the
nursing representative on the hospital’s Computer Committee, which was
actively involved in planning, designing, and implementing a hospital-wide
computer system. Johnson was responsible for projects that included order
entries, nursing care plans, nurse acuity, and nurse staffing.
In Canada, from 1978 to 1983, Joy Brown and Marjorie Wright, systems co-
ordinators at York Central Hospital in Richmond Hill, Ontario, were actively
 History of Healthcare Computing 37

involved in designing, coding, and implementing the computerized patient

care system at their hospital. They were also responsible for training many
nurse users on the system. Beginning in 1982 at Calgary General Hospital
in Calgary, Alberta, Wendy Harper, assistant director, Nursing Systems, was
responsible for all aspects of the nursing applications on the hospital infor-
mation system being installed in that hospital.
Nurses have recognized the potential for improving nursing practice and
the quality of patient care through nursing informatics. These applications
facilitate charting, care planning, patient monitoring, interdepartmental
scheduling, and communication with the hospital’s other computers. New
roles for nurses have emerged. Nurses have formed computer and nursing
informatics interest groups (see Appendix B) to provide a forum through
which information about computers and information systems is communi-
cated worldwide.

Nursing Research
During the 1960s, nursing researchers began using computers to store data
and maintain complex data sets without error.

Communicating Nursing Developments

Kathryn Hannah, of the University of Calgary, was the first nurse elected to
the Board of Directors of the Canadian Organization for the Advancement
of Computers in Health (COACH). In that capacity, with the assistance of
David Shires of Dalhousie University (and at that time program chairman
for the International Medical Informatics Association), Hannah was instru-
mental in establishing the first separate nursing section at an International
Medical Informatics Association (IMIA) meeting (Medinfo ’80, Tokyo).
Previously, nursing presentations at this international conference had been
integrated within other sections. In 1982, based on the success of this Tokyo
workshop, which Hannah also chaired, a contingent of British nurses led
by Maureen Scholes mounted an International Open Forum and Working
Conference on “The Impact of Computers on Nursing.” The international
symposium on the impact of computers on nursing was convened in London,
England, in the fall of 1982, followed immediately by an IMIA-sponsored
working conference. One outcome of the working conference was a book
that documented the developments related to nursing uses of computers
from their beginning until 1982. The second outcome was a consensus that
nurses needed a structure within an international organization to promote
future regular international exchanges of ideas related to the use of comput-
ers in nursing and healthcare. Consequently, in the spring of 1983, a proposal
to establish a permanent nursing working group (Group 8) was approved
by the General Assembly of IMIA. In August 1983, the inaugural meeting
38 Foundations of Nursing Informatics

of the IMIA Working Group on Nursing Informatics (Group 8) was held in

Amsterdam.
In 1992, the working group recommended a change of bylaws and began
its transformation to a nursing informatics society within the IMIA. This so-
ciety continues the organization of symposia every 3 years for exchange of
ideas about nursing informatics, dissemination of new ideas about nursing
informatics through its publications, provision of leadership in the devel-
opment of nursing informatics internationally, and promotion of awareness
and education of nurses about nursing informatics.
In the United States in 1981, Virginia Saba was instrumental in estab-
lishing a nursing presence at the Symposium on Computer Applications in
Medical Care (SCAMC). This annual symposium, although not a profes-
sional organization, provided opportunities for nurses in the United States
to share their experiences. In 1982 the American Association for Medical
Systems and Informatics (AAMSI) established a Nursing Professional Spe-
cialty Group. This group, which was chaired by Carol Ostrowski, provided
the benefits of a national professional organization as a focal point for dis-
cussion, exchange of ideas, and leadership for nurses involved in the use
of computers. Subsequently, AAMSI merged with SCAMC to become the
American Medical Informatics Association (AMIA). This organization con-
tinues to have a highly active nursing professional specialty group.

Summary
Despite their wide usage, computers are historically young and did not come
into prominence until 1944 when the IBM-Harvard project called Mark I
was completed. This was followed closely by the development, in 1946 at the
University of Pennsylvania, of the ENIAC I, the first electronic computer
with no moving parts. Subsequent refinement of computer technology, de-
velopment of the silicon chip in 1976, development of the Internet, and the
World Wide Web have made personal computers as common in our homes
as television sets. Handheld wireless digital telecommunications devices are
now pervasive.
During the 1950s computers entered the healthcare professions. They
were primarily used for the purposes of tabulating patient charges, calcu-
lating payrolls, controlling inventory, and analyzing medical statistics. A few
farsighted individuals saw the possibilities of automating selected nursing
activities and records. However, little action was taken because of the in-
flexibility and slowness of the equipment, the general disinterest of the man-
ufacturers in the healthcare market, and the lack of knowledge concerning
such equipment among hospital management, hospital administrators, and
nursing management.
By the 1960s, hospital administrators had been exposed to the possibil-
ity of automating healthcare activities; in addition to existing business office
 History of Healthcare Computing 39

automation, equipment had become more refined and sophisticated, and the
manufacturers had recognized the sales potential in the healthcare market.
The major focus during the 1960s was on the research aspect of computer
applications for patient care; the business applications for auditing func-
tions in the healthcare industry were becoming well established. Projects
were designed to provide justification for the initial costs of automation
and to display the variety of areas in which computers could be used to
facilitate and improve patient care. Nurses began to recognize the poten-
tial of computers for improving nursing practice and the quality of patient
care, especially in the areas of charting, care plans, patient monitoring, in-
terdepartmental scheduling, and communication and personnel time assign-
ment. These individual computer applications or modules, which were de-
veloped to support selected nursing activities, were later integrated in mod-
ular fashion into various hospital information systems. Today these hospi-
tal information systems are widely promoted and marketed by computer
vendors.
Simultaneously, advances in the uses of computers in educational environ-
ments were initiated during the 1960s. The major focus during this decade
was on showing the efficacy of computers as teaching methods. During the
1970s, many projects were designed to compare student learning via com-
puter with learning via traditional teaching methods. The mid-1970s also saw
the development of the personal microcomputer and during the latter years
of that decade their widespread dissemination throughout society. During
the 1980s nursing educators were scrambling to develop software for use
with this technology. In fact, the hardware technology has advanced beyond
nursing educators’ capacity to use it all.
Major contributions by nurses to developments leading to the use of com-
puters in nursing were also discussed. Our apologies to those nurses whose
activities were unknown to us. If readers know of other nurses whose con-
tributions merit inclusion in future editions, the authors would be pleased
to receive such information.
The future demands that computer technology be integrated into the clin-
ical practice environment, education, and research domains of the nursing
profession. The ultimate goal is always the best possible care for the patient.

References
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Bitzer, M.D. (1963). Self-Directed Inquiry in Clinical Nursing Instruction by Means of
PLATO Simulated Laboratory. Report R-184, Co-ordinated Science Laboratory.
Urbana: University of Illinois.
40 Foundations of Nursing Informatics

Blumberg, M.S. (1958). Automation offers savings opportunities. Modern Hospital

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4
Telecommunications and
Informatics

The convergence of telecommunications and informatics has opened up a

new world of communication service delivery and health information for
consumers and health professionals. This chapter is designed to provide a
basic understanding of the Internet, intranets, and extranets.

What Is the Internet?

At the most basic level, the Internet is the name for a group of worldwide
computer-based information resources that are connected. It is often de-
fined as a network of networks of computers. According to the Internet
Systems Consortium, there are more than 171 million hosts (computers)
connected throughout the world (http://www.isc.org/index.pl?/ops/ds/host-
count-history.php). These sites support more than 2 billion indexable Web
pages. It is estimated that more than 1 million sites join the Internet every
day.
One of the major challenges when using the Internet is that there is no
clear map of how all those networks are connected. There is also no master
list of what information or resource is available where. Because there is no
overall structured grand plan, the shape and face of the Internet is constantly
changing to meet the needs of the people who use it. The Internet can be
likened to a cloud in this way; it is amorphous, without boundaries and
constantly changing shape and space.
Although the thought of all those computers joined together is mind bog-
gling, the real power of the Internet is in the people and information that all
those computers connect. The Internet is a people-oriented community that
allows millions of individuals around the world to communicate with one
another. The computers move the information around and execute the pro-
grams that allow us to access the information. However, it is the information
itself and the people connected to the information that make the Internet
useful.

41
42 Foundations of Nursing Informatics

Connecting to the Internet

There are three basic ways to connect to the Internet: make a direct con-
nection over dedicated communications lines; use your computer to connect
to a university or hospital computer system that has Internet access; or buy
time and connections from a commercial Internet service provider.

Direct Connection to the Internet

A direct or dedicated connection wires a personal computer directly to the
Internet through a dedicated machine called a router or gateway. The con-
nection is made over a special kind of telephone line. The gateway identifies
the personal computer as an “official” Internet computer that must remain
on-line all the time. This type of direct connection is extremely expensive to
install and maintain. For this reason, it is usually used only by large compa-
nies or institutions rather than by individuals or small businesses.

Connecting Through Another’s Gateway

Another way to connect to the Internet is to use a gateway that another com-
pany or institution has established. In this case, a company or university or
hospital that has an Internet gateway allows individuals to connect to the In-
ternet using their system. The connection is usually made through a modem
or remote terminal. This type of access is often available to students through
the computing services department of their university. Many hospitals and
health services organizations also allow staff access to the Internet through
the institution’s facilities. To use an institution’s access, each user needs a
login identification and password. For the individual, this is the best type of
access to have if full Internet access is available. An organization maintains
the computer system and the Internet connection and, most importantly,
pays for the connection.

Connecting Through a Commercial Service Provider

Connecting to the Internet through a service provider is much the same pro-
cess as using another’s gateway. The service provider builds and maintains
the gateway and sells Internet connection access to individuals and organi-
zations. The service provider supplies a user name and password to connect
to its gateway. Service providers usually charge a flat fee to provide a certain
amount of Internet access per month or year and a personal e-mail address.
Some providers, such as America Online (AOL), also offer access to other
interesting software or participation in unique discussion groups through
their own system.
 Telecommunications and Informatics 43

Ways to Connect to a Commercial Service Provider

Today there are four main ways to connect your computer to an Internet
Service Provider: dial-up, DSL, cable, or wireless. Each method has its pros
and cons. For example, the DSL, cable, and wireless connection methods
are not available to everyone. When choosing a connection type, you can
be guided by your own needs, the available choices, and your budget. For
example, if you only need e-mail service, a dial-up connection is probably
sufficient.

Dial-up Connection
Dial-up was the first and probably is still the most common method of con-
necting to the Internet. Using software that is a normal part of your computer
and an inexpensive modem in your computer, you can establish an Internet
connection over your telephone line through your Internet Service Provider
(ISP). Your ISP gives you a local telephone number for your computer to
call. The dial-up software on your computer makes a telephone call to that
number, and your modem establishes an Internet connection through the
ISP’s computer. Most ISPs charge a flat monthly or yearly fee for unlimited
access to the Internet using this method. An advantage to this approach is
that you probably have a telephone already and your computer likely has
a modem already installed. A drawback is that you lose the normal use
of your telephone while you are connected to the Internet. Another ma-
jor drawback is that regular telephone lines cannot pass digital information
faster than about 22.8 kilobits per second. Although that seems like a large
number, it strongly limits the speed at which graphics information from the
Internet is displayed. This may limit your ability to view large graphics files.

DSL Connection
To increase the speed of regular telephone lines for Internet use, telecommu-
nication companies developed the digital subscriber line (DSL) technology.
This technology allows information to move at speeds of up to 6 megabits per
second. Your DSL provider installs a network interface card in your com-
puter, connects it to a DSL modem, and then connects it to your telephone
line. So long as your computer is turned on and plugged in, you have an “al-
ways on” Internet connection through your telephone line. An advantage,
in addition to the transmission speed, is that you can use your telephone nor-
mally even while accessing the Internet. Another advantage is that, unlike
a cable connection (see below), you do not share your telephone line with
others to access the Internet. The immediate problem with this technology
today is that there are distance limitations with DSL. You must be located
within a certain distance from your telephone company’s internal systems
44 Foundations of Nursing Informatics

for DSL to work. The only way to find out if DSL is possible for you is to
ask a DSL provider (likely a local ISP or your local telephone company).

Cable Connection
The other approach to having fast Internet service uses the cable that delivers
cable television into your home. A cable company installs a network interface
card in your computer, connects it to a cable modem, and then connects
the modem to the cable television line in your house. As with the DSL
technology, so long as your computer is turned on and plugged in, you have
an “always on” Internet connection. An advantage, beyond the speed of
Internet access, is that this approach does not affect your telephone in any
way. There are several possible problems with this approach, however. For
example, you may not have cable television installed in your house or your
cable company may not offer Internet access. Also, it is possible that, as
more people in an area share the service, performance in that area may
degrade.

Wireless Connection
A fourth approach is Internet access using cellular phones and other portable
wireless information devices. Many locations such as hospitals, airports, ho-
tels and cyber cafes have put in place a “wireless access point” that uses ra-
dio transmitter-receiver technology. Computers, personal digital assistants
(PDAs), and cell phones that are equipped with a wireless communication
card, can take advantage of these access points, or “hotspots.” The organi-
zation supporting the wireless access point control what is accessible. For
example, some hospitals allow access to internal intranets but do not allow
access to the Internet. Wireless access is limited by the speed of information
flow. Wired networks are 2 to 10 times faster than wireless access. In addi-
tion, because radio transmission is used, interference can be an issue. There
may be places in a building where reception is better than in other places.

What to Look for When Choosing an Internet Provider

There are several basic elements to consider when obtaining access to the
Internet through a provider. First, what kind of personal computer (PC) is
to be used for the connection? Generally, providers are most comfortable
supporting PC-compatible computers. The processing power and storage
capacity of the computer are also important.
Second, what is the individual’s level of technical knowledge and comfort
when working with the computer? There may be levels of technical details
not understood by computing nonprofessionals. Some Internet providers,
for a fee, help you install the connection software on your computer and get
it working.
 Telecommunications and Informatics 45

Third, look for a provider with a local telephone number that is used to
connect. Some providers advertise 1–800 numbers. The point here is to avoid
additional telephone charges. Without a local number, additional charges to
a telephone company result.
Fourth, what set of Internet services or tools does the provider offer?
Be sure to check the details of what is offered and what, if any, additional
charges there might be for things such as the number of e-mail messages
sent.
Fifth, what is the cost of this connection? Be sure that all the restrictions
and assumptions are fully identified. Last, what kind of technical support
does the provider offer? Make sure of the support policy of the provider
(i.e., 24 hours a day, business hours only).

Security Issues
Connecting to the Internet gives others the opportunity to cause trouble
for you. There are two ways your computer can be attacked: directly and
indirectly.

Hacking or Cracking—Direct Attack

The news continually has reports about people who break into computer
systems. The news reports often call these people “hackers”, but to be strictly
correct these people are “crackers.” Hacker is a term that applies to anyone
who writes computer program code. Cracker is a term that applies to people
who use their skills to attempt to access other computers without permission.
There are even programs, shared across the Internet, that allow people with
little skill to mount an attack.
If you are connected to the Internet, there is the potential for people
to attack your computer directly. This form of attack is more likely if you
have an “always on” connection such as DSL or cable. A dial-up connection
is more difficult to attack and is less likely to be attacked. To block these
direct attacks, you need something called a firewall. This is either part of
the computer hardware or a computer software program. If you connect
to the Internet indirectly through a network at your workplace, there is
probably a hardware firewall in place. If you connect to the Internet through
an ISP, you need to install a commercial personal firewall program on your
computer. Once installed on your computer, the personal firewall program
watches every piece of information that attempts to come or go through
your Internet connection. Only legitimate activities that are recognized by
the firewall program are allowed to succeed. All other activities are blocked.
As new methods of attack are discovered, the firewall manufacturer develops
new methods to detect and block them and adds these new feature to the
firewall program.
46 Foundations of Nursing Informatics

Viruses—Indirect Attack
Even if you are never attacked directly, there are always indirect attacks
happening through the use of viruses. Viruses are small programs hidden
inside legitimate files or e-mail messages. The virus-infected files might come
as part of an e-mail message or might be given to you on a computer disk.
When you access these files or e-mail messages, the viruses start running.
They are now on the other side of any personal firewall of your computer.
The main way to protect against viruses is to install a commercial antivirus
program on your computer. These programs protect your computer from
viruses in several ways. They scan your e-mail messages as you access them,
looking for telltale signatures of viruses. They constantly monitor certain
activities of your computer, looking for actions that may signal a virus starting
up. Once a virus detected, the antivirus program alerts you with a message
and guides you on how to deal with the virus. As new forms of viruses are
discovered, the antivirus program manufacturer develops new methods for
detecting and dealing with them and adds these new methods to the antivirus
program.

World Wide Web

The World Wide Web (variously called WWW, W3, or the Web) was devel-
oped in an attempt to make sense of all the Internet resources. The goal of
WWW development was to offer a simple, consistent, intuitive interface to
the vast resources of the Internet. The WWW provides the intuitive links
that humans make between information, rather than forcing people to think
like a computer and speculate at possible file names and hidden submenus,
as did the previous services. A short history of the development of the WWW
may help to understand its services.
In 1989, researchers at CERN (the European Laboratory for Particle
Physics) wanted to develop a simpler way of sharing information with a
widely dispersed research group. The problems they faced are the same
as those you face when using the previous information retrieval systems.
Because the researchers were at distant sites, any activity such as read-
ing a shared document or viewing an image required finding the location
of the desired information, making a remote connection to the machine
containing the information, and then downloading the information to a lo-
cal machine. Each of these activities required running a variety of appli-
cations such as FTP, Telnet, Archie, or an image viewer. The researchers
decided to develop a system that would allow them to access all types of
information from a common interface without the need for all the steps
required previously. Between 1990 and 1993, the CERN researchers de-
veloped this type of interface, WWW, and the necessary tools to use it.
Since 1993, WWW has become the most popular way to access Internet
resources.
 Telecommunications and Informatics 47

Hypertext
To navigate around the World Wide Web, a beginning understanding of
hypertext is essential. Hypertext is text that contains links to other data. For
example, when doing a literature search using the hard copy of CINAHL,
the first search term is selected and looked up. After reading through the
listings, another idea for a search term becomes apparent. Traditionally, the
user marks the first page (to facilitate returning at a later time) and turns
to the new term. At the bottom of the listings of the second term is a note
that says, “see also” and gives several other words to follow. In a hypertext
document, it is unnecessary to wait until the end to find the links; they may
be anywhere in the document. Links in hypertext documents are marked
either with color bars, underlining, or use of square brackets with numbers
so they stand out. Whenever a word is marked as hypertext it can be selected,
and immediately the link is made to another document related to the word
or phrase. When finished looking at the linked document, simply go back to
the previous text with the click of a mouse button, where the program has
kept its finger in the page.
This is what makes the Web so powerful. A link may go to any type of
Internet resource. For example, the link can go to a text file, a database
of information, a video or audio file, a chat room, or a UseNet newsgroup.
Another powerful feature of the Web is that hypertext allows the same piece
of information to be linked to hundreds of other documents at the same time.
The links can also span traditional boundaries. A hypertext document related
to a specific professional group may contain links to information in many
disciplines.
All Web sites have a welcome page, called a home page, which you see
when you first connect to that site. The home page may just give the name
of the site but usually contains a list of resources and links available at the
site.

Web Browsers
To access the Web, you need a Web browser program on your (or your
institution’s) computer. A Web browser program knows how to interpret
and display the hypertext documents it finds on the Web. There are many
browsers on the market. The two most popular graphical user interface
(GUI) or windows-based browsers are Microsoft Internet Explorer and
Netscape Communicator.
When you first start up your Web browser, you automatically navigate
to a Web page that the browser calls its “home” page. This home page is
a Web uniform resource locator (URL) that is initially set by the browser
manufacturer or your ISP when they connected you to the Internet. You
can navigate to the home page of your browser at any time by pressing the
48 Foundations of Nursing Informatics

browser button called “Home.” In addition to the Home button, there are
buttons that help you navigate through and display the information you find
on the Web.
The World Wide Web project developed a standard way of referencing an
item whether it was a graphics file, a document or a link to another computer.
This standardized reference is a URL. The URL is a complete description
of the item including its location on the Internet. A typical URL is:

http://www.springer-sbm.com

The first part of the URL, which ends with the colon, is the protocol that
is being used to retrieve the item. In this example, the protocol is HTTP
(hypertext transfer protocol), used for the Web. The next part is the domain
name of the computer to which you want to connect (springer-sbm.com). This
tells you that the information is on a computer in the commercial top-level
domain “(com).” The springer-sbm indicates that the Web site belongs to the
publisher Springer in New York (USA). Most Web browsers automatically
add the “http://” if you simply type the other part of the URL, www.springer-
sbm.com

Searching the Internet

Finding what you need in the sheer volume of information available on the
Internet can be daunting. Search sites bring millions of hypertext pages, with
their images and multimedia elements into an orderly and searchable struc-
ture. Software agents, or “spiders,” are sent out by search sites to “crawl”
the Web electronically, collecting home pages, keywords, and abstracts that
are used to build indexes and directories that can be searched. Search sites
use both indexes (www.altavista.com) and directories (www.yahoo.com) to
manage Internet information. Other types of search engines include such
hybrids as Excite (www.excite.com), which use both indexes and directo-
ries, and Google (www.google.com), which uses its own search technology
to rank search terms more intelligently. You can go to any search engine
or web index by typing the URL in the textbox of your web browser. Once
at the site, you begin the search for information by typing a key word or
phrase in the textbox. Once you type in the keyword, the search is per-
formed and the results are displayed on your screen. The results are in the
form of hypertext links that allow you to click on your choice and be auto-
matically connected with the selected site. Some of the search sites provide
a “degree of relevance” for each site found. This gives you a sense of how
closely matched the site is to the keyword or phase you used. The more
specific the keyword or phrase, the more likely it is that the results will be
useful.
 Telecommunications and Informatics 49

Internet Addresses
To look for information or people on the Internet, it is vital to understand
Internet addressing. Every person and every computer on the Internet is
given a unique address. All Internet addresses follow the same format: the
person’s User ID (or User Name), followed by the @ symbol, followed by the
unique name of the computer. For example, one author’s university-based
Internet address is

[email protected]

In this example, the user ID portion is marge, and the unique computer name
is athabascau.ca. That unique computer name is also called the domain.
The same author also has an Internet account with a service provider. That
address is

[email protected]

In general, an Internet address has two parts: the user ID and the domain,
put together like this:

userid@domain

This combination needs to be unique on the entire Internet so the right

person receives the right message.

Internet Applications
Electronic Mail
Electronic mail (or e-mail) was the first Internet application and is still the
most popular one. E-mail is a way of sending messages between people or
computers through networks of computer connections. Many hospitals and
healthcare agencies also have an internal e-mail system.
E-mail on the Internet is analogous to the regular postal system but has
faster delivery. E-mail combines a word processor function and a post office
function in one program. When an e-mail program is started, a command is
used to begin a new message. The message is typed into the computer along
with the recipient’s e-mail address and the return address. Then the message
is “sent,” which is something like dropping a letter in the regular postbox.
The electronic post office in the personal system takes over and passes the
message on. Electronic packets of data carry the message toward its ultimate
destination mailbox. The message often must pass through a series of inter-
mediate networks to reach the recipient’s address. Because networks can
50 Foundations of Nursing Informatics

and do use different e-mail formats, a gateway at each network translates

the format of the e-mail message into one the next network understands.
Each gateway also reads the destination address of the message and sends
the message on in the direction of the destination mailbox. The routing
choice takes into consideration the size of the message and the amount of
traffic on various networks. Because of this routing, it takes varying amounts
of time to send messages to the same person. On one occasion, it might be
only a few minutes; on others, it might be a few hours.

Anatomy of an E-Mail Message

E-mail messages always have several features in common regardless of the
program used to create the e-mail. A typical e-mail message includes a
“From” line with the sender’s electronic address; a date and time line; a
“To” line with the recipient’s electronic address; a “Subject” line; and the
body of the message. If there are any spelling or punctuation mistakes in the
recipient’s address, the message is returned from the electronic post office.
The “Subject” line is the place to give a clear, one-line description of the
message, which is usually displayed when someone checks his or her e-mail.
The recipient can decide how quickly to read the message.
If the message has been copied to others, their addresses appear in the
“Copies to” line. Copying or forwarding messages to others is easy with most
mail programs. For this reason, be prudent about what is said in a message.
There is no way to know where it will end up because there is no control
over the message once it is sent.

Legal Issues
Privacy, libel, and copyright are legal issues that can affect e-mail users.
Understand that privacy is not assured with electronic mail. There are no
legal requirements that prevent an institution or company from reading
incoming and outgoing e-mail messages. For individuals using an employer’s
equipment, this is especially applicable. In addition, once a message has
been sent, there is no control over what the recipient may do. The recipient
may send a copy to someone else without the knowledge of the message’s
originator. Also, do not assume that messages received are private. The
sender may have sent that same message to others without using the “Copies
to” function. A final note about privacy: even though a mail message has
been deleted from a mailbox, do not assume that it has been completely
erased. Many institutional and company policies require regular backups of
their computer system disks, which generally hold incoming and outgoing
mail messages. It is possible that copies of individual users’ messages were
obtained during a regular system backup. Be aware that e-mail records can
be subpoenaed.
 Telecommunications and Informatics 51

A second legal issue for e-mail users is libel. Libel is applicable within
e-mail messages and newsgroups. Take care with all comments. What you
say can be held against you. Finally, copyright law applies to transferring
files and information. It is illegal to distribute copyrighted information by
any means, including electronic transfer. It is not uncommon to find material
that has been scanned by a user for personal use and then distributed through
e-mail. Unless the copyright owner has granted specific permission for the
transfer of such material, it is illegal to do so.

Mailing Lists
Mailing lists are an extension of e-mail. When an e-mail message is sent
to someone, the address is indicated. When an individual or organization
consistently wants to mail to the same group of people, a special recipient
name called an alias can be set up. For example, a hospital could create an
alias called “nursing” that lists the e-mail addresses of all the directors of
nursing. To send a message to all the directors of nursing, simply specify
“nursing” in the “To” line and the same message will be sent to everyone
on that list (alias). The directors of nursing can use this method to have an
electronic discussion group. One director sends a message about a certain
topic that is distributed to all those users identified by the alias “nursing”
(all the other directors of nursing). When another director wants to respond
to the topic, a message is sent again to “nursing” and all the directors of
nursing receive it.
A mailing list is like an alias that contains hundreds or thousands of users
from all over the Internet. Any message sent to the mailing list “alias” is
automatically sent to everyone on the mailing list. Everything that anyone
says through the mailing list goes to everyone on the mailing list. Mailing
lists facilitate electronic discussion groups. Each mailing list resides in a
specific computer and is looked after by a human administrator. The host
computer is responsible for distributing incoming messages to all mailing list
members. The administrator is responsible for maintaining the mailing list.
Some mailing lists are also moderated. In these lists, there is a moderator
who reviews each incoming message for appropriateness and either passes it
through for distribution or rejects it. Some moderators also prepare digests,
something like an issue of a magazine. The digest is an entire set of messages
and articles in one package, making it much easier to keep up with the
messages.
Mailing lists are maintained in two ways, either by a person (manually) or
by a program. With the manual approach, the list administrator takes care
of adding or deleting addresses from the master distribution list. With the
program approach, you send messages to the address of a computer that
provides this service. The most common mailing list administration program
is called Listserv (representing List server). Mailing lists are scattered across
the Web. One place to look for a comprehensive collection of mailing lists is
52 Foundations of Nursing Informatics

www.liszt.com. This site supports searching and provides some information

about the lists.

Newsgroups
Mailing lists and newsgroups enable asynchronous or time-independent dis-
cussions on the Internet. Participants can post and read messages at any
time. They do not have to be taking part in the discussion at the same time.
Although discussions take place on the Internet using both mailing lists and
newsgroups, there is a significant difference between the two methods. A
mailing list discussion comes directly to an individual’s electronic mailbox,
just as a letter is delivered by a postal service. However, the messages that
form discussions in newsgroups are sent only to the newsgroup administra-
tor, who then sends them to Internet newsgroup system sites (not individual
subscribers). Individuals then read the messages in the newsgroup at a par-
ticular system site in the same way as walking down the hall to read the
messages posted on a bulletin board. In fact, the origin of newsgroups was
as a bulletin board service where messages could be posted for all to see.

What Is Usenet?
Usenet (users’ network) is made up of all the machines that receive network
newsgroups. A machine that receives these newsgroups is called a Usenet
Server. Any computer system that wants to carry newsgroups of interest to
that site can be a Usenet server.
Instead of forwarding all messages to all users on a mailing list, Usenet
forwards all messages (called articles to keep up the newspaper analogy) not
to individual subscribers but to other Usenet servers, who forward them on
until all machines that are part of Usenet have a copy of the article (message).
Individuals then use programs called “newsreaders” to access the newsgroup
through their own computers. A typical Usenet server receives more than
20,000 articles per day. To organize all these articles, they are assigned to spe-
cific newsgroups. Newsgroups are further collected into hierarchies, similar
to the domains described in relation to e-mail addresses.
Every Usenet server subscribes to specific newsgroups. Not all newsgroups
are available on all Usenet servers. Some newsgroups are moderated. This
means that articles cannot be posted directly to the newsgroup. Instead, all
messages sent to this newsgroup will be automatically routed to the volun-
teer moderator. The moderator then decides what articles to send on to the
newsgroup. Articles may be edited by the moderator or grouped with other
articles before they are forwarded to the newsgroup. In some cases, the mod-
erator may decide not to forward an article at all. Moderators exist to limit
the number of low-quality articles in a newsgroup, especially all those “me
too” or “I agree” type of articles.
 Telecommunications and Informatics 53

Reading Articles
To read the articles posted to a newsgroup, a program called a newsreader
is used. A newsreader is the interface to Usenet that allows individuals
to choose the newsgroups to which they wish to belong or to select and
display articles. When using a newsreader, articles can be saved to a file,
mailed to someone else, or printed. Responding to the article’s author or
the newsgroup is also done through the newsreader program. There are a
number of common newsreader programs: rn, trn, nn, and tin.
Newsgroups and mailing lists exemplify the power of the Net. An individ-
ual has the ability to call on the resources and creativity of people around
the world to help. As well, individuals can contribute their experience and
share their knowledge with others.

Internet Chat
Live or synchronous discussion is accomplished through the use of chat
rooms. Using a Web browser allows you to navigate to a chat room and
click on buttons to join the conversations. Chat rooms provide a way for you
to “talk” with anyone who is present in the chat room at the same time. Chat
rooms (sometimes called channels) generally have a specific theme such as
women’s health, seniors’ health, or endometriosis. There are also chat rooms
organized by professional practice discipline or area-of-practice nurse prac-
titioners or oncology nursing. There are no directories of chat rooms. To
find a chat room related to a specific topic you would use a Web search
engine.
There are two types of chat room: moderated and unmoderated. In the
moderated chat room, a person, often a volunteer, acts as host for the chat.
This person is responsible for keeping the discussion on track and for re-
moving offensive or unruly participants. Some moderated chat rooms use
keyword filtering software to eliminate offensive language from the con-
versations. Many moderated chat rooms have topics scheduled on a weekly
basis so you know what time to join in for a particular topic of interest.
Unmoderated chat rooms have no one monitoring them and so anything
can be and often is said. These unmoderated chats are disappointing for peo-
ple truly seeking information and support for a variety of topics listed under
health on some of the more common index sites. Instead of helpful informa-
tion, they find an unending stream of profanity and pornography. Generally,
the most profitable discussions are found in moderated chat rooms. Once
you have identified a chat room and have gone to the site, you must sign
up and select a user name and sometimes a password. The name you select
provides some degree of privacy provided you select a name that does not
identify you. Be aware that, because you cannot verify the identity of others
in the chat room, participants may take on identities or personas different
54 Foundations of Nursing Informatics

from their real selves. Many chat rooms post codes of conduct that require
appropriate behaviors and respectful conversations.
A chat room is often like being in a room full of people—there are many
conversations going on at the same time. If there are many people in a
chat room, it is often difficult to follow the simultaneous discussions. Many
chat rooms also allow you to send a private message to another person in
the chat room, without everyone else seeing it.
Although most of the people you meet in chat rooms are innocuous, there
are always some people it is best to avoid. It is almost impossible to dis-
tinguish the “reputable” from the “disreputable” based on the information
you glean from chatting, so be prudent about disclosing personal identifying
information. There have been many tragic stories in the media about unfor-
tunate face-to-face meetings between people who initially met through the
Internet. Use extreme caution and lots of common sense if you plan to meet
a new “cyberpal” in person.

Intranets and Extranets

As was stated earlier, the real power of the Internet lies in the people and
information connected by computers. Many organizations have taken the
concepts and tools of the Internet and have applied them within their own
structures. The organizations, in effect, create private internets, called in-
tranets. Information and people can then be connected in the same easy
fashion as on the larger public Internet. Organizations thus have all the ad-
vantages for information sharing and communication for their people with-
out the security concerns of using the public Internet. If organizations then
selectively allow outside agencies to connect to their intranet, they have now
created an extranet. This extranet allows several organizations with common
purpose to share information on an “extended intranet.”

Summary
The integration of telecommunications and health informatics has had a
powerful impact on healthcare delivery. We have only begun to see what
is possible when telecommunications meets health informatics. Specific ap-
plications of the Internet to healthcare (i.e., telehealth) are described in
Chapter 8.

Additional Resources
Edwards, M. (2002). The Internet for Nurses and Allied Health Professionals, 3rd ed.
New York: Springer-Verlag.
Part II
Nursing Use of Information
Systems
5
Enterprise Health Information
Systems

Healthcare institutions generate massive volumes of information that must

be collected, transmitted, recorded, retrieved, and summarized. The problem
of managing all these activities for clinical information has become monu-
mental. As a result, computer-based hospital information systems (HISs)
were designed, tested, and installed in hospitals of all sizes. The original
purpose of HISs was to provide a computer-based framework to facilitate
the communication of information within a hospital setting. Essentially, an
HIS is a communication network linking terminals and output devices in key
patient care or service areas to a central processing unit that coordinates all
essential patient care activities. Thus, the HIS provides a communication sys-
tem between departments (e.g., dietary, nursing units, pharmacy, laboratory);
a central information system for receipt, sorting, transmission, storage, and
retrieval of information; and a high-speed, data-processing system for fast,
economic processing of data to provide information in its most useful form.
The management of information in the hospital setting and its environs is
a critical component in the process of healthcare delivery. The problem of
information management has been complicated by an exponential increase
in the amount of data to be managed, the number of stakeholders in the pro-
cess, and the requirements for real-time access and response. In the United
States, 12% to 15% of the cost of healthcare is attributed to the costs asso-
ciated with information handling (Office of Technology Assessment, 1995).
The cost of information handling in the hospital setting has led to the use
of computers in an attempt to provide more data at lower costs. Estimates
of the costs of information handling vary between 25% and 39% of the to-
tal cost of healthcare (Jackson, 1969). Most health informatics professionals
agree that a reasonable expenditure on information systems in healthcare is
at least 3% to 5% of the operational budget for a health organization.

This chapter is based in part on previously published material [Hannah, K.J., &
Hammond, W.E. (1997). The evolution of clinical information systems. In: Ball, M.J.,
& Douglas, J. (eds.) Clinical Information Systems That Support Evolving Delivery
Systems. Redmond: Spacelabs.]

57
58 Nursing Use of Information Systems

Information systems currently being used in healthcare environments can

be broadly categorized into three types. The first type is composed of systems
that are limited in objective and scope. They most often exist as a stand-alone
module and address a single application area. Examples of such a system are
the nursing workload measurement systems currently being used in many
hospitals. The Medicus and GRASP systems serve a specific function and
therefore fall into this category of systems. In the hospital environment, sys-
tems commonly included in this category are dedicated clinical laboratory
systems, dedicated financial systems, and dedicated radiology, electrocar-
diography, pulmonary function, pharmacy, and dietary systems. In a public
health setting a stand-alone immunization system is a good example of this
category of systems.
The second type of information system is composed of hospital informa-
tion systems, which usually consist of a communications network, a clinical
component, and a financial/administrative component. The overall commu-
nications component integrates these three major parts into a cohesive infor-
mation system. A typical hospital information system in this category may
have computer terminals at each nursing station as well as terminals that
are in, or accessible to, each ancillary area in the hospital. The terminals are
tied together through one or more large central computers, which may be
on-site or off-site. Generally such systems are focused on acute care and are
organized around departmental functions.
The use of the third type of information system, enterprise health infor-
mation systems (EHISs), is expanding in health environments. Such systems
capture and store comprehensive patient information across the entire con-
tinuum of care in health organizations using integrated healthcare delivery
models. These records are captured and stored in multiple media including
audio, image, animation, and print. The records may be stored centrally, in
total or abstracted format, using a data warehouse approach. Alternatively,
these records may be physically stored at the point of capture and logically
linked to a virtual record that is physically assembled only when required
to meet care requirements. These systems are characterized by the fact that
they are focused on patients (rather than departments or disciplines) receiv-
ing care in multiple integrated settings (e.g., ambulatory care, acute care,
long-term care) having one common organizational structure (i.e., a single
enterprise). An expanded type of EHIS has emerged recently as the elec-
tronic health record (EHR) system. Several countries are moving toward
developing nationwide electronic EHRs.

Hospital Information Systems

Early computer applications for hospitals dealt with administration and fi-
nancial matters. Later applications included task-oriented functions such as
admission/discharge/transfer (ADT), order entry, and result reporting. With
 Enterprise Health Information Systems 59

the availability of minicomputers and finally personal computers, various de-

partmental service-related systems (e.g., laboratory, radiology, pharmacy)
were developed. Few if any of these systems were electronically connected.
The subsequent development of hospital information systems (HISs) was
a combination of factors related to technology (hardware and software),
people (developer and user), and economics.
An implicit assumption in the development of HISs is that the ability of
complete, accurate, timely data delivered at the point of care to the person
providing that care results in a higher quality of care at a more efficient
cost. Support for this assumption is provided by simple observation; for
example, such systems should eliminate redundant tests, eliminate the need
to reestablish diagnoses, increase awareness of drug allergies and adverse
events, increase awareness of the medications the patient is taking, and en-
hance communication among those involved with the patient’s care. There
are four main functions typical of such hospital information systems.
r Recognize both sending and receiving stations, format all messages, and
manage all the message routing (called message switching)
r Validate, check, and edit each message to ensure its quality
r Control all the hardware and software needed to perform the first two
functions
r Assemble transaction data and communicate with the accounting system
The first hospital computer systems developed during the late 1960s were
geared to batch accounting to meet the complexity of third-party billing, cost
statistics, and fiscal needs. The technology of that era was unsuccessfully ap-
plied to clinical systems. Terminal devices, such as cathode-ray tubes, were
expensive and unreliable. Also, hardware and software were limited, expen-
sive, and highly structured. Database systems that we take for granted today
had not appeared. During this period, some hospitals installed stand-alone
computers in clinical departments and in business offices to do specific jobs.
The most common clinical example is laboratory systems. Most of the hospi-
tals that embarked on these clinical programs for stand-alone systems were
large teaching institutions with access to federal funding or other research
grants. Usually there was no attempt to integrate the accounting computer
with the stand-alone departmental computers—this came much later.
The 200 and 400 bed hospitals that installed computers during the late
1960s for accounting had varied success. During that period accounting needs
became more complex, and this trend continues. The result is a constant
battle just to maintain and change existing systems to keep pace with reg-
ulating agencies. Many hospitals of this size turned to a shared computer
service such as Shared Medical Systems. The reason these companies pros-
pered was not only because of their products and services but also because
a small hospital simply cannot justify employing and retaining the technical
staff and management skills necessary for this complex, conflicting, changing
environment.
60 Nursing Use of Information Systems

During the early 1970s, with rampant inflation and restricted cost reim-
bursement, some large hospitals that had installed their own computers with
marginal success changed to the shared service. By this time, the shared com-
panies had better accounting software and audit controls. Most importantly,
these companies developed field personnel who understood hospital oper-
ations and were able to communicate and translate the use of computer
systems into results in their client hospitals. This added dimension of service
that is not offered or understood by the hardware vendors increased business
opportunities for the service companies. Many of these companies, in turn,
increased their scope of services beyond fiscal to clinical and communication
applications.
The hardware vendors of the 1960s (e.g., IBM, Burroughs, Honeywell,
NCR) committed themselves to large general-purpose computers that at-
tempted to support clinical, communications, and financial systems. During
the 1970s, technology such as the minicomputer and personal computer was
generally accepted as providing a better alternative to the approach than the
large general-purpose computer. In fact, the major hardware companies are
moving in this direction. During the same time frame, the service companies
began to develop on-site minicomputers to handle data communications and
specialized nonfinancial applications. They began to expand their scope of
data retention to support clinical applications that required a historical pa-
tient database. In other words, hospital information systems vendors and
service providers migrated toward a similar concept.
Current hospital information systems grew out of developmental work
that took place during the 1970s. Functional specifications, system design,
and technology selection were driven by the immediate problem at hand.
Hospital information systems were designed to deal primarily with the
problem of moving transaction-oriented data throughout an institution.
The business functions for which software applications were developed in-
cluded admission/discharge/transfer (ADT), order entry/result reporting,
and charge or cost capture. In most cases, administrative and financial per-
sonnel who had responsibility for the accounting systems controlled the
systems. Mainframe technology was utilized as the best hardware platform
for providing an extensive network.
Gradually, HISs evolved into communication networks linking terminals
and output devices in key patient care or service areas to a central process-
ing unit that coordinates all essential patient care activities. The difference
among systems that fall into this category is not in their communications
but in the complexity of the integration of their application functions. Some
systems have more sophisticated provisions for validating, checking, editing,
formatting, and documentation than others. Some respond faster and offer
a better variety of displays. These variations are differences in the communi-
cation and presentation aspects of the system. Other systems provide more
complex integration of the application structure and data retention. One
example of this is the total integration of information from the laboratory,
 Enterprise Health Information Systems 61

radiology, pharmacy, and medical records, which then interacts with the
nursing stations, providing communication from order entry to result re-
ports. Another difference in hospital information systems is the orientation
toward the data content: Some systems are oriented around the financial and
administrative data, and others are organized around patient care data. In
the latter case, administrative and financial data and functions are derived
from patient care information. More patient information, such as history,
physical examination, and progress data, is contained in these systems be-
cause they emphasize integration of direct clinical information.

Components of HIS
Administrative and Financial Modules
Accounts receivable, accounts payable, general ledger, materiel manage-
ment, payroll, and human resources applications are the minimum man-
agement functions required of the administrative and financial modules
of a hospital information system. At a minimum, accounts receivable con-
sists of charge capture for transmission to another system. Other accounts
receivable functions include utilization review; professional and technical
component billing; proration of revenue; corrections and late charges; ad-
justments and payments; account aging by method of payment, category of
patient and of physician, date of encounter, inpatient/outpatient, and date of
payment; and collections, including delinquent accounts reports, collection
comments, dunning letters, turnover letters, and collection agency reports.
Miscellaneous software applications are required to support other manage-
ment functions such as environment and energy control, marketing, fund
raising, and public relationships.
Departmental management functions include inventory control of sup-
plies, drugs, and perishables; item tracking of such things as specimens, charts,
and films; revenue and utilization statistics; word processing; electronic mail;
budget and monthly financial statements for use in variance analysis; work-
load analysis and personnel scheduling; and human resources and payroll.

Admission/Discharge/Transfer Modules
Admission/Discharge/Transfer is the core of any hospital information sys-
tem. At a minimum, this module must establish a patient record, provide
a unique encounter identification number, and document the place of en-
counter. Other functions include bed availability; call lists; scheduling; col-
lection of demographic data, referral data and reason for admission; precer-
tification; verification of benefit plan and ability to pay; and preadmission
orders and presurgery preparation procedures (Fig. 5.1).
The admission process includes updating preadmission/appointment
data; creating the hospital account number; collecting admitting diagnosis;
62 Nursing Use of Information Systems

FIGURE 5.1. Admission profile. (Photograph courtesy of Eclipsys.)

initiating concurrent review; notifying dietary, housekeeping, and human

services; collecting/initiating orders; notification of orders/requisitions; bed
assignment; notification of arrival to all interested parties; census with lo-
cators by patient name, identification number, account number, nursing
station, physician group (including primary, admitting, referring, and consul-
tant physicians); organizing work flow by data to be reviewed, reports to be
completed, and reports to be verified/signed; bed control; room charging in-
cluding variable services/room and multiple patients/day; concurrent review
including utilization, quality assurance, and risk management; transfering
the patient including bed control and discontinuing orders.
Pending discharge the process includes notifying the next admission,
preparing discharge medications, and contacting the home health provider.
At discharge the process includes verifying diagnoses and procedures, and
providing a discharge summary, patient instruction, and return appoint-
ments, as well as case abstracting, including diagnosis/procedure coding,
diagnosis related group statistics, and a retrospective review.

Order Entry Module

The order entry module is a module in a hospital information system (HIS) by
which doctors or nurses enter clinical orders or prescriptions using terminals
located in patient care areas. Orders are transmitted through the computer
system to the recipient for immediate implementation. Using this module,
 Enterprise Health Information Systems 63

errors at the time of input of the orders are theoretically minimized, and the
efficiency of data transmission in hospitals increases. Order entry can occur
at either the point of care or at a centrally located terminal. Increasingly,
caregivers are seeking systems that allow order entry at the point of care.
Order entry is a function common to almost all service departments in the
hospital. At a minimum, orders may be entered in a batch mode as a method
of charge capture. The full functionality includes initial order capture of pro-
cedure, urgency, frequency, scheduling (beginning date, time, and duration),
the performer, the ordering physician, and comments; order verification;
order sets; activation of preorders; checking for inappropriate orders in-
cluding frequency by patient, match to diagnosis, negated by medications,
and credential verification. Order follow-up includes looking up the patient
by requisition number, listing overdue pending orders and listing continuing
orders about to expire; initiating work, including insertion on work-to-be-
done list by service department and nursing station, print requisition, queue
for scheduling, and print labels; and entering any charge if billing on order
entry (Fig. 5.2).
An important capacity of the order entry system is the ability to provide
feedback to caregivers at the time they enter orders. For instance, at the
University of Tokyo Hospital, when a physician prescribes an inappropriate
dosage, the system provides a warning. The system also has the ability to alert

FIGURE 5.2. Order entry. (Photograph courtesy of Misys.)

64 Nursing Use of Information Systems

physicians when they order many clinical tests without sufficient justification.
Because the hospital is a teaching hospital, there are many young physicians
in training programs. The education and training of physicians are important
functions of the hospital. These interns and resident physicians often lack
professional self-confidence, are insecure in their clinical judgment, or are
excessively curious. Consequently, they tend to order more clinical tests
than are required by more experienced physicians. This has been a problem
from the financial perspective of the hospital because the insurance body
does not provide compensation for these excessive tests. The warning alert
on the order entry system had remarkable effects in this hospital, and the
number of clinical tests ordered decreased approximately 30% following
system implementation. The warning system was evaluated by interviewing
the users, and all agreed that the system gave them a chance to reconsider
the need for the clinical tests, which had some educational value (Fig. 5.3).

Result Reporting Module

Result reporting requirements vary markedly among departments. Mini-
mum result reporting consists of notification that a procedure is complete.
Other functionality includes canceling a procedure; entering a result includ-
ing flagging a process as complete and billing; entering the normal/abnormal
range (numeric, coded, or text); checking data for accuracy through edit ta-
bles and internal consistency such as delta checks; and reporting results in-
cluding immediate result reporting, flow sheets or graphs, related calculated
results, and physician prompts (Fig. 5.4).

Scheduling
Scheduling of admissions, surgery, outpatient encounters, and diagnostics
is critical for the smooth, integrated working of the healthcare facility. The
outpatient scheduling permits the preadmission ordering of tests and preop-
erative diagnostic assessments and coordinating the performance of those
tests and assessments with the admission. Effective management of the mix
of patients and length of time for encounters is facilitated by a good schedul-
ing system. Patient notification of pending appointments reduces no-show
rates.

Specialized Support for Clinical Functions

Software application programs are required to provide specialized support
for departmental services. Some examples are as follows.
r Clinical laboratory tasks include accession numbering, collection list, spec-
imen tracking, specimen logging, automatic capture of results from instru-
ments, and quality control: processing controls, calculation of means and
 Enterprise Health Information Systems 65

FIGURE 5.3. Order alert. (Photograph courtesy of Misys.)

standard deviation for a test, analysis of patient trends, technologist veri-

fication, check for drug/test interactions, and protocols (Fig. 5.5).
r Radiology tasks include result reporting (preliminary, final, amended re-
sults), electronic signature, reference file, and images of various types.
r Pharmacy tasks include verification of an order by the pharmacist, dual
result reporting by pharmacy (number dispensed) and nurse (number ad-
ministered), unit dose tracking (fills and returns), intravenous admixture,
and chemotherapy protocols.
r Nursing systems must provide nursing assessment, nursing diagnoses, nurs-
ing interventions, and care plans (including medication administration
records, nursing workload, and nursing note of client outcomes).
66 Nursing Use of Information Systems

FIGURE 5.4. Reporting results (Photograph courtesy of Health Vision.)

r Medical records require that the system provide a list of all diagnoses,
an encounter-oriented summary abstract, time-oriented summaries (flow
sheets), utilization review, and longitudinal studies (Fig. 5.6).
r Dietary tasks include meal planning, menu selection, food distribution,
inventory, ordering, nutrition management, and drug–food interactions.
r Consultation programs, which should be available, include bibliographic
retrieval, calculations, modeling, decision support systems, protocols, and

FIGURE 5.5. Laboratory applications. (Photograph courtesy of Sunquest.)

 Enterprise Health Information Systems 67

FIGURE 5.6. Medical documentation. (Photograph courtesy of Cerner Corporation.)

health knowledge bases such as the Physicians Desk Reference (PDR),

emergency procedures, and poison index.
r Critical care areas have special needs for electronic data capture to facili-
tate patient monitoring and charting.
r Patient support should include security, privacy, confidentiality of patient
data, information sheets for patient education and awareness, concern for
general patient welfare, reminders of appointments, admissions, tests, and
health maintenance reminders.

Issues Related to HISs

There were many problems encountered during the early implementation
efforts. The organizational discipline required to implement hospital infor-
mation systems was complicated by departmental priority differences and
sometimes departmental autonomy. Systems functions that support patient
care requirements, when given top priority, most often conflicted with exist-
ing administrative systems or at least could not communicate with these
legacy systems. Computers traditionally started in accounting, and most
hospital applications still have their roots in this area. The operations cycle of
patient care is continuous and instantaneous. Fiscal (financial and account-
ing) methodology and timing are intermittent and historical. To achieve
68 Nursing Use of Information Systems

successful utilization of information systems in healthcare, both these dis-

parate needs must be recognized and served.
As indicated previously, currently available, commercial hospital infor-
mation systems are built primarily around the framework of technologies,
design philosophies, and healthcare delivery models of the 1970s. As new
concepts and new technology have become available, these classic systems
have been modified, most usually on a superficial level, to accommodate
these changes. Most of these systems were designed with no thought of an
electronic patient record and certainly no concept of a longitudinal, cross-
sectoral, multidisciplinary, patient-specific record.
In fact, most of these systems, even today, retain only the data for a sin-
gle hospitalization and then for only a few months after discharge. The
primary orientation of these systems remains financially driven, problem-
focused, and task-oriented. These systems use a mainframe computer, a
central database, and character-based terminals. Few of these systems sup-
port a unified, multidisciplinary patient problem list and complete, integrated
studies and therapy data sets. Current systems are primarily an automated
form of the manual system for documenting hospital care. The design phi-
losophy reflects the flow of documents as the primary communication. The
traditional paper chart still exists in even the most computerized hospitals
of today. No major systems are known to exist in which all data and the
management of those data are fully computerized.
Major issues in healthcare delivery systems surfaced during the 1980s.
Most vendors moved into integrated distributed networking and shared
configurations. The initial expectations associated with general purpose com-
puters for developing hospital information systems were not met within the
time frame anticipated by early studies. Some of the reasons for this failure
to meet expectations are the following.

r The complex information and communication structure, which is required

to deliver patient care in hospitals, was grossly underestimated.
r The hardware and software of the 1960s, 1970s, and 1980s were grossly
inadequate, rigid, unreliable, and extremely expensive.
r The staffing requirements in terms of systems and data-processing profes-
sionals who could manage, define, communicate, and implement systems
in hospitals were grossly underestimated.

One more technological advance was necessary. The development of rela-

tional database management systems for use in patient care was imperative
for nursing to exploit the technology fully. As McHugh and Shultz (1982)
suggested:

Hospital nursing departments have followed the frozen asset path for their data
resources. Information contained in existing modular and turnkey systems cannot be
easily merged with other computer-stored information.
 Enterprise Health Information Systems 69

Experienced users of computers in business abandoned the traditional mod-

ular approach to computer file handling that is still being marketed by some
vendors to the healthcare industry. Database management systems have long
been available that can accomplish the following.
1. Reduce data redundancy
2. Provide quality data
3. Maintain data integrity
4. Protect data security
5. Interface relatively easily with technological advances
6. Facilitate access to a single integrated collection of data for many appli-
cations by multiple user groups

Enterprise Health Information Systems

Evolution of Health Enterprises
Most recently, healthcare organizations and health services delivery systems
internationally are under enormous pressure from all sides (Fig. 5.7). There
is a decrease in the revenue available to fund health services delivery; the
explosion of new treatments, new programs, and new technologies is ac-
companied by citizens’ increasing demands and expectations of their health

FIGURE 5.7. Pressures on National Healthcare Systems. (Adapted from Hannah KJ.
Transforming information: data management support of healthcare reorganization.
Journal of American Medical Informatics Association 1995;2:145–155.)
70 Nursing Use of Information Systems

system, reflected in such changing health services delivery modalities as man-

aged care; drug costs are rising; population demographics are characterized
by the rising average age; there is a shifting health services delivery paradigm
from acute care to community-based care; and employee expectations for
remuneration and compensation are resulting in rising labor costs. Simulta-
neously, there are expectations that the efficiency and effectiveness of health
services delivery will improve while the quality of care is maintained or even
improved.
For all these reasons, health services delivery systems around the world
are under enormous pressure to change. However, decisions about health-
care organizations and healthcare delivery systems must not be based on
opinion, emotion, historical precedent, or political expediency. Data and in-
formation are essential for rational decision-making and good management
of the health services delivery system in any country. The restructuring of
health systems worldwide must be based on data and information.
Health services, healthcare delivery systems, and health organizations
around the world are undergoing reorganization and reengineering. Ra-
tional decision-making about such activities must be based on information.
Historically, the field of medical informatics has focused on individual patient
care in acute care. Much less attention has been directed toward population-
based healthcare. Increasingly, the field is beginning to emphasize health
informatics, which has a broader multidisciplinary focus on health services
delivery including community needs assessment, population health status
indicators, health promotion, and disease prevention in addition to the treat-
ment of illness. Health informatics can and should play a major role in the
reengineering and restructuring that is occurring in many healthcare orga-
nizations and health services delivery systems. Many of the data presently
available are inadequate for these tasks; therefore, current data must be
transformed and future information requirements anticipated to support the
reengineering of healthcare enterprises and organizations. There are some
essential concepts.
r Reconceptualization of health services delivery within a jurisdiction as one
enterprise
r Use of information engineering techniques
r Development of a comprehensive information management strategy
r Need to apply information management principles
r Organizational implications of information management
r Conceptual model for achieving added value as a by-product from health
service delivery data
Enterprise health information systems (EHISs) can be conceived of as
tools intended for use by legislators, policy makers, managers, and care-
givers within a health organization to fulfill their responsibilities with re-
gard to the delivery of health services to the population being served.
New models for healthcare delivery (e.g., regionalized healthcare delivery
 Enterprise Health Information Systems 71

enterprises such as those found in the United Kingdom, South Africa,

and some Canadian provinces) and managed care such as is developing
in the United States have expanded the walls of the hospital and are re-
quiring the development of integrated health services delivery organiza-
tions (or enterprises) that involve the hospital, primary care, ambulatory
care, extended care facilities, the community, public health, and a multi-
disciplinary team of caregivers (e.g., traditional healers, physicians, nurses,
physiotherapists, nutritionists, dentists, social workers, educators, music ther-
apists, psychologists, speech therapists). This new vision encompasses the
concept of the electronic health record (EHR) that is patient-centered and
includes all data documenting a person’s contact with the healthcare or-
ganization. There is an evolution occurring from healthcare systems that
treat people only when they are ill to health enterprises that provide in-
tegrated services that support people’s activities to protect, promote, and
maintain their own health in addition to treating people’s illnesses. Health
service enterprises that provide integrated health services require an elec-
tronic health record (EHR). An EHR provides lifelong, multidisciplinary
information to document health promotion and protection indicators as well
as illnesses. All these changes require an altered approach to information
management.

The Future
Future health information systems in jurisdictions responsible for
comprehensive integrated health services must take into the account the
fundamental principle that the reason a healthcare delivery system exists
in any jurisdiction is to provide health services to its citizens. Thus, systems
to support the functions of clinical and diagnostic departments as well as
administrative and managerial information for use in operating the health-
care delivery enterprise should be a by-product of the care delivery process.
The focus is, and must continue, to shift to information management and
systems that are centered on the recipient of the care. One can envision a
future environment in which current information about health facilities and
healthcare delivery systems for use in enterprise planning and policies, as
well as resource allocation and utilization, is much more widely available to
the professional care providers than in the past.

Responsibilities
The responsibilities related to operating a health services delivery system,
that is, a comprehensive health services enterprise, within a jurisdiction
(community, state/provincial, national), can be summarized into the follow-
ing functional categories.
72 Nursing Use of Information Systems

r Assess the health status of the population

r Set health goals and objectives
r Set strategic directions
r Provide programs and services
r Communicate with stakeholders
r Manage resources
r Evaluate the health services delivery system
Such a comprehensive health services delivery enterprise in a jurisdiction
requires a health information system that is defined in the broadest and
most inclusive fashion possible. It should include the data and the most
rudimentary media for gathering the data (e.g., pencil and paper) as well
as all possible means of storing, processing, aggregating, and presenting the
information. A jurisdictional health information system also should include
the people who interface with the system, specifically those who are involved
in certain areas.
r Those who generate the data (i.e., the recipients of care and the caregivers)
r Those who use the data in its various forms (i.e., caregivers, health systems
managers, policy makers, legislators)
r Those who maintain the data and the means by which it is captured, stored,
processed, aggregated, and presented (e.g., data gatherers, filing clerks,
forms analysts, data entry clerks, computer operators, network managers)
The decisions facing health services enterprise managers are more com-
plex than decisions faced in the past.
r Decisions are patient-focused rather than discipline focused. The concept
of multidisciplinary teams is increasingly being used within healthcare
delivery, resulting in data that focus on the recipient of care rather than
the provider of care.
r Previously, decisions within the healthcare delivery system have been
focused within specific service sectors (acute care, public health mental
health, long-term care, insured services) but now are becoming focused
within jurisdictions (community, state/provincial, national), geographic ar-
eas that require a cross-sectoral perspective.
r Decisions affecting the entire health services enterprise require informa-
tion about that enterprise.
r Decisions affecting even a part of the health services enterprise still require
information about other parts of the health services enterprise because
of the impact of interdependence among the sectors; for example, early
discharge programs in the acute care sector have a major impact on the
home care delivery sector.
r Decisions to reduce expenditures on health services while maintaining
the quality and maximizing the benefits to the health of citizens require
information about the outcomes of health services. There is a need to know
whether what is done for, with, or to a client makes any difference in the
health status of that client.
 Enterprise Health Information Systems 73

The role of the professional care provider (e.g., physicians, nurses, den-
tists, physiotherapists) in managing information in healthcare facilities is, of
necessity, related to the role of the caregiver in the organization. In most
healthcare delivery facilities, it is necessary to manage both patient care and
the patient care environment in the organization. Usually, caregivers man-
age patient care, and managers administer the organization. Therefore, for
some time the caregiver’s role in the management of information gener-
ally has been considered to include the capture and use of the information
necessary to manage patient care, and caregivers have also been expected
to provide the information necessary for managing the organization (e.g.,
resource allocation and utilization, personnel management, planning and
policymaking, decision support). This dual responsibility has generated an
increasing burden on caregivers to provide information because of the re-
dundancy and duplication of information they are expected to provide.
Healthcare delivery is information-intensive. Caregivers handle enormous
volumes of patient care information. In fact, caregivers constantly process
information mentally, manually, and electronically. In every aspect of patient
care, caregivers are continually engaged in problem-solving using clinical
judgment and decision-making: assessing; identifying patient problems and
diagnoses; determining appropriate action or interventions: evaluating;
and reassessing and communicating. Care providers integrate information
from many diverse sources throughout the organization to provide patient
care and to coordinate the patient’s contact with the health system. They
manage patient care information for purposes of providing care to patients.
An implicit assumption in the development of Enterprise Health Infor-
mation Systems is that the ability to deliver complete, accurate, timely data
at the point of care to the person providing that care results in a higher qual-
ity of care at a more efficient cost. Support for this assumption is provided
by simple observation; for example, such systems should eliminate redun-
dant tests, eliminate the need to reestablish diagnoses, increase awareness of
drug allergies and adverse events, increase awareness of the medications the
patient is taking, and enhance communication among those involved with
the patient’s care.
Modern healthcare delivery generates massive volumes of information
that must be collected, transmitted, recorded, retrieved, and summarized.
The problem of managing all these activities for clinical information has
become monumental. As a result, computer-based hospital information sys-
tems (HISs) were designed, tested, and installed in hospitals of all sizes. The
original purpose of HISs was to provide a computer-based framework to
facilitate the communication of information in a healthcare setting.

Enterprise-Wide Information Systems

In most countries, the model for healthcare is moving toward integrated
delivery systems (Fig. 5.8). This process could be enhanced by developing
74 Nursing Use of Information Systems

FIGURE 5.8. Enterprise-wide integrated delivery systems service entire hospitals.

(Photograph courtesy of Sunquest.)

an electronic health record (EHR) that supports the patient, the primary
care provider, physician, nurse, other caregivers, and hospital or other criti-
cal care setting. It also supports pharmacies; nursing homes; nursing; home
healthcare; payers; federal, state or province, and local authorities; accred-
itation and quality assurance agencies; and others. All these stakeholders
must be integrated into a single, distributed system for maximum return on
investments in information management systems. Requirements include the
physical network to support such integration; an infrastructure to manage
and regulate such a structure; standards for data interchange; a common
data model defining the objects to be transmitted; a common, clinically rich
vocabulary; and processes (or methodologies) for information gathering and
aggregation. Above all, appropriate security must be built into such a sys-
tem or network to ensure that the confidentiality and privacy of individual
records is appropriately respected and protected.
Future systems must reflect the major paradigm shift in health services de-
livery models. The underlying philosophy must be patient-centered: What
are the requirements of a system whose primary purpose is to provide the
mechanism for the most effective, efficient, and economical care possible
for people receiving health services? Rather than using the computer to
improve the current paper-oriented systems, new systems must answer the
question: Given the power of modern computation devices with massive
storage and ubiquitous network linkages, graphics interfaces, image display
capabilities, capacity for vast and instant data analyses, and personalization
of function, what can and should the healthcare information system of tomor-
row provide? Much of the functionality of current systems is still required.
The transmission of orders, processing of orders, and reporting of results
remain. Functional requirements of ADT, scheduling, department service
 Enterprise Health Information Systems 75

management, supply replacement, inventory, materials management, and

documentation remain as well. Quality assurance should occur in real time,
rather than recognizing days later that something was overlooked or a mis-
take was made.
As early as an International Medical Informatics Association (IMIA)
Working Group 10 workshop on Hospital Information Systems in 1988,
Collen stated that the goal of a hospital information system should be to
. . . use computers and communications equipment to collect, store, process, retrieve,
and communicate relative patient care and administrative information for all activi-
ties and functions within the hospital, its outpatient medical offices, its clinical support
services (clinical laboratories, radiology, pharmacy, intensive care unit, etc.), and with
its affiliated [health] facilities. Such an integrated, multi-facility, [health] information
system should have the capability for communication and integration of all patient
data during the patient’s service life time, from all of the information subsystems
and all facilities in the medical system complex; and to provide administrative and
clinical decision support.

This statement is important because it recognizes that clinical information

is not the property of a single facility but, rather, is part of a global resource
that focuses on the patient-centered record.
Hospital information systems and the concepts underlying them are lim-
ited because they focus primarily on operational information and not on a
comprehensive patient record. An EHR is one component of a larger EHIS
that includes not only hospital functionality but also features of a compre-
hensive integrated delivery system. The concept of the EHR is just beginning
to emerge in some countries, notably Australia, the United Kingdom, and
Canada. At the time of this writing, multiple definitions of EHR abound
in the international community, and there is no solid consensus on a single
definition. The International Standards Organization (ISO) Technical Com-
mittee on Health Informatics (TC215) defined EHRs for integrated care
environments as (ISO, 2004):
. . . a repository of information regarding the health status of a subject of care in com-
puter processable form, stored and transmitted securely, and accessible by multiple
authorized [sic] users. It has a standardized [sic] or commonly agreed logical informa-
tion model which is independent of EHR systems. Its primary purpose is the support
of continuing, efficient and quality integrated healthcare and it contains information
which is retrospective, concurrent, and prospective.

Using anonymized information from an EHR, an EHIS can incorporate

the use of aggregated health data for use in the management of the health ser-
vices delivery system (i.e., assessing population health status, setting health
goals and objectives, defining strategic directions, program planning and de-
livery, and resource allocation).
Health service enterprises in national jurisdictions are able to exploit tech-
nological advances because of the networks that have become available.
Now the system is the network and the network is the system. Networks
76 Nursing Use of Information Systems

are enablers that allow health service enterprises to be virtual organizations.

Until recently, the various communication barriers imposed by distance and
time made concrete physical organizations essential and dictated manage-
ment structures partitioned to allow each individual geographic facility to be
managed independently. Today, management of virtual health enterprises is
possible because the technology ties the various component health facili-
ties together with communication networks. Distance, time, and location all
become almost irrelevant.
A patient-centered EHR requires that all data relating to the patient
and the patient’s well-being must be available at all times and accessi-
ble at appropriate locations. Data from all relevant sources must be inte-
grated into a single record including but not limited to demographic data,
data related to health determinants, and risk factors, along with diagnostic
and treatment data from all contacts with the health enterprise (e.g., pri-
mary care providers; all members of the multidisciplinary healthcare team;
home care; public or private acute care, long-term care, mental health fa-
cilities). This record is likely to take the form of a virtual record and may
well be stored in a variety of locations. Initial efforts at exploring such a
concept are underway in several countries, although experience with EHRs
over large geographic areas and numerous locations across multiple juris-
dictions are limited. Initial prototypes or pilot projects are beginning to be
reported in Germany, Taiwan, Europe, the United Kingdom, Australia, and
Canada.
A common problem list, a complete drug profile, and patient allergies
should be centrally stored, maintained, and accessible. Data must be readily
shared among all the providers of care. The patient’s record must be a life-
time record, extending before birth to after death. The new EHRs eventually
will contain character-based data, image data, waveforms, drawings, digital
pictures, motion videos, and voice and sound recordings. The networks ty-
ing these systems together must have a wide bandwidth to accommodate
the volume of data, which must be exchanged in real time among providers
at diverse locations. Initially, Internet or electronic mail could provide easy
linkage among the providers requesting consultation and discussing a pa-
tient’s care. A clinically rich common medical and health vocabulary whose
major purpose is communication must be developed, accepted, and used
by all stakeholders. Confidentiality and privacy issues must be adequately
supported with patient consent for the sharing of data.
The new systems must support source data capture, most specifically by
primary care providers (e.g., midwives, nurses, physicians, dentists, acupunc-
turists, traditional caregivers, psychologists, social workers). Ideally, decision
support systems would also be available at or near the point of care. Most
computer support algorithms are useful only if they are interactive with the
person making the clinical decision at the time of decision-making. Worksta-
tions customized for physicians, nurses, and other clinical caregivers as well
as administrators and researchers are mandatory for tomorrow’s systems.
 Enterprise Health Information Systems 77

The move toward managed care increases the need for informed, algorith-
mic driven order sets or regimens. Decision support systems, operating in
the background, can save much money as well as improve patient care. As
an example, a typical physician session involving ordering tests and pre-
scribing treatment may typically invoke several thousand decision rules.
These decision rules must be standardized and shared by the international
community.

Prerequisites for EHISs

A prototype for an EHIS incorporating a multimedia, lifelong, multisite com-
puterized patient record was designed and implemented at the University
Hospital in Grosshadern, Germany. The following sections describe its es-
sential design elements.

Data Model
The data model describes the medical concepts (e.g., blood pressure) that
can be recorded in the electronic patient file and handled by the patient
record system. The concepts are based on technical objects (e.g., figures,
tests, video) whose properties and relationships are explicitly defined in a
data object dictionary.

Presentation Types
Medical items must be modified, displayed, and communicated. A set of ba-
sic methods allows the manipulation, presentation, and communication of
medical items that are controlled by a large number of parameters. Presen-
tations must be adapted to the specialized needs of individual patient care
environments and their corresponding requirements. Examples of presen-
tation types include, but must not be limited to, forms, graphs, images, text,
and audio.

Communication
The computerized medical record in an EHIS environment requires stan-
dardized protocols (e.g., HL7, EDI, EDIFACT, DICOM) for exchange of
data among systems.

Interpreter
An interpreter provides analysis, presentation, and communication of pa-
tient data in the computerized patient record system. While global com-
munication techniques make the creation of telemedicine (EHIS) records
78 Nursing Use of Information Systems

possible, there are still major barriers, notably the absence of data and com-
munication standards and the lack of public acceptance (see Chapter 8 for
more discussion).
Experience in Canada, beginning in 2001 under the auspices of Canada
Health Infoway Inc. (Infoway), has seen the foundations laid for a national
EHR. The mandate is to provide the necessary national information in-
frastructure for a pan-Canadian EHR. To that end, Infoway has developed
a national EHRS Blueprint (Canada Health Infoway, 2003), conducted a
Standards Needs Analysis (Canada Health Infoway, 2004a), and launched
a Standards Collaboration Process. It has also initiated six projects that
will provide the foundation for the Canada-wide EHRS, specifically Reg-
istries, Drug Information Systems, Diagnostic Imaging Systems, Laboratory
Information Systems, Public Health Surveillance Systems, and Telehealth
(Canada Health Infoway, 2004b).
In the United States, driven by patient safety concerns, a series of re-
ports from a variety of organizations and groups (DHHS, 2004; Institute of
Medicine, 1997; PITAC, 2001, 2004) resulted in commitment to the national
health information infrastructure (NHII) in the United States in 2002. The
NHII has the following features (National Comittee on Vital and Health
Statistics, 2001).

r It is an initiative set forth to improve the effectiveness, efficiency, and

overall quality of health and healthcare in the United States.
r It is a comprehensive knowledge-based network of interoperable systems
of clinical, public health, and personal health information that can improve
decision-making by making health information available when and where
it is needed.
r It includes a set of technologies, standards, applications, systems, values,
and laws that support all facets of individual health, healthcare, and public
health.
r It is voluntary.
r It is NOT a centralized database of medical records or a government reg-
ulation.

Thus, as illustrated by the preceding examples, EHISs must have a broad

multidisciplinary focus on health services delivery, including community
needs assessment, population health status indicators, health promotion,
and disease prevention, in addition to the treatment of illness. EHISs can
and should support the reengineering and restructuring that is occurring in
many healthcare organizations and health services delivery systems. Many of
the data presently available are inadequate for these tasks; therefore, current
data must be transformed and future information requirements anticipated
to support the reengineering of healthcare enterprises and organizations
using EHIS.
 Enterprise Health Information Systems 79

Producing Value-Added Information

Future EHISs must take into the account the fundamental principle that the
reason a healthcare delivery system exists in any jurisdiction is to provide
health services to its citizens. Thus, administrative and managerial informa-
tion for use in operating the healthcare delivery enterprise should be a by-
product of the care delivery process. One can envision a future environment
in which current information about health facilities and healthcare delivery
systems for use in enterprise planning and policies as well as resource al-
location and utilization must be more widely available to professional care
providers than in the past.
As reengineering or restructuring proceeds, information products are of
interest to health system decision makers.
r Residents: information about the health needs and health status of the
population, their families, and communities
r Recipients: information about residents receiving services from the health
services enterprise
r Providers: information about available persons and organizations with
health service skills (health workforce)
r Services: information about the range of health-affecting interventions
and activities available in the health system
r Programs: information about the objectives, target recipients/populations,
resource allocation, and bundling of particular sets of services
r Resources: distribution of fiscal (financial), physical (facilities and equip-
ment), human (people working within the health services enterprise), and
information resources
r Utilization: use of resources by the provider of the service, the recipient
of the service, the program, and the type of service

Impact of EHISs
The impact of EHISs, which provide healthcare information over wide areas
in a secure manner, is profound. Such availability potentially allows data
mining of information that are advantageous for both patient and physician.
r Using the information to discover and analyze associations between dis-
ease entities and previously unknown risk factors (recorded in the patient
history)
r Testing hypotheses regarding putative risk factors or studying disease dis-
tribution using demographic data
r Enabling a physician to perform a comparative analysis of a particular
patient’s symptoms with the symptoms of other patients with similar or
different diseases
80 Nursing Use of Information Systems

r Allowing more intelligent video consultations (During these consultation,

along with the video, specialists in multiple locations could simultaneously
see and annotate a patient’s record.)
r Improving the outcome analysis
r Gathering decision support information
r Providing better education of patients to manage their own health

As we move into a new century, the major problems hospitals have expe-
rienced with hospital information systems can be resolved if the emerging
health enterprises learn from the experiences of others. They must realisti-
cally address the following issues.
r The complex information and communication structure related to patient
care can be improved by redesigning and reengineering the functions and
processes of institutions to capitalize on the efficiencies permitted by mod-
ern information management techniques and equipment.
r Involve caregivers (including nursing) in the design and implementation
stage.
r Every health enterprise should develop a strategic business plan that pro-
vides the foundation for its information management strategic plan. The
information management strategic plan is implemented using tactical and
operation plans.
r The development of client/server architectures and graphical user inter-
faces, working with powerful database software and proven application
software that is flexible, can now be reasonably implemented.
r Staffing continues to be a major problem. Our academic institutions must
address the need for health informatics preparation at all levels of educa-
tion: undergraduate, graduate, and continuing education.
r With the arrival of reliable software and more graphical user interfaces,
the use of information management technology can be expected to benefit
the patient.

As we look toward enterprise information systems from the perspective

of where health informatics has been, where it is now, what we have learned,
and where we are heading in this new century, there is no doubt that the
following observations are true.
r Nursing will play a major role in EHIS development.
r Information management, as applied to a wide variety of healthcare disci-
plines, is a proven reality and will continue to expand during the foresee-
able future.
r Financial data processing has been the mainstay in hospital computing but
is rapidly being superseded by clinical, administrative, management, and
educational applications. In the future, the core of EHISs will be patient
care data, with all other uses being value-added reprocessing of these
data.
 Enterprise Health Information Systems 81

r The introduction of client/server architectures and networks to the health

arena is revolutionizing the older concepts of centralized data processing.
r Real-time distributed use, in conjunction with central data storage, data
warehousing, or infomart technology, will continue as a rapidly growing
trend.
r Cost of hardware has decreased, making new options for the user increas-
ingly feasible. Indeed, major technological changes will influence the entire
medical and health science professions.
r Advances in technology will enable the use of multiple media to capture,
store, and retrieve data and information
r Government policy statements will lead to further growth and support of
health informatics. This has further implications for information manage-
ment regarding rural medicine.
r A final prediction is that during the coming decade, caregivers, including
nurses, will have portable, handheld, personal, digital telecommunications
devices that enhance productivity by their capacity to access information
and navigate through databases in remote geographic locations.
Advantages for nurses accruing from the use of an EHIS include the
following.
r It is time-saving by reducing clerical activities, telephone calls between
departments, and hand-written information transfer.
r Continuity of care through the current and status documentation is avail-
able on the system for the nurse.
r There is elimination of duplicate effort and more effective use of personnel,
providing financial savings for the patient and time-saving for the nurse.
r Patient records and data for patient care, quality assurance, and research
are more complete.
r Evidence-based nursing practice is enhanced because of the greater accu-
racy and speed of information transfer.
r The scope of nursing practice is expanded.

Time saved from manual information-processing tasks provides more time

for the nursing process. More complete patient records, greater accuracy,
and the increased speed of transferring information facilitate the nursing
assessment and enhance patient safety by reducing communication errors.
More effective use of personnel, continuity of care, support for evidence-
based nursing practice, and the expanded scope of nursing practice can only
result in better quality care for patients.

Summary
Countries around the globe are searching for ways to improve the deli-
very of healthcare and reduce the costs connected with providing this care
82 Enterprise Health Information Systems

simultaneously. The ultimate goal of sustaining and improving the health

status of the population of a local state, national, or even international com-
munity purportedly guides all such efforts. An interesting phenomenon asso-
ciated with the changes being undertaken in a number of healthcare systems
emerges when even cursory comparisons of various attempts are drawn. Var-
ious countries demonstrate remarkable differences in approach, sometimes
even adopting strategies that seem to move their healthcare systems in oppo-
site directions (e.g., health reform initiatives in the British National Health
Services, Canadian provincial healthcare systems, and the United States are
striking examples). Yet these initiatives and many others claim to support
improved healthcare and health status among their respective populations.
The common goal is “health for all.” However, if health systems are changing
in different ways for the same reasons, can all the strategies for change be
effective? How can they be evaluated? How can the outcomes of the health
systems and health services be evaluated? Previous concepts of the scope of
a hospital information system must change along with changes in the health-
care process and the restructuring of national and regional health systems.
The functionality presently provided by such systems merely provides a base
for beginning the development of the health information systems of the fu-
ture. Information is key, and information systems are essential for enabling
and informing the delivery of health services and for the effectiveness of
national health systems.

References
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Canada Health Infoway. (2004a). Standards Needs Analysis. http://www.
canadahealthinfoway.ca/home.php?lang=en (accessed December 15, 2004).
Canada Health Infoway. (2004b). Coming Together 2003–2004 Annual Report. http://
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M.J., Scherrer, J.R., & Willems, J.L. Towards new hospital information systems.
Amsterdam: North Holland. p. 3
International Standards Organization. (2004). Health Informatics—Electronic
Health Record—Definition, Scope, and Context. TR 20514.
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Jackson, G.G. (1969). Information handling costs in hospitals. Datamation 15:56.
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National Committee on Vital and Health Statistics. (2001). A Strategy for Building the
National Health Information Infrastructure. Washington, D.C.: U.S. Department of
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Health and Human Services. http://aspe.hhs.gov/sp/nhii/Documents/NHIIReport

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tionizing HealthCare Through Information Technology. Arlington, VA: National
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Additional Resources
Adelhard, K., Eckel, R., Holzel, D., & Tretter, W. (1996). Design elements of a
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sium, pp. 473–477.
Alvarez, R.C., Curry, J., Hodge, T., Chatwin, B.J., & Hannah, K.J. (1992). A provincial
health information processing strategy: a case study. In: Lunn, K.C., Degoulet, P.,
Piemme, T.E., Reinhoff, O. (eds.) Medinfo ’92 Proceedings. Amsterdam: North-
Holland.
Ballardini, L., Mazzoleni, M.C., Tramarin R., & Caprotti, M. (1996). Remote manage-
ment of a cardiac magnetic resonance imaging session by a low cost teleconsulting
system. In: Cimino, J.J. (ed.) Proceedings, AMIA Fall Symposium, p. 825.
Chang, I.F., Suarez, H.H., Ho, L.C., Cheung, P.S., & Ke, J.S. (1996). Nationwide
implementation of telemedicine and CPR systems in Taiwan. In: Cimino, J.J. (ed.)
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Donsez, D., Tiers, G., Modjeddi, B., & Beuscart, R. (1996). Improving the continuity
of care: The ISAR–Telematics European Project. In: Cimino, J.J. (ed.) Proceedings,
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Forslund, D.W., Phillips, R.L., Kilman, D.G., & Cook, J.L. (1996). Experiences with a
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Fall Symposium, pp. 483–487.
Hannah, K.J. (1995). Transforming information: data management support of health-
care reorganization. Journal of the American Medical Informatics Association
2:147–155.
6
Nursing Aspects of
Health Information Systems

Motivation for the development and implementation of computerized hos-

pital information systems has been financial and administrative (i.e., driven
by the need to capture charges, reduce costs, and document patient care for
legal reasons). Most of the systems marketed today have been motivated by
those two factors. Historically, such systems have required a major invest-
ment in hardware (typically a mainframe and networks); and even though
they have demonstrated significant improvement in hospital communica-
tions (with a corresponding reduction in paper flow), they have been char-
acteristically weak in supporting professional nursing practice. These factors
have prevented the level of acceptance by nurses that was originally fore-
seen. Only recently have developers and vendors begun to consider the na-
ture of modern nursing practice and its information-processing requirements
(Fig. 6.1).
If one considers the original principles that Campbell (1978) identified
when observing the activities nurses perform when caring for patients, nurs-
ing roles fall into three global categories. The first is managerial roles or
coordinating activities that involve the gathering and transmission of pa-
tient information, such as order entry, results reporting, requisition gen-
eration, and telephone booking of appointments. Although many of these
activities have been delegated to unit clerks (at least on day shifts), cur-
rent hospital information systems can help nurses with those activities.
The second category is physician-delegated tasks. Current systems can cap-
ture these tasks from the physicians’ order entry set and then incorporate
them into the patient care plan. The third category is autonomous nurs-
ing function, characteristic of professional nursing practice, when knowl-
edge unique to nursing is applied to patient care. Current systems are
beginning to support nurses in fulfilling their responsibilities in this cate-
gory. All three categories—managerial/coordinating, physician-delegated,
autonomous nursing function—must fit together to create a fully opera-
tional system. Current systems, although they release nurses to focus on
professional nursing practice, fail to provide the appropriate support essen-
tial to professional nursing practice. The future requires decision-making

84
 Nursing Aspects of Health Information Systems 85

FIGURE 6.1. Evolution of nursing information systems.

support for professional nursing practice and the capture of information

from the patient care plan for nursing administration decision-making re-
lated to nursing resource allocation.

Nursing Management Information Systems

From an economic point of view, the combination of the shrinking healthcare
dollar and escalating healthcare costs makes it imperative that the produc-
tivity issues associated with nursing dollars spent be considered. To that
end, nurse managers must ensure that appropriate nursing information is
incorporated into any management information system. The major objec-
tive of such systems is the provision of information on which decisions can
be based that effectively and efficiently allocate nursing resources for the
highest quality of patient care. Nursing management information needs to
integrate the clinical data about patients that ultimately affect the cost of
providing patient care. Historically, nursing costs have never been reliably
projected because they did not incorporate fluctuating patient acuity levels
and the associated needs for nursing care. Based on the integration of pa-
tient clinical data, some current systems now have the capacity to ascertain
costs of nursing care for individual patients. This costing must incorporate
multiple components such as quality and workload measurements, financial
considerations (payroll and general ledger), and staff utilization as well as ed-
86 Nursing Use of Information Systems

ucational and professional qualifications, contractual obligations, and costs.

Such a nursing management system enables the development of productivity
standards by which one can compare patient care outcomes as well as vari-
ance analysis, which enables the manager to rationalize deviations from the
budget. Furthermore, when the nursing costs associated with patient type
are accurately and reliably quantified, such a system has great potential in
forecasting and long-range planning. This ability has potential for healthcare
planning that incorporates costs associated with patient care groupings. On
an operational level, the nursing management information system includes
human resource capabilities such as staff profiles, educational credentials,
professional licensure status, and scheduling, all of which facilitate effective
development and deployment of nursing resources.
The overall goal must be the development of comprehensive, integrated
nursing management information. Such information may reside in a separate
system or be contained in an integrated management information system.
In any case, it must clearly identify, sort, and analyze uniquely nursing infor-
mation. Such a system must have the capacity to integrate with, and build
upon, a variety of hospital information systems. In addition, systems gen-
erating nursing management information must capitalize on the distributed
processing concepts as well as the communication capacity of networks and
the power of client-server architecture to provide clinical workstations for
decision support. Achieving such a goal requires the application and use of
existing technology in an innovative manner. These concepts are elaborated
in Chapter 9.

Clinical Nursing Documentation

Clinical documentation is an essential part of the healthcare delivery system,
with a wealth of information residing in the documentation compiled at each
patient encounter. The current process of gathering and using this informa-
tion is such that documentation is fragmented rather than synergistic, and its
potential to improve the delivery of healthcare and clinical outcomes is not
being realized. The application of information technologies in healthcare has
the potential to transform clinical documentation into an integrated, multi-
disciplinary tool with the prospect of improving clinical outcomes and en-
hancing the overall healthcare environment. Several healthcare institutions
have begun to implement technology-enabled clinical documentation solu-
tions and are experiencing positive outcomes. Building on these experiences,
the approach to clinical documentation that holds the greatest promise lies
in the implementation of an integrated, multidisciplinary, patient-centered
electronic health record, with provider order entry and a problem-driven
approach at its core.
Developments in nursing informatics must assist nurses in the gather-
ing and aggregating of clinical nursing data to make decisions related to
 Nursing Aspects of Health Information Systems 87

the nursing care of patients. Modern nursing practice no longer focuses on

the assessment and labeling phase of the nursing process (i.e., defining the
nursing diagnosis, nursing problem, or nursing phenomenon). Instead, it
emphasizes decision-making and exercising clinical nursing judgment in pa-
tient care. Because of the growing complexity of patient care and the rising
acuity level of patients in hospitals today, nurses have acquired an expanded
repertoire of intervention skills. These skills reflect the autonomous aspects
of nursing practice that are based on the body of nursing knowledge and
the nurse’s professional judgment. Autonomous nursing interventions are
complementary to, not competitive with, physician-prescribed treatments.
The major objective in this section is to discuss the evolving role of clin-
ical documentation and to show how the application of information tech-
nologies can lead to a new paradigm, integrated and multidisciplinary in
nature, that can ultimately transform the quality and continuity of patient
care.

Definition and Role of Documentation in Clinical Care

According to The Compact Oxford English Dictionary (Second Edition)
1993, to “document” means to show proof; give evidence. Clinical docu-
mentation, therefore, is written evidence of the following.
r Interactions among members of the healthcare team
r Administration of assessments, tests, procedures, treatments, and patient
education
r Results or evaluation of a patient’s response to diagnostic tests and inter-
ventions
r Outcomes, or expected outcomes, of the patient’s interaction with, and as
a part of, the plan of care

The task of completing documentation in highly complex healthcare en-

vironments poses a significant, often unmanageable challenge and has be-
come the root cause of many patient safety issues and other problems. Busy
physicians may not view and access nurses’ notes as critical data. Busy
nurses may not have time to read the physicians’ notes. Moveover, infor-
mation entered into the patient record by other healthcare professionals is
seldom integrated into the physician and/or nursing documentation. This
lack of integration of multidisciplinary documentation leads to a less-than-
perfect care plan for the patient. Data generated by one group of healthcare
providers—especially nurses—that is of significant interest to another group
of providers—especially physicians—needs to be made easily accessible.
Areas of common interest to a number of clinicians regarding patient care
include vital signs, intake/output, Kardex/care plan data, and the medication
administration record. Narrative notes, which capture patient information
88 Nursing Use of Information Systems

essential for decision-making, still comprise most of the patient record and
is the area most seriously in need of improvement.
One of the challenges of healthcare documentation is that the primary
purpose or intention behind documentation is the clinicians’ need to fullfill
explicit requirements about what and when items should be documented
to show that a standard of care was met. The patient’s clinical record
is the best defense against litigation involving malpractice or negligence.
Nurses, physicians, and the rest of the healthcare team contribute signif-
icantly to meeting the regulatory requirements of federal and state reg-
ulatory agencies, payers, accreditation organizations, healthcare consumer
groups, and legal entities. Utilizing documentation as a tool that promotes
patient-centric communication and care coordination at the same time one
is documenting to protect the hospital, physicians, and nurses makes it
difficult to keep the patient’s immediate needs in mind. A computerized,
longitudinal patient record enables clinicians to meet both purposes (see
Chapter 5).
In the current, fragmented, fast-paced, healthcare environment, the elec-
tronic patient record (EPR) takes on primary importance as a communi-
cation tool among members of the healthcare team. To be effective in this
environment, the record must be easily completed and organized. It should
facilitate teamwork and integration of clinical care workflow among all dis-
ciplines involved and allow real-time entries so diagnosis and treatment
happen in a safe and timely manner.
Most attempts to computerize clinical documentation have done little
more than mimic paper documentation on a computer. In the information
age, documentation ought to be driven by the nature and content of the
information itself and to best support a patient-centric work process. In the
information age, the only limitations to moving from documentation as a
burdensome, redundant task to documentation as a tool that enables clinical
judgment and decision-making for quality care are lack of imagination and
practicality.
Knowledge-based documentation contains content that enables clinicians
to utilize current or best practice clinical research as part of their documen-
tation work process. When one documents, one uses critical thinking skills
to review information that is in the record and to analyze data and arrive
at conclusions. Many times the output of this analysis is an order for assess-
ment or interventions or the decision to monitor for signs and symptoms of
a potential complication. Clinical documentation is embedded in the clini-
cian’s work process. Expert practitioners can always tell what information
they need to care for patients. They also know how they would like to see
that information and what reference material or reminders would be best to
assist them in ensuring that the standard of care is met. Clinical information
is, in fact, distinct from the medium through which it is recorded and can
truly serve the patient’s—and the healthcare worker’s—best interest only
when it is treated as such.
 Nursing Aspects of Health Information Systems 89

Documentation Style Document Type

care plan

narrative physician's progress note

discharge summary
flow sheet charting by exception history and physical
nurse's shift assessment
list operative note
care path

problem-oriented
focus charting

source-oriented time-oriented

proprietarily organized

Organizational Scheme

FIGURE 6.2. Forms of documentation according to their function.

Documentation Approaches
Some document approaches are document types, some are documentation
styles, and some are combinations thereof, as illustrated in Figure 6.2 (Ball
et al., 2004).
Popular documentation approaches include the following.
r Charting by exception
r Narrative
r Flow sheets
r Source of origination (e.g., laboratory, respiratory therapy)
r Problem-oriented
r Focus charting
r Care plan
r Critical pathways, protocols, collaborative problems
There are overlaps in documentation styles and organizational schema
between and among nurses.

Nursing Orders as Documentation

Orders perform the function of clinical documentation, and they should
be considered as such. They initiate the treatments carried out by nurses,
90 Nursing Use of Information Systems

pharmacists, respiratory therapists, and other healthcare providers. Fre-

quently nursing orders are used interchangeably with nursing interventions.
Nursing interventions describe the activities and behaviors used to deliver
nursing treatments (McCloskey and Bulechek, 1996). As previously indi-
cated, some of these respond to a physician’s order but many do not.
Reimbursement systems are heavily focused on physician services, which
has contributed to fragmentation of the patient record. The computerized
patient record does not have to be limited by this reality. Overly focusing
on care as being driven by the order workflow alone limits the degree to
which the clinical information system becomes a tool that is useful to all
disciplines caring for the patient.

Characteristics of Clinical Documentation

In some situations, clinical documentation is an endpoint, whereas in oth-
ers it is not. From one perspective, clinical documentation can be consid-
ered an endpoint only when it is not utilized after it has been recorded.
Although one cannot predict whether a document will be consulted after
it has been created, certain documents have a greater likelihood of being
accessed. Clinical documentation is surely not an endpoint when the docu-
ments influence future clinical decision making by members of the healthcare
team, whether in the short or long term. The repeatability aspect of infor-
mation is a key benefit of implementing an integrated computerized patient
record. Without integration the ability to view current and past key patient
information is impeded by needing to access disparate systems for viewing
results.
From another perspective, clinical documentation can be considered an
endpoint when it does not serve as the direct basis for future documentation.
When there is no required continuity between serial notes (as is currently the
case for most clinical documentation), each note can stand by itself without
reference to issues raised in previous notes and without any assurance of
consistency, continuity, or closure. The lengthy history and physicals (H+P)
document is often an endpoint. The H+P is an especially poignant example
in which smart information technology can create major efficiency gains by
distinguishing between the document and the information that it conveys.
Nurses, physicians, and other disciplines utilize similar document types for
H+P. A case can be made for the creation of an integrated H+P format
that allows users to filter their views to see all the information they want: all
disciplines, all history or some disciplines, some history. This process closely
follows the clinician’s clinical decision-making process. Technology can en-
able evolution and acceleration of clinical decision-making and knowledge
through an integrated world view of information, contributing to decisions
made regarding patient care. Currently, an integrated computerized patient
record best facilitates this.
 Nursing Aspects of Health Information Systems 91

Informatics Approaches to Clinical

Documentation Issues
Nurses are utilizing informatics to address clinical documentation issues on
a continuum from the most primitive to the most advanced. On the most
primitive end of the continuum, hospitals continue to provide nurses with
plenty of paper and writing instruments. Stepping up the evolutionary ladder,
some institutions have skeletal paper forms or templates available for many
highly detailed forms for nursing documentation.
Some hospitals have begun to “pave the cow path” by introducing elec-
tronic health records (EHRs), which allow nurses to word-process free-text
notes and even eliminate new paper notes. The more savvy users soon learn
to copy, paste, and edit old notes to be able to write new notes quickly and
efficiently (Hier, 2002). Many EHRs also offer boilerplate template function-
ality. Even though they tend to be static, they are still useful in prompting
the nurse for information. Some EHRs support automatic import of labora-
tory results, medications given, and so on (e.g., the Veterans Administration’s
EHRs) into free-text notes, although people who know how to do this are the
exception. (This speaks to the importance of interface design and training.)
The VA system, especially, makes document retrieval easier by requiring
users to assign a formal a coded document type (Brown et al., 2001).
Enabling clinical documentation and results viewing via interfacing differ-
ent information systems can produce a less than elegant information flow.
Well designed information retrieval and viewing, with ease of data entry,
speeds up the clinical decision-making process, innovates current research
content into practice, and can improve care. To the extent that any piece
of documentation can be used for legal defense, one can assuredly say that
documentation is never an endpoint.
Belmont et al. (2003) identified four key guiding principles to be followed
to strike a new path for clinical documentation systems.
1. “Build a Coherent Patient Story . . . a story unique to one patient—across
the continuum of care. Instead of being a collection of dissociated forms,
clinical documentation must build a story in partnership with the patient
that includes the evidence-based, patient-specific care given as the patient
moves through the system.
2. “Empower Interdisciplinary Care . . . keep the members of the interdis-
ciplinary clinical team informed of the care other members are provid-
ing . . . Because no one clinician has all the expertise a patient might need,
clinical documentation must empower the interdisciplinary team to pro-
vide care as a team, not a separate and distinct disciplines and caregivers.
3. “Support Integrated Scopes of Practice for All Clinicians . . . support
defined scopes of practice that clarify the responsibilities, competencies,
and evidence-based knowledge for which each member of the interdisci-
plinary team is accountable.
92 Nursing Use of Information Systems

4. “Provide Evidence Based Information at Point of Care . . . Clinical prac-

tice guidelines take evidenced based information, combine it with indi-
vidual patient data, and relate it to individual patients.”

Characteristics of Electronic Clinical

Nursing Documentation
As aspects of a plan for informatics-enabled clinical documentation are de-
veloped, the following areas of focus and issues need to be addressed.
r Understanding the distinction between content and form (or data and
display)
r Standardization of the clinical data and content, given the above diversity
of methods used at present
r Content in conjunction with workflow process through the system
r Data gathering and recording
r Data and information retrieval and review
r Handling inter- and intrashift and interdepartmental communications
The objectives for standard interdisciplinary documentation might be the
following.
r Eliminate redundancies and duplication in documentation
r Enhance the quality and reporting of clinical care from a multidisciplinary
perspective through standardization
r Define and standardize common clinical documentation data element
needs for all patients
r Develop an approach for standardizing clinical documentation practices
for both automated and manual (paper) settings
r Automate an ideal clinical documentation workflow
The overarching goal is to transform care. The complexities and trans-
formation processes resulting in new innovative actions begin to unravel.
The greatest challenge is to determine how to integrate the documentation
generated by each healthcare provider, so each can then benefit from the
work done by his or her colleagues. There is no doubt that nursing docu-
mentation, in and of itself, serves a valuable purpose. As we move into a
multidisciplinary environment, if the goal is to have all caregivers, including
nurses, perform their documentation in an integrated fashion at the point
of entry, as currently called for by the computerized provider order entry
initiative in the United States, the end-product is similar in nature to the
problem-driven medical record this chapter has described. System devel-
opers, however, have been remiss in capitalizing on where these functions
intersect on the Venn diagram (see Fig. 6.2) and in providing relevant, useful
information to the various healthcare professionals involved in the care of
the patient.
 Nursing Aspects of Health Information Systems 93

How can technology help nurses care for patients? The ideal nursing sys-
tem requires the technology for source data capture and considerable work
by nurses on the development of the nursing knowledge base. Until rela-
tively recently, it was not possible to even consider such a system because
the technology did not exist. Now that it does, the onus is on nursing to
develop effective means to use the technology.
From the nursing perspective, there are three major areas related to health
information systems that must be addressed in the immediate future. To
provide information management assistance to nurses, the areas of (1) source
data capture, (2) nursing data standards, and (3) decision support systems
must be addressed. These three areas are crucial to providing computer
support for nurses in the delivery of patient care.

Source Data Capture

In this context, source data capture means gathering data and information
about patients where it originates, that is, with the patient. The concept
of “terminals by the bedside” was introduced during the mid-1980s. Most
experts agree that bringing the computer access closer to the patient (i.e.,
locating it at the “point of care”) is a valid premise, and clinicians appear
to favor the bedside terminal as a means to reduce much of the clerical
workload and improve access to clinical data.
Point of care systems are still not in widespread use. Their potential has
yet to be fully realized. As more facilities and organizations implement
source data capture systems, including bedside terminals, the concept will
gain acceptance in the industry and, in fact, become the standard for nurs-
ing systems. This conclusion is based also on the fact that significant funds
are presently being channeled toward research and development of bedside
and other point of care devices in Canada, the United States, and around
the world.

Criteria for Source Data Capture

Such technology must meet specific criteria. Specifically, it must permit
nurses at the patient’s bedside, be it in the patient’s home or in the hos-
pital, to interact with the main patient database and the main care planning
system or hospital information system. It must have the capacity to inter-
act with existing hospital information systems or regional EHRs so effort
already expended in developing hospital and health information systems is
not wasted. Such technology must be small and compact so as to occupy the
minimum amount of space at the patient’s bedside or the nurse’s bag and,
therefore, not interfere with the use of other important equipment necessary
to the care of the patient. This technology must be rugged and durable.
94 Nursing Use of Information Systems

In addition, it must be constructed so it can be disinfected between patients.

Also, it must be easy and uncomplicated to use and have high-resolution
screens with graphics capability that can be read in the dark. Provision must
be made for a variety of means of data entry (e.g., bar code reader, physiolog-
ical probe, digital camera, natural language, or keyboard). A volume control
is necessary to mute any keyboard sounds. Moreover, because patients do
not always stay in hospitals or beds or even at home, this type of technology
must allow nurses the maximum degree of mobility to enter data wherever
the patient may be. Wireless transmission of encrypted data can now be
configured to provide an acceptable level of security and confidentiality for
patient information. Much work remains to be done before a satisfactory
system for source data capture is fully developed.

“Point of Care” Devices

Three “point of care” devices are presently available. The first is the standard
stationary terminal. The most expedient approach to the concept of source
data capture was simply to place a standard keyboard and monitor (i.e., a
CRT) at the bedside; Misys CPR (formerly Ulticare) has used this approach
(Misys Healthcare, 2005). The second type of terminal is specially designed
for the purpose of source data capture. One variety of special-purpose ter-
minal is a small footprint terminal, fixed at the bedside and having special
function keys for data input. The systems used in critical care usually are
of this type; Spacelabs (2005) and GE Healthcare (2005) patient monitor-
ing systems are both examples of this type of system. The third device is a
handheld portable terminal, not restricted to a particular space such as the
patient’s room in a hospital.
Overall, there is still far too little experience in the healthcare field with
point of care, or source data capture, devices to allow a consensus as to
whether a fixed bedside terminal or a portable handheld terminal is best
suited for both patient care and optimum system utilization. However, there
is an emerging consensus that the choice should be made based the purpose
for which the device is to be used. For example, fixed, small footprint termi-
nals are likely the best choice in critical care environments where space is at
a premium, whereas portable wireless hand held devices are most useful to
nurses providing care in patients’ homes.

Uses of Source Data Capture in Healthcare

Sensmeier et al. carefully and succinctly show that “Documenting at the
point of care gets nursing back into the ‘chart as you go’ workflow, elim-
inating long hours of overtime charting at the end of the shift, struggling
 Nursing Aspects of Health Information Systems 95

to remember what was done hours earlier”(Sensmeier et al., 2003). The ca-
pacity for source data capture could be more greatly exploited by nurses if
assessment guidelines and interview instruments were developed with a view
to remote access and downloading to the point of care device. Data input
of responses in an interactive fashion at the patient’s bedside would permit
source data capture. More accurate documentation of patient care would be
the first outcome. Ultimately, it should be possible to develop and deliver de-
cision support systems or knowledge bases for nursing use in evidence-based
practice at the patient’s bedside. The initial uses of such technology will likely
be in acute care facilities. Eventually, extended-care and long-term care fa-
cilities, the occupational health field, outpatient clinics, community health,
and home care are prime areas for development of software for use with this
technology. The latter areas have been sorely underserved by the healthcare
computing industry primarily because until now the technology was unable
to serve the highly mobile and geographically dispersed nature of practice
in these fields of healthcare.
With the convergence that is occurring among wireless technologies
[personal digital assistants (PDAs), PC-compatible productivity tools,
cellphones, text mail, the Web], there is almost unlimited opportunity
(Blackberry, 2005; PalmOne, 2005). With these advances, point of care tech-
nology has exceeded, at least temporarily, nurses’ capacity to develop clinical
uses and applications for it.

Nursing Data Standards

Nurses continually use mental processes, often unconsciously, to organize
information systematically by grouping data according to common features.
We do this to make sense of the massive amounts of information with which
we are daily bombarded. The problem arises because nurses do not have a
common system or language with which to communicate precisely, even with
each other. Lang has well described the situation: “If we cannot name it, we
cannot control it, finance it, teach it, search it or put it into public policy”
(Clark and Lang, 1992, p. 109). Because nursing has not had universally
accepted methods for defining and collecting nursing data, nursing data have
not been collected. For example, the patient discharge abstracts prepared by
medical records departments in hospitals contain no nursing care delivery
information. The abstracts therefore fail to acknowledge the contribution
of nursing during the patient’s stay in the hospital. The abstracts are used
by many agencies for a variety of statistical and funding purposes. Patient
discharge summaries need to include nursing workload data that recognize
the personnel providing the care in addition to the substance of that care (i.e.,
the nursing components of patient care, the type of nursing care provided,
and the impact of that care on patient outcome). Presently, much valuable
information is being lost.
96 Nursing Use of Information Systems

Information about and for nursing is essential not only for funding pur-
poses but also for nurses to be able to develop evidence-based practice. Data
to support evidence-based practice is required not only for clinical prac-
tice but also to inform evidence-based decision-making by nurse managers.
Therefore, as the development of nationwide health databases increases, it
is vital that a minimum number of essential nursing elements be included in
local and national databases.
A variety of concepts interlink when considering the capture of nursing
practice data. They include the derivation from nursing practice of nomencla-
ture, terminologies, language, classification systems, reference terminology
model and minimum data set, and the resulting feedback loop (Clark and
Lang, 1992, p. 11).

The practicing nurse finds word (labels) for the elements of her/his practice. When
these words are standardized among nurses, they can be called a nursing nomencla-
ture. These word-labels can then be combined within a defined structure and system-
atic management to form a language system for nursing. From this point onward, the
data that are labeled according to a nursing nomenclature, structured into a nursing
language, and classified by means of common features, can be collated for inclusion
in a nursing minimum data set which in turn can be fed back into nursing practice at
the center of the spiral; and the continuous process of development, refinement and
modification in response to external change begins again.

Chapter 12 describes the interaction of these concepts in detail and the ways
that various countries have addressed the need for nursing data standards.

Issues in the Development and Use of Nursing Data

As nurses embark on the development of nursing data standards, several
issues emerge. Attention must be directed to the coordination and linkage
of data. Three aspects of data linkage demand attention. First, the computer
hardware must support database linkage. Second, the content of the nursing
data standard must be developed in a way that lends itself to integration
with other information. Finally, the ethics of data linkage with respect to
patient information, including security confidentiality and privacy of data,
must be addressed. Integration is a key consideration as the developments
in various countries converge. Once nursing data standards are developed,
three more issues emerge: (1) promoting the idea to ensure widespread use,
(2) educating the users to ensure the quality of the data that are collected, and
(3) establishing mechanisms for review and revision of the data elements.

Evidence-Based Nursing
Increasingly, nursing, like other health professions, is moving toward
evidence-based practice. This means that no longer are nursing judgments
 Nursing Aspects of Health Information Systems 97

based on intuition, ritual, or tradition. Nurses increasingly are basing their

practice on knowledge that has been developed through empirical research.
However, because of the rapid increase in the volume of information in the
body of nursing knowledge, it is no longer possible to expect nurses to retain
the entire knowledge base of the profession in their heads. Consequently,
nurses require access to the resources that contain empirically developed
nursing knowledge.

Decision Support Systems

The nursing literature regarding decision support systems exhibits confusion
and lack of clarity because of the various definitions and conceptualizations.
It is characterized by authors who use the same term to refer to different
concepts or who use different terms for the same concept. A broad defi-
nition that has some professional consensus is that computerized decision
support systems (CDS or DSS) include “any computer software employing
a knowledge base (facts and/or rules) designed for use by a clinician in-
volved in patient care, as a direct aid to clinical decision-making” (Langton
et al., 1992, p. 626). There is a consensus among authors that decision sup-
port systems should be used to extend the nurse’s decision-making capacity
rather than to replace it. Most care planning systems now in use are not deci-
sion support systems. Standardized care plans, whether manual or computer-
based, provide care only for standardized patients. Standardized care plans
neither enhance nor support nursing decision-making; on the contrary,
their “cookbook” approach discourages active decision-making by nurses.
Therefore, they are not congruent with a professional practice model of
nursing.
A decision support system for nursing practice is intended to support
nurses by providing them with information to facilitate rational decision-
making about patients’ care. In other words, decision support systems help
nurses maintain and maximize their decision-making responsibilities and
focus on the highest priority aspects of patient care. The major caveat
that must be considered in a professional practice model of nursing is
that clinical judgment that considers contextual factors as well as the rec-
ommendations of decision support systems must be exercised. In addi-
tion, because the current status of computer technology and understanding
human cognition restricts the performance of such systems, nurses must be
discriminating users of these systems and ensure that the systems are pro-
viding appropriate recommendations before acting on the output of such
systems.
Eddy (1990) believed that the complexity of modern healthcare has now
exceeded the limitations of the unaided human mind. Decision support sys-
tems offer great potential to help nurses handle the volumes of data and
information required. Pryor (1994, p. 300) has identified six major uses of
decision support.
98 Nursing Use of Information Systems

1. Alerting: Alerting systems are those that notify the clinician of an imme-
diate problem that calls for a prompt action or decision. These alerts are
commonly clinician alerts that appear on the screen at the time of entry of
orders, assessments, or laboratory values. These systems may also provide
management alerts based on problems with an individual patient (DRG
cost overrun) or an individual clinician (use of expensive resources not
generally warranted).
2. Interpretation: This type of CDS system is one that works to interpret
particular data such as from the electrocardiogram or blood gas assays.
A system such as this works by assimilating the data and transforming it
into a conceptual understanding or interpretation. The interpretation is
then presented to the clinician for use in decision-making.
3. Assisting: A system that is used to speed or simplify clinician interactions
with the computer is classified as an assisting system. These systems usually
assist in the ordering or charting process by offering the clinician such
things as standing order lists, patient-specific drug dosing, or appropriate
parameters for charting based on earlier identified patient problems.
4. Critiquing: Systems that provide critiques are primarily in the research
stage and not yet available for implementation. This type of system is
designed to critique a set of orders for particular problems. For example,
a clinician might enter orders for a change in respirator settings, which
the system would then critique in light of the most recently entered blood
gas results. The clinician would be presented with an alternate set of
orders and the rationale for changes made. The clinician would have the
option of accepting or rejecting the changes suggested by the computer.
5. Diagnosing: This type of decision support system uses general assessment
data to generate suggested diagnoses. These systems may then ask
for additional data to rule out, rule in, or otherwise refine the list of
diagnostic possibilities. Other systems that can be considered in this
category are those that provide predictive scoring of mortality, estimation
of treatment benefits based on effects of competing risks, or prediction
of specific risks (pressure ulcers, falls).
6. Managing: The computer automatically generates the treatment or
plan of care from assessment data and/or diagnostic categories, and the
nurse or physician then critiques the computer and its logic. Although
those systems with fixed protocols are easy to program and implement,
the lack of individualization leaves the clinician with the job of extensive
critiquing. This type of system can be used in a developmental manner,
however, so the clinician gives a rationale for changing the plan or the
protocol; this rationale is then used to determine further data needs
and decision rules so the protocols are further refined. The variation
in intervention and the rationale offered can be combined with data of
outcomes of care to determine which interventions are most effective
in producing the desired outcome. Thus, the refined protocols result in a
progressively higher quality of care.
 Nursing Aspects of Health Information Systems 99

Knowledge-Based Systems
All six types of decision support systems outlined have been combined in
a knowledge-based or expert system. For the sake of simplicity, the term
“expert system” is used here to encompass advisory systems and knowledge-
based systems. The purpose of expert systems is to recommend solutions to
nursing problems that reflect the judgment of nurse experts regarding the
most expedient response to nursing situations. Expert systems capture or
encapsulate, in a computer system, the knowledge of a human expert within
a particular domain of practice. Their function is to mimic the clinical rea-
soning and judgment of one specific human expert in the aggregation and
interpretation of data in a precisely defined area of practice. Expert systems
are characterized by using artificial intelligence principles, specifically the
symbolic representation of specialist knowledge to make decisions within a
specified domain; the capacity to interrogate the user sensibly; and explana-
tion of reasoning (rationale) underlying a decision on request by the user;
and incorporation into the knowledge base of systematic feedback about the
effects of decisions.
General approaches used as the basis for expert systems are knowledge
engineering elicitation of a knowledge base and decision rules from an ex-
pert; actuarial data based on multiple observations of patient encounters;
and objective probability based on the subjective judgment of multiple ex-
perts using heuristics to determine what a reasonable professional nurse
would decide in a particular situation. The components of an expert system
include a knowledge base, an inference engine, a patient database, and a
user interface. The knowledge base may incorporate that which constitutes
empirically validated research; clinical experience-based heuristics; and au-
thority, tradition, and textbooks. An inference engine deals with the inter-
pretation of knowledge using such techniques as logical deduction (decision
rules), semantic networks, and logical relationships (Bayesian, probabilistic,
or “fuzzy” logic). The patient database is composed of the data gathered from
the patient who is the subject of the decisions. The user interface provides the
capacity for natural language communication with the system to enable the
user to pose questions and to enter and receive information. Nursing deci-
sion support systems and nursing expert systems are reported in the literature
(Caelli et al., 2003; Carter and Cox, 2000; Harris et al., 2000; Jovic et al., 2002;
Lyons and Richardson, 2003; New 2000; Reilly et al., 2000; Ruland, 1999),
but none has progressed much beyond research, development, or testing to
widespread incorporation into production systems incorporated into soft-
ware marketed by vendors of hospital/health information systems and EHRs.
There is still much work to be done, both when considering the impli-
cations of expert systems in a care-giving environment and when devel-
oping and implementing expert systems—to say nothing of their content.
Issues that remain outstanding relate to legal liability; ethical concerns such
as privacy, confidentiality, and data integrity when using electronic patient
100 Nursing Aspects of Health Information Systems

records, and professional practice. Expert systems integrated into nursing

information systems and hospital/health information systems informed by
source data capture and made possible through nursing data standards offer
the potential to affect significantly the evidence-based practice of nurses for
the purpose of enhancing patient care.

Summary
There is no doubt that the problem-driven approach can eliminate redun-
dancies between and among the various providers, will eventually create
major operational improvements, and will lead to a much more effective, ef-
ficient way to document patient care. It is high time that some of these new
innovative solutions be put to work to assist nurses in their work environ-
ments. Healthcare providers, administrators, and patients can work together
to transform our patient care delivery system in a way that not only reduces
the risks of medical error but provides health professionals with a better-
quality work environment and the satisfaction that comes from providing the
best possible care to patients. As hospital information systems move beyond
the developmental stage and are marketed and installed on a wide scale, they
provide nurses with access to a great deal of information about their practice
and increase the time needed to analyze and consider this information.
Simultaneously, the level of educational preparation of nurses began to
rise with the proliferation of master’s and doctoral programs that produced a
cadre of nurses with much greater appreciation for, as well as sophistication
and skill at, data analysis and research. We believe that the consequence
of this concurrent evolution of both technology and the nursing profession
will be advances of astronomic proportions in nursing practice. We are just
beginning to initiate the cycle whereby information availability promotes
greater understanding of nursing decision-making and diagnosis. This, in
turn, not only facilitates higher level functioning of nurses but generates
additional information and further stimulates the cycle.

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Campbell, C. (1978). Nursing Diagnosis and Nursing Intervention. New York: Wiley.
Carter, M., & Cox, R. (2000). Nurse managers’ use of a computer decision support
system: Differences in nursing labor costs per patient day. Nursing Leadership
Forum 5(2):57–64.
Clark, J., & Lang, N. (1992). Nursing’s next advance: An international classification
for nursing practice. International Journal of Nursing 39(4):102–112, 128.
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making: From theory to practice (series). Journal of the American Medical Asso-
ciation 263:1265–1275.
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ded structures and representation of nursing knowledge. Journal of the American
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Hier, D.B. (2002). Physician buy-in for an EMR. Healthcare Informatics 19(10):37–40.
Johnson, M., Maas, M., & Moorhead, S. (1997). Nursing Outcomes Classifica-
tion(NOC). St. Louis: Mosby.
Jovic, L., Compagnon, A., & Fabre, F. (2002). [Best practice tools and decision support
aids for nursing care.] Rech Soins Infirm 69:30–40.
Langton, K.B., Johnston, M.E., Haynes, R.B., & Mathieu, A. (1992). A critical ap-
praisal of the literature on the effects of computer-based clinical decision sup-
port systems on clinician performance and patient outcomes. In:Proceedings of
the Annual Symposium on Computer Applications in Medical Care (SCAMC),
pp. 626–630.
Lyons, A., & Richardson, S. (2003). Clinical decision support in critical care nursing.
AACN Clinical Issues 14(3):295–301.
McCloskey, J.C., & Bulechek, G.M. (1996). Nursing Interventions Classification
(NIC), 2nd ed. St. Louis: Mosby.
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New, T.D. (2000). Clinical decision support tools in A&E nursing: a preliminary study.
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Pryor, T.A. (1994). Development of decision support systems. In: Shabot, M.M., &
Gardner, R.M. (eds) Decision Support Systems in Critical Care. New York:
Springer-Verlag, pp. 61–72. Cited in Braden, B.J., Corritore, C., & McNees, P.
(1994). Computerized decision support systems: Implications for practice. In:
Gerdin, U., Tallberg, M., & Wainwright, P. (eds.) The Impact of Nursing Knowledge
on HealthCare Informatics. Amsterdam: IOS Press, pp. 300–304.
Reilly, C.A., Zielstorff, R.D., & Fox, R.L., et al. (2000). A knowledge-based patient
assessment system: conceptual and technical design. Proceedings of AMIA Sym-
posium, pp. 680–684.
Ruland, C.M. (1999). Decision support for patient preference-based care planning:
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102 Nursing Use of Information Systems

Additional Resources
Urden, L.D. (1996). Development of a nurse executive decision support database: A
model for outcomes evaluation. Journal of Nursing Administration 26(10):15–21.
Zielstorff, R.D., Estey, G., & Vickery, A., et al. (1997). Evaluation of a decision sup-
port system for pressure ulcer prevention and management: preliminary findings.
Journal of the American Medical Informatics Association, Symposium Supplement.
Nashville: Hanley & Belfus, pp. 248–252.
Part III
Applications of Nursing
Informatics
7
Clinical Practice Applications:
Facility Based

New applications for facility-based clinical practice continue to be the fastest

growing area of interest in nursing informatics (Fig. 7.1). Although there are
many technological advances discussed here, the areas of greatest interest
are conceptual. Source data capture, the development and use of decision
support and expert systems, and the development of a nursing minimum
data set as they relate to facility-based care are the most important issues
(see Chapter 12 for a full discussion). Although none of these concepts is
easily categorized, the nursing process provides the structure for this chap-
ter. Clinical applications of nursing informatics are related to assessment,
planning, implementation, and evaluation.

Assessment
Computerization helps when gathering and storing data about each patient.
For example, assessment data can be physiological measures automatically
charted through a patient monitoring system (Newbold, 2003; Varon and
Marik, 2002; Wong et al., 2003). Other assessment data are added to the
electronic patient record by departments such as the laboratory and radi-
ology. The largest source of assessment data is the ongoing nursing assess-
ment. The following sections briefly describe these sources of assessment
data.

Patient Monitoring
The major area of development for automated patient monitoring originally
was coronary care. In coronary care units and pacemaker clinics, computers
were initially used to monitor electrocardiograms, analyze the information,
and reduce former volumes of data to manageable proportions, generally
some type of graph. The computers were also programmed to recognize
deviations from accepted norms and to alert attending personnel to the
deviation by some indication (e.g., an alarm or light).

105
106 Applications of Nursing Informatics

FIGURE 7.1. Facility-based nursing informatics. (Photograph courtesy of Cerner

Corporation and St. Joseph’s Health Care, London.)

In addition to arrhythmia monitoring, computers in acute care areas, such

as emergency departments and intensive care (ICU), coronary care (CCU),
and neonatal intensive care units, are now widely used for hemodynamic and
vital sign monitoring, calculation of physiological indices such as peripheral
vascular resistance and cardiac output, and environmental regulation of iso-
lets. Sophisticated computerized ICU monitoring systems for management
of patient data, including patients’ heart rates, arterial blood pressure, tem-
perature, respiratory rate, central venous pressure, intracranial pressure, and
pulmonary artery pressures, are used around the world (Varon and Marik,
2002; Wong et al., 2003). Automated approaches to patient monitoring free
the nurses from the technician role of watching machinery and allow them
to focus their attention on the patient, the family, and the nursing process.
It is now widely accepted that computerized cardiac monitoring of patients
dramatically increases the early detection of arrhythmias and contributes to
decreased mortality of CCU patients. Additionally, many of these monitor-
ing systems are integrated into decision support systems (Staggers, 2003).

Assessment Data from Other Departments

Detailed discussion of computer systems designed for use in special diag-
noses (e.g., laboratory, radiography), support (e.g., pharmacy, dietary), or
special treatment (e.g., radiation therapy, dialysis) is beyond the scope of
this book. However, patient data from many departments forms the basis
 Clinical Practice Applications: Facility Based 107

for computerized patient care plans and many decision support systems.
Nurses must be able to retrieve and use these data to provide quality patient
care.

Nursing-Generated Assessment Data

Source data capture is the key to useful nursing generation of patient data.
Source data capture means gathering data and information about patients
where it originates, that is, with the patient. By entering data wherever the
patient is, the reliability of the data is increased. There is less chance of
transcription errors than if the nurses copy data they have written on their
hands (or on pieces of paper towel) into the patient chart.
For source data capture to be feasible, nurses must be able to enter patient
data from many places other than the nursing station. This need has required
a revolution in computer hardware. The local nursing station terminal of the
hospital mainframe computer is no longer adequate. Computer data entry
must occur wherever patients are found. This is called a “point of care”
information system. Goals for moving to point of care systems are identified
as follows (Hughes, 1995).
r To minimize the time spent documenting patient information
r To eliminate redundancies and inaccuracies of charted information
r To improve the timeliness of data communication
r To optimize access to information
r To provide information required by the clinician to make the best possible
patient care decisions
Source data capture is the first step reducing the time nurses spend charting
and eliminating redundancies and inaccuracies. When information can be
entered directly into the patient’s electronic health record at the point of
care by the healthcare professional or a medical device such as hemodynamic
monitors, infusion pumps, or ventilators and it is made immediately available
to others involved in the patient’s care, time is saved and data have been
accurately transformed into usable information (Hughes, 1995). Point of
care systems use a variety of computer hardware. Ideally, a portable, real-
time communication device with many input options (e.g., touch, pen, voice)
able to display patient information as needed, including graphics, an easy
documentation method, and long battery life, is preferred. Technology is fast
moving toward this ideal. However, most point of care systems in existence
rely on full-sized personal computers, workstations, bedside terminals, and
some portable terminals (Figs. 7.2–7.4).
When considering the adoption of point of care systems, the following
points should be evaluated.
1. Point of care systems must allow the nurse to interact with the main in-
formation system. Systems that do not allow information to be extracted,
as well as entered, are not useful to nurses.
108 Applications of Nursing Informatics

FIGURE 7.2. Portable terminal. (Photograph courtesy of Cerner Corporation.)

2. Point of care systems must interface with the existing hospital information
system. The nurse at the patient’s bedside must be able to access data that
has been generated by the laboratory, or radiology, or pharmacy.
3. The open systems concept is valuable to nurses considering point of care
systems. This concept allows machines from all vendors to communicate.
Open systems allow the most appropriate type of machine to be selected
for each nursing environment.
4. Point of care systems must have a small footprint (take up a small amount
of floor space). Not all hospitals have the opportunity to configure a new
building from the ground up. Most hospitals are trying to fit new technol-
ogy into “old skin.” Early examples of bedside terminals took up a large
amount of space in patient rooms. With limited electrical outlets and no
piped-in oxygen or suction, a patient room that had all the equipment
necessary to care for seriously ill patients left no room for the nurse.
5. Point of care systems must be easy to use and must adapt to a variety of
nursing environments. Patient contact occurs 24 hours a day. For example,
bedside terminals must allow the nurse to access and input data without
turning on the lights or disturbing the patient. The annoying little “beeps”
a computer makes when you have made a mistake in data entry have no
place in bedside terminals.
6. Point of care systems must be easily disinfected and cleaned between
patients. Bedside keyboards should have a membrane keyboard or a pro-
tective “skin” over the keyboard to protect it from liquids.
 Clinical Practice Applications: Facility Based 109

FIGURE 7.3. Portable terminal. (Photograph courtesy of palmOne.)

7. For source data capture to be easily accomplished, nurses require a variety

of ways for entering data. Keyboards require some typing skills. Other de-
vices include bar code readers (Fig. 7.5) for scanning identification bands
and medications, physiological probes, microphones for voice input, light
pens and touch screens, digital cameras, and natural speech input devices.
The touch screen illustrated in Chapter 2 uses icons (pictures) rather than
words. Icon menus are easier to use, especially if the exact key word is
not known.
8. For effective source data capture, the nurse must go wherever the patient
is. If that is the visiting lounge or the coffee shop or the outside deck,
a fixed bedside terminal is not appropriate. Notebook technology and
pen-based portable systems offer the best choice for mobility.
110 Applications of Nursing Informatics

FIGURE 7.4. Portable terminal. (Photograph courtesy of Misys.)

9. Information to be retrieved using the point of care system must be repre-

sented in ways that can be quickly used and easily understood by nurses.
Traditional nursing notes are voluminous. Trying to find key data in a nar-
rative is too time-consuming when the information is urgently needed.
Figure 7.6 illustrates a cardiac risk assessment tool. At a glance, the nurse
can tell which factors must be addressed.

We have talked about the advantages of using source data capture through
point of care systems. Alternatives to traditional charting have also been
mentioned. However, a brief discussion of computer-mediated documenta-
tion is necessary because it is the primary application of nursing informatics
in many institutions.
 Clinical Practice Applications: Facility Based 111

FIGURE 7.5. Bar code reader. (Photograph courtesy of Bridge Medical.)

FIGURE 7.6. Cardiac risk assessment. (From Bakker AR, Ball MJ, Scherver JR,
Willems JL (eds). Towards New Hospital Information Systems. New York: Elsevier-
North Holland, 1988, with permission.)
112 Applications of Nursing Informatics

Documentation
Good nurses’ notes are generally lengthy, narrative, handwritten, and unbi-
ased observations. At their worst, they are inaccurate, inconsistent, incom-
plete, or consist of such trivia as, “Had a good day.” Automated methods for
recording nursing observations are some of the most readily available nurs-
ing informatics applications. Two approaches predominate. With the first
approach, a computerized library of frequently used phrases is arranged in
subject categories. The nurse chooses the phrase or combination of phrases
that best describes the patient’s condition. For example, by selecting a pri-
mary subject such as “sleeping habits,” a screen menu of standard descrip-
tions appear, allowing for additionally selected comments such as “slept
through breakfast—voluntarily” or “awoke early at a.m.” When completed,
the nursing station printer immediately prints a standard, easy-to-read, com-
plete narrative that could then be attached to the patient’s chart. An example
of an assessment screen is shown in Figure 7.7.
The second approach has been to develop a “branching questionnaire.”
The terminal displays a list of choices, and the nurse selects her choice and in-
dicates it by pressing the corresponding number on the keyboard or touching
the terminal with a light-sensitive input device (called a light pen). The termi-
nal then displays a further list of choices appropriate to the original selection.
Thus, the nurse is led through a series of questions that can be “customized”

FIGURE 7.7. Example of an assessment screen. (Photograph courtesy of Department

of Veterans Affairs, Office of Information.)
 Clinical Practice Applications: Facility Based 113

for each patient. For example, a question might be “Skin intact—yes, no.”
If “yes” was selected, no further questions in that set would be necessary.
If “no” was selected, other choices might appear such as a choice between
“wounds,” “pressure ulcers,” and so on. The option of free-form input is usu-
ally available via the terminal’s keyboard. At the user’s signal that the entry
has been completed, the computer processes the information and provides a
narrative printout for the patient’s chart. In both approaches, the option of
free-form narrative text input, using the keyboard, is usually also available.
Many advantages that have been claimed for automated documentation
of nursing observations include the following (Husting and Cintron, 2003;
Moody et al., 2004).
r Content standardization: increased charting completeness including in-
creased numbers of observations because of prompting or forced recall
and increased standardization, accuracy, and reliability of observations
r Improved standards compliance
r Increased efficiency: legible notes, which decrease reading time and in-
crease accuracy of interpretation and elimination of repetitive data record-
ing and resulting transcription errors
r Enhanced timeliness: less time spent writing notes, specifically end-of-shift
charting
r Expanded accessibility: data available on-line immediately and access not
limited to one person at a time as with paper record
r Augmented data archive: ready statistical analysis and easier nursing audit
because of the use of standard terminology
Better observations—that is, increased number, accuracy, and reliability of
observations—facilitate better assessment, planning, and evaluation of nurs-
ing care. Less time spent writing notes provides more time for assessment,
planning, implementing, and evaluating care. Increased use and accuracy
when interpreting notes facilitates consistency and continuity of care. Statis-
tical analysis facilitates research that ultimately leads to refinements in the
nursing process and improved patient care.

Data Issues
Nurses spend a great deal of time and energy gathering data. Unfortunately,
many of these data are probably for someone else’s use (e.g., administrative
or government statistics). Often these same data are duplicated by the data-
gathering activities of other healthcare professionals (e.g., how many times
are patients who are being admitted to your institution asked by different
categories of staff why these patients have presented themselves). Similarly,
data are gathered ostensibly for nursing use but are never looked at again
(e.g., the voluminous nursing histories gathered in many institutions). Nurses
should only be gathering data that are essential for nursing decisions about
114 Applications of Nursing Informatics

patient care. The principle involved is to gather essential information while

avoiding replication and duplication of data that waste resources such as
manpower, storage space, and memory. Although much research remains
to be done in this aspect of nursing practice, the foundation work has been
done that defines that essential information (see Chapter 12 for a detailed
discussion of minimum data sets and nursing classification systems).

Planning
Automated Care Planning
In most healthcare settings, the kardex or some similar tool has been the
repository of nursing care plans. This tool has had drawbacks similar to
those encountered with nursing notes as well as other drawbacks that are
unique to the kardex. Nursing care plans, if they are ever entered in the
kardex at all, are usually outdated, illegible, inconsistent, and incomplete.
Notations are made by all levels of nursing personnel from nursing aides to
head nurses. Written patient care assignments are usually accompanied by
verbal explanations that are often forgotten.
Alternate approaches to the automation of nursing care plans is to design
care maps or pathways for meeting patient needs, store them in the com-
puter memory banks, and then adapt them to individual patients (Catt et al.,
1997; Renholm et al., 2002). The resulting printout is unique for each pa-
tient’s assessed needs for daily care. In all cases, it is the nurse who assesses,
plans, and evaluates the plan for care, although auxiliary personnel might be
involved in implementing the plan. The evolving approach to care planning
is the development of decision support systems for nursing practice.
The following list summarizes the advantages of automated care plans or
pathways over traditional nursing care plans.
r Time is saved by eliminating the need for daily handwriting of patient
assignments and by decreasing the amount of verbal explanation required.
r Accountability is increased because personnel have printouts of care plans
for each of their patients.
r Errors and omissions are decreased.
r Consistency of care from shift to shift and day to day is increased; quality
of patient care improves.
r Judgments for nursing care are no longer delegated to whoever walks into a
room to care for the patient; they are the responsibility of the professional
nurse who now has tools available to help make nursing judgments.

There are many implications of these advantages for nursing practice

(DeLuc, 2000). Time saved during the preparation and communication of
care plans means more time available for the nursing process. Increased
accountability for care improves nursing practice because documentation
is available to evaluate the quality of care and thus the quality of practice.
 Clinical Practice Applications: Facility Based 115

Benefits to patient care of decreased errors and omissions and increased

consistency of care include more rapid diagnosis, more valid assessment,
and more rapid recovery. These factors all reduce the cost of healthcare for
the patient and open the system to more patients. Placing the responsibil-
ity for nursing judgments clearly on the shoulders of the professional nurse
helps define nursing practice and helps the profession in its search for a
clearly delineated identity.

Decision Support Systems

Decision support systems help nurses maintain and maximize their decision-
making responsibilities and focus on the highest priority aspects of patient
care. The care planning systems previously described are not decision sup-
port systems. Standardized care plans, whether manual or computer-based,
provide care only for standardized patients. Standardized care plans do not
enhance nursing decision-making; on the contrary, their “cook-book” ap-
proach discourages active decision-making by nurses.
A true decision support system allows nurses to enter their assessments
at the bedside using source data capture technology (discussed earlier) and
then use the computer to analyze those assessments and recommend nursing
diagnoses. The nurse then accepts or rejects the recommendations. Having
accepted a particular diagnosis, the range of interventions acceptable in that
agency or institution can be retrieved and presented by the computer. The
nurse can then choose the nursing interventions appropriate for the patient
(Wong et al., 2000).
Decision support systems are being developed for a variety of care settings
and situations. Decision support systems are useful because each nurse’s
repertoire of interventions is based solely on previous professional experi-
ence. The nurse’s repertoire is also influenced by a “forgetting” curve. If the
nurse has not encountered a specific nursing diagnosis for a long time, the
remembered interventions may not reflect the whole repertoire. The advi-
sory or expert system not only accumulates the experience of all nurses in
the organization but also serves as a “reminding” function. Decision sup-
port systems have been developed for a variety of settings, including critical
care (Lyons and Richardson, 2003), cancer pain management (Im and Chee,
2003), and pediatric fever (Lambell et al., 2003).
As you may have noted, decision support systems are not appropriate
for all patient care settings or at all times. Emergencies such as cardiac
arrest do not allow time for the nurse to scroll through suggested actions.
Highly complex patient problems may also prove too great a challenge for
the current types of decision support systems. In addition, decision support
systems are usually designed to address nursing diagnoses one at a time, not
in combination.
Decision support systems can never replace the need for nurses with ex-
pert clinical and decision-making skills. Brennan and McHugh (1988, p. 93)
stated that the “complexity and/or detail necessary in the decision making
116 Clinical Practice Applications: Facility Based

process are beyond human capacities, yet some human judgment is neces-
sary either because all the information needed to make a decision is not
available to the computer, or because the decision making process is too
poorly understood to specify the steps in such a way that the computer can
be programmed to make the decision.” Therefore, the nurse is still required
to exercise clinical judgment, regardless of whether a decision-modeling or
expert system has been used. The fundamental idea that must be stressed
is that decision support tools should add to the nurse’s decision-making ca-
pacity, not attempt to replace it.

Implementation
Computers rarely help the nurse in the giving of care or nursing service.
Generally, computers are used more in other phases of the nursing process.
One example of how computers are used in intervention is the programmed
administration of preloaded drugs in the ICU.

Evaluation
Computers can be used to evaluate nursing care through real-time audit-
ing and quality management activities. These uses are discussed in detail in
Chapter 9.

Summary
Nurses must respond to the challenge to identify the data essential for de-
cisions about patient care; “Nurses cannot leave the decision making about
nursing’s essential retrievable data to vendors and other healthcare profes-
sionals; those decisions are part of the responsibilities that members of an au-
tonomous profession must assume” (Werley, 1988, p. 431). Nurses must also
evaluate technology so it better serves their needs and the needs of their pa-
tients. Finally, now is the time to capture the immense collective knowledge
of nurses to create the decision support systems that will lead to consistent,
high-quality patient care and acknowledgment of our nursing expertise.

References
Brennan, P.F., & McHugh, M. (1988). Clinical decision-making and computer sup-
port. Applied Nursing Research 1(2):89–93.
Catt, M.A., Nagle, L.M., & Shamian, J.S. (1997). The patient care process: Pathways in
transition. In: Gerdin, U., Talberg, M., & Wainwright, P. (eds.) Nursing Informatics:
The Impact of Nursing Knowledge on HealthCare Informatics. Amsterdam: IOS
Press, pp. 318–329.
 Clinical Practice Applications: Facility Based 117

De Luc, K. (2000). Care pathways: an evaluation of their effectiveness. Journal of

Advanced Nursing 32(2):485–496.
Hughes, S.J. (1995). Point-of-care information systems: state of the art. In: Ball, M.J.,
Hannah, K.J., Newbold, S.K., & Douglas, J.V. (eds.) Nursing Informatics: Where
Caring and Technology Meet, 2nd ed. New York: Springer, pp. 144–154.
Husting, P.M., & Cintron, L. (2003). Healthcare information systems: education
lessons learned. Journal for Nurses in Staff Development 19(5):249–253.
Im, E.O., Chee, W. (2003). Decision support computer program for cancer pain
management. CIN: Computers, Informatics, Nursing 21(1):12–21.
Lambell, P., Coopers, A., Hoyles, S., Pygall, S.A., & O’Cathain, A. (2003). An audit
of paediatric fever in MHS Direct: consistency of advice by nurses using comput-
erized decision support software systems. Clinical Governance 8(3):222–227.
Lyons, A., & Richardson, S. (2003). Clinical decision support in critical care nursing.
AACN Clinical Issues: Advanced Practice in Acute Critical Care 14(3):295–301.
Moody, L.E., Slocumb, E., Berg, B., & Jackson, D. (2004). Electronic health records
documentation in nursing: nurses’ perceptions, attitudes, and preferences. CIN:
Computers, Informatics, Nursing 22(6):337–344.
Newbold, S.K. (2003). New uses for wireless technology. Nursing Management
October: 22–27, Special edition: IT Solutions.
Renholm, M., Leino-Kilpi, H., & Suominen, T. (2002). Critical pathways: a systematic
review. Journal of Nursing Administration 32(4):196–202.
Staggers, N. (2003). Human factors: imperative concepts for information systems in
critical care. AACN Clinical Issues: Advanced Practice in Acute & Critical Care
14(3):310–319.
Varon, J., & Marik, P. (2002). Clinical information systems and the electronic medical
record in the intensive care unit. Current Opinion in Critical Care 8(6):616–624.
Werley, H.H. (1988). Research directions. In: Werley, H.H., Lang, N.M. (eds.) Iden-
tification of the Nursing Minimum Data Set. New York: Springer, pp. 427–431.
Wong, D.H., Gallegos, Y., Weinger, M.B., Clock, S., Slagle, J. & Anderson, C.T.
(2003). Changes in intensive care unit nurse task activity after installation of a
third-generation intensive care unit information system. Critical Care Medicine
31(10):2488–2494.
Wong, H.J., Legnini, M.W., & Whitmore, H.H. (2000). The diffusion of decision
support systems in healthcare: are we there yet? Journal of Healthcare Management
45(4):240–249.
8
Clinical Practice Applications:
Community Based

Community-based care is the fastest growing segment of healthcare. Health

reform in all parts of the world has meant a decrease in the number of
hospital beds and an increase in home care. Community-based health pro-
motion and illness prevention programs are also increasing. Surveillance
programs must also be maintained. Informatics are playing an integral role
in facilitating community-based care. Many community-based organizations
have information systems that mirror those of hospital facilities. Systems are
typically used for tracking, scheduling, billing, and human resources func-
tions. Because of health reform reorganization, many community-based care
providers and organizations are now incorporated into regional health sys-
tems. Often the information systems are also combined.
Patient appointment-identification systems are found in many
community-based settings. At this level of computer support for nurs-
ing, three functions are performed by the automated system. The patient
appointment system helps the scheduling of a patient’s clinic visits to mini-
mize waiting time, smooth the clinic load, and establish patient priorities for
appointments along carefully delineated guidelines. The second function is
to maintain the patient registry and determine the extent to which the patient
must pay for services and establish billing procedures for third-party liability
for each individual patient. The third function of this system is to maintain
security and guarantee the privacy and confidentiality of the remainder of
the patient record. Access is limited to authorized personnel: Nurses and
physicians have total access, secretaries and laboratory technicians have
limited access. This type of system frees the nurse from many tedious clerical
chores. By restricting access to the patient record, this system maintains
the confidentiality of the patient record and thus increases the credibility
of the professional staff by assuring patients that their confidences are truly
confidential. This fact is particularly important in such areas of distributive
nursing as mental health clinics and venereal disease clinics, where the risk
of social stigma is a significant factor in an individual’s decision to seek care.
The greatest gains in applying informatics to the community setting have
come from the linkage with telecommunications. This chapter describes the

118
 Clinical Practice Applications: Community Based 119

concepts of telehealth and provides examples of applications in a variety of

settings.

Telehealth
The nurse in the community and the hospital-based nurse require similar
information to deliver the required patient care. Both practitioners require
patient demographic data, past medical history, diagnosis, laboratory, and ra-
diology test results, and a treatment and/or care plan. Additionally, whether
in the hospital or community setting, delivery of patient care is facilitated
by the availability of patient teaching materials, policies and procedures,
drug and treatment information, technical data, community services listings,
and current contact directions. The point of care is in the community or the
patient’s home. Traditionally, however, the patient’s medical record, policy
and procedure manuals, teaching materials, and clinical reference books are
inaccessible because they are kept in the agency offices. Another key miss-
ing link in community-based care, yet traditional in the hospital setting, is
collaboration with a multidisciplinary health team during delivery of patient
care. Telehealth offers technological and information systems solutions to
many of the challenges of community-based nursing practice.
There have been many definitions of telemedicine in the literature, but
few definitions to aptly define telehealth, an integrating and more holistic
term encompassing all the telematics applications in health and healthcare.
In Europe, the field is referred to as healthcare telematics. Also in Europe,
Telenursing is not related to telecommunications applications specifically but
is the name of the European Community (EC) classification and nomen-
clature project. Telehealth is defined as “the use of communications and
information technology to deliver health and healthcare services and infor-
mation over large and small distances” (Picot, 1997). Telehealth is born of
the confluence of information technology and telecommunications (IT&T),
healthcare, and medical technology. Each of these three sectors is undergoing
transformation although in quite different directions. The first, IT&T, is en-
joying accelerated growth with rapid technological and regulatory changes.
Healthcare and medical technology, however, have lately been subject to
downsizing and restructuring in many parts of the world. Several factors are
influencing the development of telehealth.
r Aging population: The needs of aging healthcare consumers have initiated
efforts to develop and adopt better telehealth systems outside institutional
walls, systems that would be better geared for home-based applications.
r Cost containment: Telehealth systems are facilitating redistribution of
healthcare services, reducing duplication, reducing numbers of drug
interactions and inappropriate prescriptions, and reducing patient and pro-
fessional travel.
120 Applications of Nursing Informatics

r Access: Demand is increasing for equitable access to healthcare services

for inhabitants of isolated geographic areas (e.g., in sparsely populated
areas of Canada’s north and in many parts of Latin America, China, and
Africa).
r Technology: Ever more powerful technologies and communications band-
widths are becoming available at decreasing costs.
r Demand: The increasing consumer demand for wellness and health infor-
mation of all kinds has fueled increased access to the Internet and the
World Wide Web.
r Information explosion: The exponential increase in medical and health in-
formation has given rise to demands for better information management
systems, faster and more efficient electronic access, and better on-line re-
search networks.
Telehealth encompasses practices, products, and services bringing health-
care and health information to remote locations. Remote can mean across
the street or across the globe. Telehealth extends the arm of the healthcare
system for people at home and provides health services direct to consumers.
It offers continuing medical, nursing, and health education and assists con-
sumers in obtaining emergency assistance wherever they may be. Health
informatics and telematics applications are incorporated, using communi-
cations technologies in association with monitoring and medical devices;
emergency systems; health, medical, and computer systems to transform
and transfer health content and deliver health services; education; and assis-
tance at a distance. An overview of possible applications is found in Table 8.1
(Picot, 1997, p. 8). Specific applications are described later in the chapter.
Nursing telepractice is nursing-specific application of telehealth that in-
cludes all client-centered forms of nursing practice and the provision of infor-
mation, conferences, and courses for health professionals occurring through,
or facilitated by, the use of telecommunications or electronic means (CNA,
2001). A nursing role in telehealth is found in a variety of applications
including call centers (Omery, 2003; Valanis et al., 2003), specific disease
management (Hill et al., 2004; Pierce et al., 2002; Roupe, 2004; Wilbright
et al., 2004), and community health (Hill and Weinert, 2004; Johnston, et al.,
2000; Young and Ireson, 2003). The remainder of the chapter describes a
variety of telehealth applications used by nurses in nursing telepractice.
The technologies and systems used for telehealth vary greatly from one ap-
plication to another. However, each application, even the simplest, contains
at least three components.
1. A device or means to capture, process, and store content (input)—whether
sound only, electronic or digital images, tracings, alpha-numeric data, or
a combination
2. Content and a means to transfer or exchange the content (throughput)—
communications, telecommunications, or network technologies of all
kinds and their associated software
 Clinical Practice Applications: Community Based 121

TABLE 8.1. Telehealth applications that can facilitate healthcare procedures

Healthcare procedure, process Possible telehealth application
Telephone-based or face-to-face Videoconferencing, IATV, computer-based
consultation between specialists and e-mail
general practitioner
Physical transfer of medical image for Electronic transfer of images to specialists via
specialist opinion on radiographs, any number of networks
ultrasound, CT scans, pathology slides Comparison of images against banks of stored
electronic slides and images for comparison
Handwritten, paper-based patient files and Palmtop pen-based computer tablets, desktop
charts workstations, computerized patient records
Handwritten, paper-based prescriptions Electronic ordering of the prescription using a
CHIN, HIN, or pharmanet
Consulting CPS for information regarding Drug interaction software, drug information
drug being prescribed database on line
Home visits unassisted by technology Laptop or portable computer with modern to
communicate with physician or healthcare
institution
Home care, elder care Telemonitoring from the home; assisted
devices and technologies
Visits to the emergency room of the local Telecare, tele-assisted triage, 1–900 telephone
hospital calls to obtain assistance, video visits
Referrals from general practitioner Appointments by e-mail, by electronic
scheduling from general practitioner’s office
Patient traveling from remote location if Videoconsultation with specialist from afar
requiring specialized counselling,
diagnosis, or treatment
Literature search in medical library for Electronic search from home or office using
current literature on new procedures, Medline or other medical information
clinical trials, etc. management and database retrieval service
Travel to another location for grand rounds, Attendance from home or office via audio,
CME, conference, meetings, seminars video, or computer conferencing, or IATV
Clinical trials Clinical trial management systems, expert
advice on line

CT, computed tomography; CPS, Compendium of Pharmaceutical Specialties;

CME, Continuing medical education; IATV, interactive television;
CHIN, community health information network; HIN, health information network.

3. A means for receiving, storing, and displaying the content (output)—

possibly a video monitor, a computer file server, or a recorder of some
kind

The various technological systems are used to transfer different kinds

of information, such as epidemiological, clinical, research, or educational.
Users range from healthcare professionals and administrators to patients
and consumers. Settings for telehealth include pharmacies, hospitals, clin-
ics, physician’s offices, remote nursing stations, and private homes. Table 8.2
122 Applications of Nursing Informatics

TABLE 8.2. Categorization of telehealth applications and users

Category User
1. All forms of healthcare at a distance: Physicians
teleconsultations, telepathology, teleradiology, Nurses
telepsychiatrty, teledermatology, Psychologists
telecardiology Other healthcare professionals
Healthcare institutions
2. Interinstitutional patient and clinical records Healthcare institutions and
and information systems: electronic health and organizations
clinical records and databases accessible by Healthcare professionals
network Researchers
Physicians offices and community health
centers
3. Public Health and Community Health Government (including policy makers)
Information Networks (CHINs) and Epidemiologists
multiple-use health information networks Public health professionals
Pharmacies
Healthcare providers’ offices and clinics
4. Tele-education and multimedia applications Healthcare professionals
for health professionals, and patients, and Patients and consumers
networked research databases. Internet Universities and colleges
services
5. Telemonitoring, telecare networks, telephone Consumers
triage, remote home care and emergency Elderly
networks Chronically ill
Telenurses
Call center users and operators

categorizes telehealth applications and users (Picot, 1997). This categoriza-

tion is used to structure the following discussion of more specific telehealth
applications.
1. All forms of healthcare at a distance: teleconsultations, telepathology,
teleradiology, telepsychiatry, teledermatology, telecardiology. The Telemedi-
cine Exchange Database (http://tie.telemed.org) reports more than 200
telemedicine projects worldwide, including those concerned with derma-
tology, oncology, radiology, pathology, surgery, cardiology, and psychiatry.
Echocardiograms, frozen sections, ultrasound seans, computed tomography
(CT) scans, and mammograms are routinely sent by telemedicine applica-
tions between remote centers and receiving institutions and between re-
searchers requiring more than the written word. Many of these applications
have implications for nurses in both remote and urban areas. In remote
areas, videophones, digital medical imaging (X-rays), and electrocardiog-
raphy (ECG) monitors transmitting over a regular telephone line can be
used to provide information for a consultation with a physician or hospital
(Artinian, 2004; Halstead et al., 2003). In the same way, in urban areas it is
often the nurse who uses the technology to gather the patient information
that is transmitted to medical facilities.
 Clinical Practice Applications: Community Based 123

The U.S. military operates one of the largest telemedicine organiza-

tions and is especially active in researching new applications and tech-
nologies (Zajchuk and Zajchuk, 1996). With its military personnel located
in 70 geographic locations worldwide, telemedicine provides medical per-
sonnel in the field with 24-hour tertiary care capability. The MERMAID
(medical emergency aid through telematics) system uses the full range
of telecommunications technology, including two-way transfer of live im-
ages to maximize the effectiveness of medical assistance to sailors at sea
(Anogianakis and Maglavera, 1997). Several areas use telemedicine in cor-
rectional facilities to decrease transfers of inmates, thereby improving the
safety of healthcare personnel and the public (Picot, 1997; TRC, 1997).
2. Interinstitutional patient and clinical records and information systems:
electronic health and clinical records and databases accessible by network.
Telehealth covers the use of networks to link care providers and their insti-
tutions. Regional health networks and community health information net-
works (CHINs) often include pharmanets, which link clinics and physicians’
offices to pharmacies for the transmission of information regarding pre-
scriptions. At the basis of the CHIN and the community health management
information system (CHMIS) is the electronical health information system
(EHIS) or electronic health record (EHR) (see Chapter 5 for more detail). A
major trend in telehealth applications is the integration of health networks,
including institution-based and community-based systems. The major bene-
fits are realized from avoiding duplication, timely provision of information,
reducing unnecessary multiple diagnostical procedures, and optimizing re-
sources.
3. Public health and community health information networks (CHINs)
and multiple-use health information networks. Surveillance systems and reg-
istries are being used increasingly by policy makers and funders to measure
progress and compare delivery systems. Population health networks permit
epidemiologists, health policy makers, and governments as well as public
health officials to exchange information regarding the health status of entire
populations. This type of information has become all the more valuable in
recent times because of the prevalence of certain diseases believed to have
environmental causes. The WHO makes increasing use of the Internet to
disseminate population health information widely (http://www.who.org).
Disease surveillance networks are designed to identify epidemics and
emerging diseases. National governments have supported such networks to
support disease prevention efforts and to monitor and control risks to health.
It will be some years before fully operational global emergency and disease
prevention networks become a reality. There is a growing realization that
such networks are essential in light of the high volume of travel and exchange
between countries and the growing number of senior and frail travelers.
4. Tele-education and multimedia applications for health professionals and
patients; networked research databases, and Internet services. Tele-education,
not telemedicine, constitutes the principal content in many telehealth
124 Applications of Nursing Informatics

networks. Mediated distance education for health professionals has been

ongoing since the 1930s, when radio was the main communication medium.
Many universities and colleges worldwide offer credit and noncredit courses
by distance using all forms of telecommunications, from videoconferencing
to the Internet. Virtual nursing education for postbasic degree programs
is available across North America and Europe from a variety of universi-
ties. Continuing medical education (CME) and continuing nursing education
(CNE) are increasingly offered via telecommunications and computer-based
networks. In many institutional settings, the teleconferencing facilities used
for telemedicine applications are also used for tele-educational purposes.
Patient education remains a growing field. The advent of the Internet
and the World Wide Web (WWW) have had a substantial impact on tele-
education for consumers (Dauz et al., 2004). Consumers now have access to
health information that previously was unavailable to them, even in public
libraries. Web sites offering medical advice are popular, as are newsgroups,
electronic medical forums, virtual hospital, and even disease support net-
works, such as Global Health Network (www.globalhealthnetwork.org). The
WWW is also a source of wellness information, although with quackery as
a potential hazard there is rising demand for guarantors granting legitimate
status to the content published by various information providers.
5. Telemonitoring, telecare networks, telephone triage, remote home care,
and emergency networks. It is difficult to discuss each of these applications
separately as many overlaps occur in reality. The rise of ambulatory care,
shorter hospital stays, and the care of the elderly and chronically ill in the
home setting have all generated community care needs that can be effectively
met, in part, with video visits or telemonitoring devices. New products such
as cardiac monitoring and hemodialysis systems complete with telephone
coupling mechanisms have been developed to serve this need. Videocon-
ferencing systems, including the use of videophones for home care video
visits, are gaining in popularity. Examples include the use of videophones
to monitor persons with congestive heart failure (Jenkins and McSweeney,
2001; Johnston et al., 2000), home-ventilated children (Miyasaka, 1997), and
cystic fibrosis patients (Adachi, 1997) and to provide stroke rehabilitation
(Clark et al., 2002). Videophones are becoming widely available and, as the
cost decreases, will be used increasingly in healthcare. Videophones do not
require a computer; they use standard telephone lines; and the technology is
as simple as making a phone call. Videophones include a wide range of fea-
tures to facilitate telehealth applications including electronic pan, tilt, zoom,
self-view, and autoanswer.
Telecounseling using videoconferencing or videophone technology has
been reported as having high user satisfaction and reducing travel costs to
both patient and professional. Some patients prefer the television moni-
tor or videophone to the face-to-face experience (Elford and House, 1997;
Johnston et al., 2000; Strecher et al., 2002). Telepyschiatry and telecounseling
applications are expected to rise, as practitioners are increasingly located in
large urban areas where most patients are located. Relocating psychiatrical
 Clinical Practice Applications: Community Based 125

and mental health professionals to rural areas may not be feasible because
of the lower numbers of patients in rural or remote areas.
Another outgrowth of the telecounseling application is the advent of
on-line support groups, either sponsored by an organization specifically
for its patients (Hill and Weinert, 2004; Pierce et al. 2002) or open to
the general public. ComputerLink projects serving persons living with ac-
quired immuno-deficiency syndrome (AIDS) and caregivers of persons with
Alzheimer’s disease provide information organized in an electronic encyclo-
pedia, electronic communication including public bulletin boards and private
mail, and a decision support service. Comments from users have indicated
that the ComputerLink serves as a “support system without walls” (Brennan,
1997, p. 522).
In-home monitoring is available for ECG, blood pressure, heart rate, and
peak-flow spirometer readings (Artinian, 2004; Johnston et al., 2000). In
many instances the facility receiving the transmissions speaks directly to the
patient while the information is being transmitted. Immediate feedback can
be given to the patient; and if necessary, ambulance services or mobile inten-
sive care units can be summoned. This approach removes the intervention
of third parties who have traditionally taken the ECG and transmitted it to
the physician and reduces the number of unnecessary visits to emergency
departments. Natori et al. (1997) has reported on a program for low risk
pregnant women to transmit their own cardiotocograms via e-mail and thus
reduce routine physician visits.
Video and telecommunications technology, sometimes but not always cou-
pled with telemonitoring, has spawned the development of many remote
home care programs for the elderly (Clark, 2002; Johnston et al., 2000). The
benefits of this type of program are identified as follows (Roman, 1997, p. 79).
r Empowerment and independence of the elderly patient
r Return to the comfort of home with the security of flexible healthcare for
an estimated 5% of those currently in nursing homes
r Great savings to nations
Some additional home care services that can be teleassisted, partly re-
placing and augmenting home care visits, include the following: wound
management; oncology patient management via home infusion; electronic
and tele-house calls; remote programmable infusion; blood glucose meters
with telecommunication capabilities; telemonitoring of hemodialysis; use of
laptop computers by home care nurses to note and check the medication and
progress on patients’ electronic health records and to communicate electron-
ically with home care teams; and emergency or alert systems linking homes
to clinics or hospitals (Picot, 1997) (Fig. 8.1).
The healthcare sector is increasingly using the concept of call centers in the
delivery of services. Many jurisdictions and managed care organizations have
implemented toll-free numbers and call centers to handle healthcare queries
and problems. Nurses are providing emergency or first level information and
triage and advice over the telephone (Omery, 2003; Valanis et al., 2003).
126 Applications of Nursing Informatics

FIGURE 8.1. Community-based nursing informatics. (Courtesy of Prologix.)

Challenges Related to Telehealth

Although the potential for telehealth applications to contribute to healthcare
is unlimited, several challenges remain to be addressed.
r Obsolescence: Many of the technologies have a short shelf life. Rapid obso-
lescence is a major concern for managers and administrators because most
information technologies come in 18- to 36-month cycles, each bringing sig-
nificant increases in processing speeds, flexibility, and storage capacity and
decreases in price.
r Access: Even with user acceptance and available funding, telehealth is not
accessible to any and all who need it. Technical infrastructure dictates at
least in part the if, how, where, when, and what of telehealth technologies
that can be implemented.
r Health information infrastructures: The creation of a health information
infrastructure requires integration of existing and new architectures and
application systems and services. A core element of this infrastructure
includes patient-centered care facilitated by computer-based patient
record systems (electronic patient record).
r Provider reimbursement: The issue of physician and other provider com-
pensation for telehealth services has yet to be resolved in most jurisdic-
tions.
r Interdisciplinary and interinstitutional collaboration: Jurisdictional con-
flicts between institutions and among physicians, nurses, pharmacists, ra-
diologists, and nuclear medicine specialists must be resolved.
r Documentation standards: Telehealth documentation standards must be
developed for use by all providers to ensure a useful and usable patient
record.
 Clinical Practice Applications: Community Based 127

r Data security: Confidentiality, privacy, and security issues related to the

collection, storage, and transmission of patient information must be re-
solved to the satisfaction of professionals and consumers alike.
r Liability issues: Medical and nursing responsibility issues related to con-
tinuing responsibility for a patient’s care, liability of consultants’ opinions,
and licensing for cross-jurisdictional consultation must be resolved.

Summary
The development of inexpensive, reliable telecommunications technology
enables health professionals, patients, and consumers to access health infor-
mation, healthcare resources, and health service delivery directly from and
in their homes. Telehealth applications exist as discrete nursing interventions
and provide pathways for nurses to reach patients and provide nursing inter-
ventions. Nurses can use technology to assist them in providing home care
and in-home monitoring. Networks serve as educational vehicles whereby
nurses can reach patients and clients with health promotion, disease and pre-
vention, information, and illness management nursing interventions. Tele-
health applications hold, great promise for extending the ability of nurses to
reach individuals in communities and the communities themselves.

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9
Administration Applications
With Contributions by Hélène Clément

Managers and caregivers throughout the healthcare system are being asked
to increase the efficiency and effectiveness of patient care while simulta-
neously reducing or at least maintaining levels of resource consumption. A
principal strategy being used to achieve these goals is to consider information
as a corporate strategic resource and provide enhanced information manage-
ment methods and tools to caregivers and managers across the health sector.
The idea is to use information to help managers utilize available resources
most effectively.
Administrative uses of information systems in nursing can be classified in
two ways: those that provide nurse managers with information for decision
making and those that help nurse managers communicate the decisions. In
this chapter, the administrative uses of information systems that help nurse
managers with decision making are called “management information sys-
tems.” Those applications of information systems in nursing administration
that help nurse managers communicate their decisions are called “nursing
office automation systems.” This chapter defines management information
systems and describes the nursing information needs related to the man-
agement of nursing units. The chapter concludes with the nursing role in
the management of information and obstacles and issues in management
information systems.

Definition of Management Information Systems

The idea of management information systems was developed in the business
and industrial sectors. It has been studied, analyzed, and evaluated in detail
by management scientists for a considerable time. In those sectors, there
are many definitions of the concept of management information systems
(MISs). Some definitions place an emphasis on the physical elements and
design of the system, and others focus on the function of an MIS in an
organization. In this book, MIS refers to the classic notion of “a method
of collecting, storing, retrieving, and processing information that is used or

129
130 Applications of Nursing Informatics

FIGURE 9.1. Management information system.

desired by one or more managers in the performance of their duties” (Ein-

Dor and Segev, 1978). Although this definition could include both manual
and computerized systems, we discuss only computerized MISs in this book.
Figure 9.1 illustrates a simplified management information system.

Nursing Information Needs for the Management

of Nursing Units
This aspect of information need focuses on the information that the organi-
zation (as represented by its nurse managers) needs to fulfill that aspect of
its mission related to providing patient or client care. Management informa-
tion systems help nursing in the areas of quality management, unit staffing,
and ongoing reporting. Such systems also support nurse managers in their
responsibilities for allocation and utilization of the following resources nec-
essary to accomplish the nursing function in the patient/client care environ-
ments: human resources, fiscal resources (including payroll, supplies, and
materiel), and physical resources (including physical facilities, equipment,
and furniture).
 Administration Applications 131

Quality Management
Total quality management (TQM) and continuous quality improvement
(CQI) continue to be commonly encountered approaches to quality man-
agement and improvement (Shojania and Grimshaw, 2005). TQM is an im-
portant process for staff nurses and administrators alike. It is useful to staff
nurses in two ways: It provides them with feedback about the nature of
their individual practice and provides them with opportunity to influence
patient care in their organization. Nurse administrators use it to assess the
general quality of patient care provided within their institutions and as a
process to receive and communicate opportunities to enhance patient care
and organizational effectiveness.
A process of establishing and maintaining organizational effectiveness
(i.e., the quality of care provided to patients), TQM is an institutional plan
of action to establish a process for empowering staff to influence corporate
achievement of the highest possible standards for patient care. The delivery
of patient care is monitored by all staff to ensure that these standards are
met or surpassed. Implicit in the concept of TQM is the ongoing evaluation
of the standards themselves, thus ensuring that they reflect current norms
and practices in healthcare. Institutions use a variety of formal and infor-
mal means to gather information to evaluate the quality of care provided
to patients. The formal means are encompassed in a quality assurance pro-
gram. Information needs associated with quality assurance might include
patient care databases, patient evaluations of care received, nurses’ notes
on the chart, patient care plans, performance appraisals, and incident re-
ports. These sources of information are reviewed by either a concurrent or
retrospective audit. Concurrent nursing audits occur during the patient’s
stay in the hospital, whereas retrospective nursing audits occur after the
patient leaves the hospital. Audit reviews are a major tool for any TQM
program.
Originally, the impetus for the establishment of quality assurance pro-
grams came during the 1970s as the result of rising consumer awareness,
increasing healthcare costs, and the growing professionalism of nursing. An
additional factor was the desire of the U.S. government to monitor the cost
and quality of care associated with its Medicaid program. Almost simultane-
ously, three things happened: Professional standards review organizations
were established in the United States, the American Nurses Association
published its standards for practice, and the American Joint Commission
on Accreditation for Hospitals established the requirement for medical and
nursing audits. These events added pressure to the entire quality assurance
process. The established quality assurance programs were dependent on
reviewing and evaluating massive amounts of data. These reviews and au-
dits consumed enormous amounts of nursing time. As these audits were
done, nurses gained an increased awareness of their professional account-
ability. This greater awareness, in turn, prompted nurses to produce more
132 Applications of Nursing Informatics

documentation in the form of nursing care plans and patient records. This
further increased the volume of information to be reviewed and evaluated
in the nursing audits.
As the pressure from nursing audits was building, integrated hospital
information systems made their timely entry into the healthcare delivery sys-
tem. Quality assurance programs in nursing needed two things to succeed:
standardized terminology and standardized care plans. These two things
were also required if information systems were to be any help to nurses.
The standardization of terminology required for computerized documen-
tation of nurses’ notes, and the development of standardized care plans
for use in generating computerized patient care plans, coincided with the
need for standardized terminology (see Chapter 13) and quality assurance
standards.
The ability of a computer to retrieve, summarize, and compare large
volumes of information rapidly has proven useful for nurse administra-
tors charged with the responsibility of implementing quality assurance pro-
grams. The first obstacle to using computers for this purpose is the lack of
widespread availability of integrated hospital information systems. The sec-
ond obstacle is the lack of a widely implemented common nursing vocabulary
and method of coding nursing diagnoses and interventions (see Chapter 12).
Both obstacles are on the verge of being overcome. The lack of widely
available integrated hospital information systems is being resolved by the de-
creasing cost of such systems and their greater sophistication. Taxonomies for
nursing diagnoses, interventions, and contributions to patient care outcomes
have been developed (Lunney et al., 2005). Unfortunately, much of this work
has not yet received widespread implementation in the nursing profession
and has not yet been incorporated as a framework for the organization of
nursing databases by developers of information systems. Figure 9.2 attempts
to summarize the interrelationships between clinical practice, informatics,
and computer technology.
Another problem associated with computerized quality assurance pro-
grams is the quality of the tools used to provide input to the program. The
validity of even the most widely used audit tools and criteria is largely un-
substantiated. Consequently, much effort has been focused on the process
aspects incorporated in the TQM concept. Unfortunately, the vendors of
computer software have not given high priority to the information needs
related to TQM or the development of clinical software packages for health-
care institutions. This situation has created a major barrier to the effective,
widespread use of information systems for quality monitoring in hospitals.
Several institutions have developed sophisticated TQM programs that in-
corporate procedures for conducting concurrent chart audits. These institu-
tions use a manual concurrent audit conducted by staff nurses (with special
training in concurrent auditing) on the nursing units. The data from the
completed audit forms are then put into the computer for tabulation, anal-
ysis, and summarizing. This combination of manual and computer methods
 Administration Applications 133

FIGURE 9.2. Relationships between clinical practice, informatics, and computer

technology.

partially reduces the labor-intensive process associated with totally manual

audits.
There is a growing emphasis on patient care outcomes as the major focus
of nursing TQM programs. Similarly, there is a growing trend away from
the problem resolution model to a planning model as the major criterion for
measuring quality assurance. Simultaneously, there is an increasing demand
from the public for better resource management in the healthcare sector,
and the public has an increasing awareness of quality as a cost component
of healthcare. These factors are creating a demand for the most sophisti-
cated computerized information handling in the form of relational database
software.
134 Applications of Nursing Informatics

Patient Classification, Nursing Workload,

and Unit Staffing
In the past, innumerable head nurses and supervisors in healthcare institu-
tions and agencies around the world spent countless hours each day “doing
the time.” Even when master rotation plans were used, manual scheduling
of personnel work rotations could not eliminate all the problems, such as
vulnerability to accusations of bias when assigning days off or shift rotation,
difficulty establishing minimum staffing to avoid wasting manpower, and de-
pending on an individual’s memory in the nursing administrative structure.
Consequently, automated staff scheduling is a highly desired component of
a management information system for nursing administration. Frequently,
when an institution has limited resources and no other computerized nursing
management information system, it mobilizes resources to set up a comput-
erized staffing system.
Researchers at many healthcare institutions have developed diverse sys-
tems for personnel time assignment. The complexity of these systems varies
greatly. Some merely use the computer to print names into what was formerly
a manual master rotation schedule; others adjust staffing interactively and
dynamically on a shift-to-shift basis by considering patient acuity, nursing
workload levels, and the expertise of available personnel. To develop com-
plex, sophisticated systems for automated personnel scheduling, a great deal
of planning and data gathering is required: The nursing workload must be
identified in the institution; the various levels of expertise of staff members
must be categorized and documented; criteria for determining patient acuity
and nursing workload must be established; personnel policies must be clearly
defined; and the elements of union contracts must be summarized. When all
this information is available, a computer program is designed to schedule
nursing staff on nursing units. The capacity of the computer to manipulate
large numbers of variables consistently and quickly makes personnel time
assignment an excellent use of this technology.
Documented advantages of automated scheduling of personnel include
the following.

r Easier recruitment and increased job satisfaction because schedules are

known well in advance
r Less time spent on manual scheduling, thereby providing more time for
nurse managers to carry out other duties
r Advance notice of staff shortages requiring temporary replacements
r Unbiased assignment of days off and shift rotation
r More effective utilization and distribution of personnel throughout the
institution or agency
r Capacity to document the effect of staff size on quality of care
r Ability to relate quantity and quality of nursing staff to patient acuity
 Administration Applications 135

Workload measurement systems function with automated scheduling.

Nursing workload measurement systems (NWMSs), sometimes called pa-
tient classification systems (PCSs) are tools that measure the number of
direct, indirect, and nonclinical patient care hours by patient acuity on a
daily basis (Hall et al., 2003; Seago, 2002). PCSs and NWMSs have evolved
to focus on providing uniform, reliable productivity information to help with
staffing, budgeting, planning, and quality assurance. NWMS have become a
valuable management tool for nursing unit managers, nursing department
heads, hospital administrators, and governments alike. As healthcare costs
and demands continue to escalate, the appropriate and effective utilization
of scarce human resources becomes increasingly onerous. There are many
PCSs and NWMSs on the market. All differ in one or many respects, and
the criteria used to choose such a system ultimately depend on the specific
institution’s needs.
Increased job satisfaction, easier recruitment of staff, unbiased rota-
tion assignment, workstation printouts, and advance notice of temporary
shortages—all contribute to improved staff morale and thus indirectly re-
sult in better patient care. Administrative time saved and more effective
utilization and distribution of personnel have also been suggested as factors
influencing quality of patient care within the agency or institution. Docu-
mentation of the relation between staffing and quality of patient care gives
the nurse manager strong data to justify staffing requests and decisions to
senior hospital management.

Reporting
In most hospitals, nursing costs represent upward of 40% of the entire hospi-
tal budget. Management information systems collect, summarize, and format
data for use in administrative decision making related to the nursing compo-
nent of the hospital budget. Nurse managers are familiar with periodically
produced budget summaries that allow monitoring of the budget, adjust-
ments between overcommitted and undercommitted categories, and help
when planning next year’s budget. A variety of retrieval modules have been
designed and are being refined to provide similar decision-making support
in areas ranging from the nosocomial infection rate to sickness and absen-
tee abuses by staff members. The emphasis in these reports is on graphic
displays (e.g., histograms, time series charts, map plots). The advantages for
nurse managers with this level of support lie mainly in the speed with which
data can be retrieved, compiled, summarized, and presented in a meaningful
and comprehensive form. Another major advantage is the ability to tailor
reports to each nurse manager’s information needs. Furthermore, sharing
data and developing knowledge of clinical staff at all levels not only im-
prove data quality but also assist in a more effective and efficient use of the
136 Applications of Nursing Informatics

data included in reports for decision-making. This facilitates the ongoing

monitoring of activities within the institution and the preparation of reports
by the nurse manager to superiors or outside agencies.

Human Resource Management

Management of people on a nursing unit is a complex, time-consuming task.
In the increasingly decentralized administrative structures that character-
ize hospitals, nurse managers need information related to all aspects of
the allocation and utilization of staff on nursing units. For example, the
nurse manager must have immediate access to such information as the
following.
r Skills and education of all nursing employees
r Job classification and salary level for all staff on the unit
r Dates for performance reviews
r Dates for recertification of medically delegated and transferred functions
r Dates for annual inservice education sessions, whether required by con-
tract, by organizational policy, or by accreditation standards (e.g., back
care, cardiopulmonary resuscitation, fire and disaster response, restraints)
r Annual vacation schedule summary for the unit
r Statutory holiday schedules
r Labor relationships contracts for all collective bargaining units represent-
ing employees employed on the unit, including grievance procedures
r Sick time records for each employee

Through access to hospital information systems from a personal computer or

terminal, including human resources databases, the nurse manager is quickly
able to obtain the necessary information without the need to maintain du-
plicate records.

Fiscal Resources
Hospitals are gradually moving toward the implementation of business-
oriented management information systems. These systems identify, define,
collect, process, and report the information necessary for the planning, bud-
geting, operating, and controlling aspects of the management function. The
current demands for fiscal responsibility in hospitals exceed all previous
experience in the healthcare sector. Increasingly, nursing managers are ex-
pected to understand the contextual challenges of their organizational en-
vironment. To respond to internal and external factors influencing the cor-
porate environment in which they function, nurse managers must do many
things.
 Administration Applications 137

r Understand their fiscal responsibilities and situation

r Identify the issues and opportunities
r Generate solutions
r Monitor progress toward unit and organization goals
r Evaluate the effectiveness of the solutions or the achievement of goals and
objectives
r Link data with process improvement and best practice in a cost-efficient
model.

These activities require the management of financial and statistical data.

The ultimate objective is to relate the cost of resources consumed to patient
outcomes. To manage effectively the information related to their responsibil-
ities for fiscal accountability, nurse managers require financial information
(including payroll, supplies/materiel, and services) and statistical informa-
tion (e.g., patient length of stay, nursing hours per patient-day). This informa-
tion must be timely, accurate, relevant, comprehensive, complete, consistent,
concise, sensitive, and comparable.

Physical Resources
Nursing managers are also responsible for overseeing the care and mainte-
nance of the physical facilities of their patient care unit. They are responsible
for equipment and furniture on their units and ensuring that it is in good
working order. Although the actual inventory may be conducted by another
department (such as materiel management), nursing managers are account-
able for budgeting, ordering, and retaining capital assets on their units and
for initiating maintenance or replacement procedures. Consequently, nurs-
ing managers need access to capital asset inventory for their unit. In addi-
tion, they should conduct regular systematic inspection of the workplace for
physical hazards such as faulty electrical equipment or loose floor tiles. These
inspections must document identified hazards, the date on which corrective
action was requested or initiated, and the date that the hazard was repaired
or removed from the workplace. Such information must be stored on the
nursing unit in an easily retrievable format with a calendar to bring forward
reminders of follow-up items.

Office Automation
Nursing office automation is the integrated electronic technology distributed
throughout the nursing administrative office. The purposes of nursing office
automation are to improve effectiveness, efficiency, and control of nurs-
ing office operations. This technology can have application in nursing ad-
ministration, nursing education, continuing nursing education, and nursing
138 Applications of Nursing Informatics

research. Office automation affects the filing and retrieval of documents,

text processing, telephone communications, and informal meetings. Nursing
office requirements demand more skills in transcription, word processing,
spreadsheets, and electronic filing. Offices have special printers, telecon-
ferencing and video conferencing, voice response systems, voice mail, and
e-mail systems.

Nursing’s Role in Managing Information in

Healthcare Facilities
Nursing’s role in managing information in healthcare facilities is, of necessity,
related to the role of nursing in the organization. In most hospitals, nurses
manage both patient care and patient care units in the organization. Usually,
nurse clinicians manage patient care and nurse managers administer the
patient care units in the organization. Therefore, for some time, nursing’s role
in the management of information generally has been considered to include
the information necessary to manage nursing care using the nursing process
(see Chapter 6) and the information necessary for managing patient care
units in the organization (e.g., resource allocation and utilization, personnel
management, planning and policymaking, decision support).
As the role of staff nurses in organizational governance and decision-
making diversifies, their role and responsibility for information management
to support these decision-making responsibilities will also change. Informa-
tion related to organizational planning and policies, as well as resource allo-
cation and utilization, widely available to nursing staff, supports these roles
and responsibilities.

Obstacles to Effective Nursing Management

of Information
In most hospitals, the major obstacles to more effective nursing manage-
ment of information are the sheer volume of information, the lack of access
to information-handling techniques and equipment, and the inadequate in-
formation management infrastructure. As the reader must have noted from
reading Chapter 6 and the preceding sections, the volume of information that
nurses manage on a daily basis, for patient care purposes or organizational
management purposes, is enormous and continues to grow. Nurses continue
to respond to this growth with incredible mental agility. However, humans
do have limits, and one of the major sources of job dissatisfaction among
nurses is information overload, resulting in information-induced job stress.
Manual information systems (e.g., handwriting an order, a requisition, a
medication card, and a kardex entry for each medication) and outdated in-
formation transfer facilities (e.g., nurses hand-carrying requisitions and spec-
imens for stat blood work to the laboratory on nights because the pneumatic
 Administration Applications 139

1 14 13
FLOOR CLERK FLOOR CLERK FLOOR CLERK
ASSEMBLISE OF CKPT CHARTS, WHEN ORDER
BLANK ADDRESSOGRAPH COMPLETE DELETE
FORMS OF PAT. STUFF AS REQ. DAILY FROM KARDEX
CHART
CHART
FORMS
2 12
FLOOR CLERK RN, FLOOR CLERK
ADDRESSOGRAPH
NURS. TRANSCRIBE ORDER
FORM SET &
ASSIGN. TONSG. ASSIGN.
INSERT IN CHART
WKSHT. WKSHT.
BACK
PATIENT
3 CHART 11
R.N. R.N.
PREPARE REPLACE
ADMISSION NOTES CARDS PLACE
CHART IN
RACK

4 KARDEX 10
CARD KARDEX PHYS
FLOOR CLERK R.N.
FILE ORDER
TYPE KARDEX SHEET REMOVE PART
INCL. NURSING 2 OF ORDER
CARE PLAN SHEET

5 6 7 8 9
R.N. PHYSICIAN R.N. FLOOR CLERK R.N. R.N.
TRANSCRIBE CHECK ORDER ON
RECEIVE PHONE WRITE MED KARDEX AGAINST SIGN DATE & TIME
ORDER TO
ORDER ORDER PHYS ORDER SHEET ORDER
KARDEX

FIGURE 9.3. Manual preparation of new chart and processing of new medical order.

tube system and the portering system are not available between the hours
of 2400 and 0700) are information-redundant and labor-intensive processes,
to say nothing of an inappropriate use of an expensive human resource.
Electronic information transfer and communication systems allow rapid,
accurate transfer of information along electronic communication networks
(Figs. 9.3 and 9.4).
The lack of the software and hardware for electronic communication net-
works is only one aspect inhibiting the development of an information in-
frastructure. The other major aspect lacking in most hospitals is appropri-
ate support staff to facilitate information management. Information systems
support staff require preparation in health information science to gain exper-
tise in both information systems and a solid understanding of the functioning
of the healthcare system, its organizations, and its institutions. Similarly, fi-
nancial and statistical support staff are necessary to help nursing managers
appropriately interpret information.

Issues Related to Effective Nursing Management

of Information
Primary among the nursing issues regarding information management is the
lack of adequate educational programs in information management tech-
niques and strategies for nursing managers. Presently, there are only a few
140 Applications of Nursing Informatics

FIGURE 9.4. Electronic preparation of new chart and processing of new medical order.

programs in prelicensure nursing education programs offering a course in

electronic information management techniques and strategies related to
nursing. At a minimum, such a course must include advanced study of in-
formation management techniques and strategies such as information flow
analysis, the use of spreadsheets, databases, and word-processing packages.
Ideally, such courses would also introduce concepts and provide hands-on
experience related to the use of patient care information systems.
Nursing involvement and participation in the selection and installation
of patient care information systems and financial management systems is
imperative. Regrettably, many senior nurse managers fail to recognize the
importance of this activity and opt out of the process. They then complain
when the systems do not meet the needs of nursing. Senior nursing executives
must recognize the importance of allocating staff and money to participate in
the strategic planning process for information systems in their organizations.
Other senior management personnel must also recognize the importance of
nursing input into the strategic planning process for information systems.
In any hospital, nurses are the single largest group of professionals using a
patient care system, and nursing represents the largest part of the budget
requiring financial management. Nursing, therefore, represents the single
largest stakeholder group related to either a patient care information system
or an enterprise health information system.
 Administration Applications 141

The final major issue that nursing must address regarding information
management in hospitals is the patient discharge abstract. The patient dis-
charge abstracts prepared by medical records departments across Canada
and the United States currently contain little if any nursing care delivery
information. Therefore, the abstracts fail to acknowledge the contribution
of nursing during the patient’s stay in the hospital. This is important because
the abstracts are used by many agencies for a variety of statistical purposes
including funding allocation. Presently, much valuable information is be-
ing lost. This information is important for determining hospitalization costs
and the effectiveness of nursing care. As the importance of national health
databases increases, it is imperative that a minimum number of essential
nursing elements be included in that database. Such a set of data elements
would be similar to the nursing minimum data set (see Chapter 6). Such data
are essential to allow description of the health status of populations with re-
lation to nursing care needs, establish outcome measures for nursing care,
and investigate the use and cost of nursing resources. The nursing profession
must provide leadership when defining appropriate nursing data elements
that must be included in the patient discharge abstract.

Summary
Management information systems and nursing office automation systems
enable the nurse manager to contribute to organizational efforts to increase
the efficiency and effectiveness of patient care while simultaneously reducing
or at least maintaining levels of resource consumption. This can be accom-
plished in part by considering information as a corporate strategic resource
and thinking of nurse managers’ use of information as a management method
and tool, thereby empowering nurse managers to utilize available resources
most effectively.

References
Ein-Dor, P., & Segev, E. (1978). Managing Management Information Systems.
Toronto: Lexington Books.
Hall, L.M., Doran, D., & Laschinger, H.S., et al. (2003). A balanced scorecard ap-
proach for nursing report card development. Outcomes Management 7(1):17–22.
Lunney, M., Delaney, C., Duffy, M., Moorhead, S., & Welton, J. (2005). Advocating
for standardized nursing languages in electronic health records. Journal of Nursing
Administration 35(1):1–3.
Seago, J.A. (2002). A comparison of two patient classification instruments in an acute
care hospital. Journal of Nursing Administration 32(5):243–249.
Shojania, K.G., & Grimshaw, J.M. (2005). Evidence-based quality improvement: The
state of the science. Health Affairs 24(1):138–151.
10
Education Applications
Richard S. Hannah

Impact of Computers on Education

Technological change has placed a strain on the educational system. In trying
to keep pace with the information explosion associated with the technology
revolution, educators have had to devote more time and energy to simple
information transfer, leaving little time to help beginners apply information.
Historically, three eras, or “waves,” of education can be identified. The
“first wave” of education preceded the printed word. Education was a con-
trolled, tutorial process that was available for the few under special circum-
stances. It was reserved for the literate elite: the clergy and nobility. The
Gutenberg press ushered in the “second wave.” With the printed word, a
centralized education process evolved. Colleges and universities multiplied
and became the focal points of learning. Their libraries served as the repos-
itories of existing knowledge. The first two waves of education relied on
approaches to learning that remain the cornerstones of today’s educational
system. These two traditional approaches are academic education and train-
ing. Academic education encompasses the conceptual learning process. It
is subject-driven. Credit is given for learning achievement, and the appli-
cation of knowledge gained is usually deferred. Achievement is decided
by examination. Training is task- and skills-oriented. Application of knowl-
edge is immediate, and achievement is demonstrated by performance and
behavior.
Computer-based multimedia is the “third wave” in education. Computer-
based multimedia aids in the knowledge and information transfer process,
provides feedback to students about the efficiency of their learning processes,
provides access to a vast warehouse of electronic databases, and enables
students to problem solve and apply their learning. Ultimately, computer-
based multimedia frees the teaching staff to concentrate on helping students
with their individual learning needs, with emphasis on the “art” rather than
the “science” of nursing. The computer applications in this chapter can be
applied to the initial entry into practice education of nursing students, to
staff development (continuing education), and to patient education.

142
 Education Applications 143

When educating healthcare professionals, as in all areas of education, the

traditional modes of learning are straining under the requirements of tech-
nological change. The good news is that although technology has created
problems in the traditional educational system, it has also provided the so-
lutions for resolving them. Computer-based multimedia has the potential to
help educators create a new order from confusion and chaos. With computer-
based multimedia, education can move from an era of scarce resources into
an era of abundant learning resources. Computer technology and informa-
tion management have moved faster than the ability of educational and
healthcare systems to assimilate it. The integration of technology-assisted in-
formation gathering and learning into the educational system will take time.
Three basic stages of assimilating technology can be described as follows.
r Stage 1: Replacement. New technology replaces old technology, but out-
comes are not altered. An example is the use of computers to perform
accounting functions. Stage 1 data-processing functions such as automated
record-keeping, drill and practice, and machine-scored multiple-choice ex-
aminations have been successfully introduced into healthcare education.
Universities use search systems and software for cataloguing, accessing,
and retrieving library information, student records, and other types of
data.
r Stage 2: Innovation. The capabilities of technologies are combined with
traditional functions to create new tasks. For example, increased comput-
ing speed and the establishment of wide area networks have created new
home learning opportunities including literature searches and data gath-
ering over the internet. CD-ROM technology, which allows storage and
retrieval of vast amounts of information, makes literature searches fast,
feasible, and complete.
r Stage 3: Transformation. Innovations accumulate, transforming the way we
live. For example, telecommunications and computers have transformed
the life and work of radiologists to provide services that would have been
impossible, at any cost, a decade ago. Computed tomography (CT) and
magnetic resonance imaging (MRI) scanning have transformed X-ray de-
partments into diagnostic imaging departments, and radiologists now read
and interpret images from their homes.
Current applications of computer technology in the education system are
concentrated during stages 1 and 2 of development. In many areas, computer
technology has been adapted to the established approaches of academic
education and training. Stage 3 transformations are beginning to be seen
in education of nurses after entry into practice. There are now numerous
distance education programs for nurses to pursue studies at the post-RN
baccalaureate and graduate level.
The remainder of this chapter focuses on the use of computer technology in
health education. This is not to imply that other technologies (e.g., television,
two-way audiovisual communication, videotext) are unimportant, merely
144 Applications of Nursing Informatics

that they are beyond the scope of this book. Large central computer systems,
minicomputers, personal computers, digital video disks, and other modes of
interactive learning provide a means for individualizing learning even within
a centralized learning system. The traditional modes of academic instruction
and training will always have their place. However, they will be augmented by
the power of individualized learning systems to act as information and knowl-
edge transfer vehicles, freeing faculty members to do what only people can
do: develop understanding, skill, judgment, and wisdom (Jenkins et al., 1983).
The use of computers in nursing education dates back to 1966 when Bitzer
and Bitzer (1973) reported using computer assisted instruction (CAI) via
the PLATO system to teach nursing courses. In 1971, the earliest forms
of simulated patient management problems were instituted (Harless et al.,
1971). There has been a trend during the intervening period since these
developments toward the increasing use of technology in nursing education.
This is the result of the need to individualize instruction in nursing education
and the availability of the technology to do so. Many factors have contributed
to the development of this trend: among them are influences arising from
general education and nursing practice factors.

General Education
r Tremendous growth in human knowledge and the resulting increase in the
amount of information to be learned
r Increased understanding of the teaching-learning process and greater so-
phistication in identifying the learning styles of individual students with
diverse abilities and rates of learning
r Financial retrenchment and budgetary restraint internationally in postsec-
ondary educational institutions, which has produced a need to maximize
effective use of limited human and financial resources. Increased wide-
scale availability and affordability of educational hardware (e.g., micro-
computers, personal computers, television, video players, CD ROM/DVD
players, videotext).

Nursing Practice
r Increased diversity in the settings where nursing is practiced. The focus
of nursing practice ranges from the highly technical and largely physical
nursing care required by individuals in acute critical care areas (e.g., emer-
gency departments and intensive care, coronary care, and neonatal inten-
sive care units) to the predominantly psychosocial nursing care provided
to families in communities (e.g., family counseling, health maintenance,
and health promotion)
r Need for nurses to have greater skills in independent decision-making
r Need for nurses to have skills that allow them to continue learning through-
out their professional careers
 Education Applications 145

What’s in a Name?
The term computer-assisted learning (CAL) and its subdivisions, computer-
assisted instruction (CAI) and computer-managed instruction (CMI), have
been in existence for some time. Initially, CAI involved using video display
terminals (monitors) linked to mainframe computers where the student was
asked a series of questions and the computer responded with statements
like “Yes that is correct” and suitable feedback for wrong answers such
as “No that is incorrect because . . . try again.” Students quickly learned to
answer incorrectly to view all the feedback responses placed in the program
by the instructor. When personal computers became available they were
still primitive by today’s standards, and CAI slowly evolved to include text-
based lessons with a few images and colors added but was still referred to
as CAI. Because the computer has become a much more multipurpose tool
since these terms were defined, how do we rationalize this older terminology
with what the computer is capable of today? During a past number of years,
the addition of words such as interactive and multimedia to the existing
terminology has resulted in a taxonomic nightmare. A brief survey of the
literature resulted in the following list of synonymous terms, which is by no
means all-inclusive.
r Computer-mediated multimedia
r Interactive multimedia instruction
r Interactive multimedia
r Learner-controlled instruction
r Learner-controlled computer-assisted instruction
r Interactive computer-assisted instruction
r Multimedia computer-assisted instruction
r Multimedia computer-based training
r e-Learning

This inconsistent terminology is confusing to the novice and expert alike.

What Is Multimedia?
In general, multimedia refers to computer-based technologies that permit an
integration of traditional forms of communication to allow seamless access
or interaction by users. It also implies that the computer-based technologies
go beyond a single computer to include national and international networks
such as the Internet. Because the field is evolving so fast, with so many
diverse interest groups, a more concise definition is not possible at this time.
The primary advantage of a multimedia approach over more traditional
forms of communication is based in the freedom it allows for the creative and
innovative expression of ideas and the opportunity it provides for interactive
146 Applications of Nursing Informatics

FIGURE 10.1. “Pieces” of the multimedia puzzle.

student–teacher dialogue through a common tool—the computer. How well

multimedia will be able to fulfill its enormous potential remains to be seen.
The many traditional forms of communication that form the “pieces” com-
prising multimedia are summarized in Figure 10.1. They include textual ma-
terial, graphics, video (both still and motion), animation, and sound; and
most recently virtual reality capabilities have been added to this list. Who
knows when the senses of taste and smell will also be accommodated?
Just as there are many diverse tools that come together to make up a
multimedia program, so there are many ways in which this thing called mul-
timedia can be used. The major hurdle to overcome lies in making sense
of the multiplicity of terms and categories that abound in the literature. As
demonstrated in Figure 10.2, there are many flavors of multimedia but only
two basic or primary goals.

r Information-gathering activities: Information gathering programs provide

the user with information and are controlled by the user.
r Learning activities: Learning activities programs generate learning
through exercises and developing skills and are controlled by the system.

Information-gathering programs can currently be divided into three types:

hypermedia/hypertext, multimedia books, and multimedia databases.

r Hypermedia/hypertext programs use highlighted text or terms the user

selects to receive more information, such as a definition, graphic, or an-
imation about that term or to link to another area or topic. The World
Wide Web is a hypermedia/hypertext system.
 Education Applications 147

FIGURE 10.2. The many “flavors” of multimedia.

r Multimedia books are electronic versions of conventional textbooks. In

addition to text and images, they contain video and audio clips and allow
the reader to interact dynamically with the content.
r Multimedia databases are set up as records and fields such as the conven-
tional text-based databases with which readers are already familiar. The
difference lies in the fact that there is user-controlled access to all the
“pieces” that comprise multimedia, such as graphics and video.
Learning activities programs fall into four basic categories: tutorials, sim-
ulation, practice, and problem-solving.
r Tutorial is the category in which one would place classic computer-assisted
instruction (CAI). Historically, the user was presented with some informa-
tion followed by an activity such as a question, with appropriate feedback
for a wrong response. CAI has evolved so much over the years that some
use this term to mean multimedia or refer to it as multimedia CAI. How-
ever, because of the negative connotation associated with the term CAI,
meaning merely drill and practice format, which was all early computers
were capable of doing, the term has fallen into disfavor. A modern multi-
media tutorial attempts to mimic a live lecture that takes the user through
148 Applications of Nursing Informatics

a series of objectives but allows the user to undertake the operation at their
own pace and still provide the option of interactivity with the “teacher.”
The main difference is an emphasis on thinking and motivation rather
than a simple stimulus response. Several national nursing organizations,
including the Canadian Nurses Association and the National Council of
State Boards of Nursing in the United States, have developed computer-
ized testing programs to measure competence as a component of licensure
or specialty certification examinations.
r Simulations, in the health sciences, are usually of patients. The patient
simulation attempts to provide the user with the same type of experience
with patients they would encounter in a clinical environment. Health-
related examples are programs such as “Ethical Dilemmas in Nursing” by
the American Journal of Nursing.
r Practice programs allow the user to develop skills by using repetition. They
somewhat overlap simulation programs.
r Problem-solving programs present the user with a problem, provide a
number of resources to solve the problem, and let the user come up with
the correct answer on their own.
Several resources discuss the process of authoring and delivery of multi-
media material (Hannah, 1998; Jerram and Gosney, 1996; Kristof and Satran,
1995; Locatis, 1992; Lopuck, 1996). It should be noted that many available
programs are so varied in content and presentation that they use combina-
tions of these categories. An excellent example is the program “Learning
and Using ICNP” (http://www.omv.la.se/icnp).

What Is Worldware
Definition
Worldware can be defined as software that isn’t specifically developed for
instruction but can be educationally valuable. Word processors, e-mail, and
the Internet are all examples of Worldware. A practical example of integrat-
ing these applications would be Web-based on-line courses using discussion
boards and e-mail. Worldware packages are valuable for a variety of rea-
sons. They are in instructional demand because students know they need to
learn to use them and to think with them. Instructors are already familiar
with them as a result of their daily academic activities, and vendors have
a large enough market to make it financially feasible to provide continual
upgrades and enhancements. New versions of worldware are usually com-
patible with their older counterparts, which eases the burden on instructors
when it comes to updating and modifying their courses, year after year, with-
out last year’s material becoming obsolete (and thus unusable) because of
the software format.
 Education Applications 149

Learning and Using ICNP

The software package called Learning and Using ICNP is a prototype of
a web-based environment for learning to navigate within the International
Classification for Nursing Practice (ICNP). It is also an interactive tool for
nurses in practice or research and nursing students around the world to
share their experience of nursing; it contributes to the continuing develop-
ment of a unifying classification. Nurses can participate and contribute to
this ongoing process of development to make sure that the ICNP continues
to be developed as an international, practice-based instrument for nurses.
(This paragraph was provided by Gunilla Nilsson and Lars Rundgren Lund
University, Lund, Sweden.)
This application is designed to acquaint the user with the ICNP. Interac-
tive procedures according to learning needs and requirements are built into
the application to facilitate learning and training within the classification
of nursing phenomena. There are opportunities in each module to make
comments, statements, and suggestions and to submit them to a database
for retrieval. There are also opportunities to create various exercises and
assignments for use in learning environments.

Nursing Education Settings Using Computers

Whether used for information gathering or learning, the computers are being
used in all facets of nursing education. Their use in basic nursing education at
both the diploma and baccalaureate and graduate levels is widely reported.
In addition, their use in continuing education programs and in-service ed-
ucation is growing at a logarithmic rate. Most educational institutions and
many hospitals and clinics now provide Internet access. An excellent source
of information on the Internet can be found in The Internet for Nurses and
Allied Health Professionals (Edwards, 2002).
One of the largest growth areas during the last few years is distance learn-
ing, on-line learning, or e-learning. It is generally agreed that these terms
are basically synonymous in that they represent any learning that takes place
with the instructor and student physically separated from each other. This
process can occur by mail, video, interactive or cable television, satellite
broadcast, e-mail, or the World Wide Web (or any combination of these
technologies). It appears that the health sciences sector has preferentially
chosen the term e-learning over any other. In its broadest sense, e-learning
can be defined as any type of learning that utilizes a network for delivery,
with student–instructor interaction (e-learners, 2005).
There are many software packages used to deliver e-learning in nursing,
but two predominate, WebCT and BlackBoard with WebCT being the most
popular in nursing circles. There is little discernible difference between the
150 Applications of Nursing Informatics

two, and the choice of one or the other is largely based on personal preference
(Anthony, 2002).
Whether attempting to establish an e-learning component to a curriculum
or initiating just one course, several key factors must be addressed (Adams,
2004; Longman and Gabriel, 2004).
1. A commitment by the instructor and the administration to make the
program successful by believing that for the right subject e-learning can
achieve the same results as the conventional classroom
2. To provide relevant, high-quality, learner-centered course material
3. Financial support to provide continuous evaluation of the program
In summary, traditional paper-based distance education courses and e-
learning courses have many similar pros and cons when compared to class-
room teaching. However, e-learning when compared to paper-based courses,
excels in interactivity and access to information.

Effectiveness of Multimedia Technology

Many studies of learner achievement using classic computer-assisted instruc-
tion (CAI) have been conducted in undergraduate nursing education. These
studies consistently conclude that classic CAI is at least as effective as other
teaching strategies in effecting behavioral changes in students (Nyamathi
et al., 1989). Substantial reductions in the time spent learning subject matter
have been shown in studies of classic CAI (Chang, 1986). Similarly, when
classic CAI was compared with traditional strategies, significant cost bene-
fit in favor of CAI was shown. These findings, regarding the effectiveness
of nursing CAI with respect to learner achievement, time savings, and cost
benefit, are consistent with findings in the health professions collectively and
with findings in general education. The consensus among findings from a va-
riety of disciplines, however, lends support to the generalization that classic
CAI is at least as effective as other means of teaching (Belfry and Winne,
1988; Gaston, 1988).
The development of multimedia computers and software and the resulting
enhanced capabilities have led to yet another round of comparison studies.
The time has come finally to accept that computers are now as effective
as any other traditional teaching tool—no better, no worse. Several factors
are involved with determining the effectiveness of computer instruction,
including the quality of the programs, environment of use (location and
accessibility of computers), and characteristics of the learner (e.g., anxiety,
level of computer knowledge) (Khoiny, 1996). Future research should be
aimed at developing tools for evaluating new programs and determining how
students learn with computers so existing programs and new programs can
be improved rather than continual comparison with other teaching methods.
 Education Applications 151

Limitations of Multimedia Technology

Limitations that emerge from detailed study of computer usage in nursing
education include the following.
r Cost factors: The initial time investment in developing good programs is ex-
tensive. For example, to author 1 hour of effective, terminal-tested tutorials
requires 120 to 150 hours of work. Once instructors become more adept at
design strategies, the time required is reduced. However, extensive analy-
ses of cost benefit and detailed studies of cost figures for the development
and operation of nursing CAI programs are unavailable. Although the cost
of the hardware may be dropping consistently, software development costs
are not. Hopefully, in the future institutions will enter into joint develop-
ment projects to control costs. One such enterprise is called MERLOT,
an acronym for Multimedia Educational Resource for Learning and On-
line Teaching; it is a consortium of U.S. and Canadian universities that
maintains an on-line peer reviewed catalog of learning materials that are
easily incorporated into faculty-designed courses. Although all university
disciplines are represented, nursing is extremely active in the submission
and peer review process of the organization, resulting in large number
of learning materials encompassing all aspects of nursing (MERLOT,
2005).
r Content control: Unless more nurse educators become knowledgeable in
the area of multimedia, there could be a tendency to abdicate the prepara-
tion of computer programs for nursing to educational computer software
firms. Decisions about nursing and nursing education could slip out of nurs-
ing hands. Nursing educators must monitor their own learning programs
to ensure that decisions related to nursing remain in the hands of nursing
content experts. Conversely, without a firm foundation, a sophisticated
computerized nursing curriculum, instead, become a patchwork coverage
of course material.
r Altered professorial roles: Teachers who have felt secure in their role as
dispensers of information may feel uncomfortable as they find their role
changing to that of facilitators, moderators, and coordinators. In addi-
tion, active involvement by faculty members in computerized instruction
requires that a reward structure exists that places value on published in-
structional design efforts to the same extent that it values research and
other publication activities.
r Technology: The dominance of the Windows and Macintosh personal com-
puter operating systems, along with Internet access, has greatly facilitated
the sharing of programs within and among institutions. However, many
programs are still locked into a single proprietary computer language and
hardware system. Translating an existing program from one computer op-
erating system and language to another may require more programming
152 Applications of Nursing Informatics

time than was required to produce the original. This is an impediment to

wider dissemination of nursing material. For this reason, there is probably
a redundancy of lessons among nursing users.
r Large central (or mainframe) computer systems or centrally controlled
servers: These systems place the nurse user at the whim of the individ-
ual or group controlling the system. The autonomy and control provided
by personal computers has removed this limitation. Nursing multimedia is
now dominated by the personal computer world. However, with the num-
ber of programs available on the Internet increasing at a dramatic rate [at
the time of writing, the MERLOT catalog housed 129 groups of nursing
lessons (MERLOT, 2005)] and with the huge potential of distance educa-
tion via the Internet soon to be realized, nursing institutions must consider
developing a balance between personal computers and large computer
systems.
r Lack of formal communication among users: In North America most
information about multimedia in nursing education is communicated
among nursing educators who meet at annual conferences, such as the
American Medical Informatics Association (AMIA) annual fall confer-
ence, or MERLOT, the American Nurses’ Association Council on Con-
tinuing Education. International exchanges, such as Medinfo and the
International Symposium on Nursing Informatics, also permit formal and
extensive exchange of information about the quality and quantity of avail-
able nursing programs.

Summary
The objective of this chapter has been to provide a macroscopic perspective
and conceptual framework concerning the place of computers in nursing
education. The “third wave” requirements of education are here. The deficits
in the existing system and the capability of using the computer to resolve
those deficits must be acknowledged. Taking advantage of these capabilities
means changes for educators, learners, and healthcare professionals, as well
as changes in work processes and the educational system. The potential of
multimedia technology offers education and healthcare professionals the
opportunity to move out of the reactive positions into which they have been
forced. Success will be achieved when these professionals contribute their
efforts to these phases.

1. Adapt the technology to the needs of the professions

2. Provide users with quality, professionally validated educational resources
3. Develop, update, and monitor multimedia resources
4. Support the utilization of multimedia technology by healthcare profes-
sionals
 Education Applications 153

Commitment to these efforts will lead to innovation and transformation

in learning. Although education will surely continue in the classroom, it will
also expand beyond it and into every area of professional life. Indeed, far
from making traditional approaches obsolete, multimedia technology can
become a source of revenue for institutions now hard pressed to make ends
meet. The demand for effective learning resources is great.
Computer technology is an exciting addition to the repertoire of teaching
strategies available for use by nurse educators. Its use must be based on
substantive content expertise, however, and its success will be dictated by
the imagination and creativity of nurse educators who author multimedia
materials.

References
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nal of Advanced Nursing 46(1):5–12.
Anthony, D. (2002). Online courses in the therapies survey. Information Technology
in Nursing 14(4):13–25.
Belfry, M.J., & Winne, P. (1988). A review of the effectiveness of computer-assisted
instruction in nursing education. Computers in Nursing 6(2):77–85.
Bitzer, M.D., & Bitzer, D.L. (1973). Teaching nursing by computer: an evaluative
study. Computers in Biology and Medicine 3:187–204.
Chang, B. (1986). Computer-aided instruction in nursing education. In: WereIy, H.H.,
J. Fitzpatrick, & R. Traunton, (eds.) Annual Review of Nursing Research, vol. 4.
New York: Springer, pp. 217–233.
Edwards, M.J.A. (2002). The Internet for Nurses and Allied Health Professionals, 3rd
ed. New York: Springer.
e-learners.com Inc. (2005). What Is e-Learning? http://www.elearners.com/-
resources/elearning-faq1.asp (accessed February 21, 2005).
Gaston, S. (1988). Knowledge, retention and attitude effects of computer-assisted
instruction. Journal of Nursing Education 27(1):30–34.
Hannah, R.S. (1998). Designing Multimedia for Health Education. Unpublished.
Harless, W.G., Drennan, G.G., Marxer, J.J., Root, W.G., & Miller, G.E. (1971). CASE:
a computer-aided simulation of the clinical encounter. Journal of Medical Educa-
tion 47:443–448.
Jenkins, T.M., Ball, M.J., & Bruns, B.M. (1983). The state of the art in technology
assisted learning. In: AAMSI Proceedings.
Jerram, P., & Gosney, M. (1996). Multimedia Power Tools. New York: Random House.
Khoiny, F.E. (1996). Factors that contribute to computer-assisted instruction effec-
tiveness. Computers in Nursing 13(4):165–168.
Kristof, R., & Satran, A. (1995). Interactivity by Design, Mountain View, CA: Adobe
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Locatis, C. (1992). Authoring Systems. Bethesda, MD: US Department of Health and
Human Services, Public Health Service, National Institutes of Health, National
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Longman, S., & Gabriel, M. (2004). Staff perceptions of E-learning. Canadian Nurse
100(1):23–27.
154 Applications of Nursing Informatics

Lopuck, L. (1996). Designing Multimedia: A Visual Guide to Multimedia and Online

Graphic Design. Berkeley, CA: Peachpit Press.
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ary 21, 2005).
Nyamathi, A., Chang, B., Sherman, B., & Grech, M. (1989). Computer use and nursing
research: CAI versus traditional learning. Western Journal of Nursing Research
11(4):498–501.
11
Research Applications
With Contributions by Ann Casebeer

For many nurse researchers, computer-mediated communication has be-

come as essential as the telephone.
—(Norris, 1999, p. 197)

Computer applications are an integral part of most research. Computing

hardware and software comprise useful timesaving tools and information-
gathering sources that are used regularly by researchers of all kinds (Parker,
2003). Whereas the basic principles and approaches to the conduct of nursing
research have remained relatively constant, great strides continue to be made
in the ways researchers can access evidence and manage and transfer data
and findings (Cotton, 2003b). This chapter focuses on some of the ways in
which nursing research can be enhanced by computer applications and the
research information and analytical tools to which they provide access.
Nursing, as a profession, must continue to develop a research-based body
of nursing practice knowledge as a central means to continuous improvement
of patient care. Nursing research also has an expanding role in contributing
to broader interdisciplinary health research focused on identifying and im-
plementing better healthcare practice. Therefore the focus in this chapter is
on clinical nursing practice research rather than on research related to nurs-
ing education or nursing administration, although many of the principles and
approaches discussed apply equally well to these areas. It is not our purpose
to provide a comprehensive discussion of clinical nursing research [see Gillis
and Jackson (2002) and Polit and Beck (2004) for an extensive description
of the principles and methods of nursing research]. Rather, the purpose of
this chapter is to provide an overview of the use of computer technology
and the web-based information to which it allows access in support of clini-
cal nursing research. Clinical nursing researchers must exploit all available
tools to aid the development of empirically based nursing practice.
The beginnings of clinical nursing research can be traced to Florence
Nightingale. In Notes on Nursing, Nightingale stated her firm belief in ap-
plied nursing research: “Averages again seduce us away from minute obser-
vation. . . . We know, say, that from 22 to 24 per 1000 will die in London next

155
156 Applications of Nursing Informatics

year. But minute enquiries enable us to know that in such a district, nay, in
such a street—or even on one side of the street, in a particular house, will
be the excess of mortality, that is, the person will die who ought not to have
died before old age” (Nightingale, 1860/1969, p. 124). Unfortunately, much
of nursing practice has been founded on intuition-based apprentice train-
ing programs. Much of that intuition was experiential, either the nurse’s or
the nursing teachers’, and was passed on to new learners using practitioner
authority as validation. The nursing profession is making a concerted effort
in its quest for empirical knowledge that will develop a scientific structure
for the practice of nursing. To know the true effectiveness of nursing ac-
tions, practice-oriented research grounded in sound theoretical concepts is
essential (Polit and Beck, 2004). Nursing must continue to challenge and ex-
amine its traditions, experiences, and intuitive actions by actively engaging
in nursing research.

Searching the Literature

Nursing research is predicated in part on the ability of the nurse researcher
to carry out a comprehensive review of the relevant literature and, in turn, to
appraise this literature critically (Brettle and Gambling, 2003; Griffin-Sobel,
2003). This task used to be conducted manually by spending untold hours
in the library thumbing through the cumulative indexes and journals. This
time-consuming task may or may not allow the researcher to locate relevant
material and most certainly would not result in a comprehensive collection
of all pertinent evidence. Computer-assisted systematic reviews yield much
more complete and valid compilations of the most relevant and up-to-date
information related to research and practice questions (Egger et al., 2003;
Helmer et al., 2001).
The advent of computerized databases of literature during the 1960s al-
lowed researchers, initially with the help of librarians, to search rapidly and
retrieve abstracts of literature immediately. University and college libraries
as well as the libraries of many large teaching hospitals continue to provide
this mediated literature searching to their staff, faculty, and students. Many
databases that were available only from online vendors have been mounted
locally by hospitals, colleges, and universities through a subscription process
enabling end-users to search these databases themselves via the Internet.
Many less commonly used databases are still available only through on-line
vendors, requiring password access from an organization or subscription.
Databases of primary interest to nurses conducting literature searches in-
clude CINAHL and MEDLINE. A description of these and other relevant
databases is found in Appendix G.
Even with easier, more rapid direct access to databases, effective litera-
ture searching remains a skilled process that must be acquired either through
training or through the assistance of someone with the expertise required.
 Research Applications 157

Literature searches of certain types are more problematic than others. For
example, finding relevant “gray” (unpublished) literature may be important
to the clinical research of interest but difficult to locate and evaluate (Conn
et al., 2003). Additionally, searching for qualitative evidence often pertinent
to nursing research poses unique problems. Barroso and colleagues (2003)
discuss the challenges of searching for qualitative research and made rec-
ommendations for improving the quality of such searches.
In mediated literature searching, a professional librarian works with the
researcher to identify appropriate keywords and subject headings to gen-
erate a printout of citations and abstracts related to the topic. With the
abstracts, the researcher can determine the relevance of a particular ar-
ticle to the research question before attempting to locate the article in a
database, local library or ordering it through an interlibrary loan system.
Researchers who choose to conduct their own searches should both ac-
quire training and seek the advice and assistance of a professional librarian.
Library staff can provide guidance in the selection of keywords and sub-
ject headings, as well as the correct search protocol for a given database,
saving the user hours of frustration. The capacity of a researcher to per-
sonally search the literature provides the opportunity for browsing and the
serendipitous discovery of information, which might appear unrelated to
another researcher or librarian but is important to the particular research
question or problem being pursued. Another innovation that helped re-
searchers was the development of on-line full-text information services. For
example, Ovid Technologies Inc. provides enhanced electronic full text to
more than 1500 leading scientific, academic, and medical journals and books
(http//www.ovid.com). Ovid is available through libraries and also as an in-
dividual subscription.
Once the researcher has searched appropriate literature databases, iden-
tified potentially useful citations, located and read the articles, and deter-
mined which are relevant to the research question, there is the matter of
indexing and filing the information that has been so laboriously gathered.
While it is still possible to use a manual system involving index cards or
photocopied pages covered with highlighter pen, general-purpose database
software packages are available for both office and personal computers. Bib-
liographic packages have undergone many changes and improvements in the
past several years. These packages allow the researcher to set up a personal
database of bibliographic references. Further, most of these packages allow
reformatting of entries automatically with only one command. If, for exam-
ple, the researcher has entered all the references in a personal bibliographic
file in APA format but the journal to which a paper is being submitted re-
quires Terabian format, the researcher selects the appropriate references,
issues a command, the computer automatically reformats the selected ref-
erences, and they are ready to be printed out. Commonly used programs in
biomedical/nursing research are Reference Manager, ProCite, and EndNote
(Nicoll, 2003).
158 Applications of Nursing Informatics

Preparation of Research Documents

The bane of every researcher’s existence is the paperwork. Grant proposals,
correspondence with funding agencies, consent forms, data-gathering forms
and instruments, ethics applications, consent forms, progress reports, grant
renewals, manuscripts for publication, all require multiple copies of essen-
tially the same information with minor modifications or slight revisions. The
advent of electronic text editing facilities and word processing equipment
has been a boon to all researchers when preparing research documents. The
speed and ease of computer use is well established—assisting in the prepa-
ration, revision, and formatting of research documents and reducing the
time spent on the paperwork associated with research. Today’s research en-
vironment demands a high level of computer literacy from all researchers
who intend to compete for grant funding and who wish to collaborate effec-
tively with other colleagues in obtaining existing evidence or creating new
knowledge for future improvement in clinical practice.
Text editing facilities today are a regular component of all word process-
ing software available for computers. Standard software packages (such as
Microsoft Word or Word Perfect) have become increasingly sophisticated
and easy to use. Centers of nursing research and learning resource centers
now include computers with appropriate word processing and other software
packages as required equipment for their researchers. Journal manuscripts
are typeset directly from the word-processing file prepared by the nurse re-
searcher. Additionally, many journals are now available only electronically,
not in a print version. For these journals, the author’s article file is reformat-
ted for online presentation. Similarly, book publishers, including this book’s
publisher, Springer, are typesetting books directly from authors’ electronic
files sent via the Internet. Web-based publishing is creating expanded op-
portunities to publish and access research. It is also raising issues around
ownership and production costs for both online and off-line journals and
literature generally (Graczynski and Moses, 2004).
The benefits of computerized methods of producing research documents
include reduced costs and fewer errors resulting from repeated retyping of
the manuscript, increased control of the document by the author, faster pro-
duction of the finished work, and greater ease of revision. In other words,
speed, accuracy, flexibility, and control are the result. The costs incurred are
the investment of the researcher’s time in acquiring keyboarding skills, locat-
ing appropriate software, and learning to use the available software tools.
Additional costs are purchase, lease, or rental of appropriate equipment
and software. All these are one-time costs that provide long-term benefits.
Access to and ability to use computerized word-processing packages has be-
come essential. As practitioners and researchers, we live in a computerized
world, and basic computer and word-processing skills and technology access
are essential areas of professional competence.
 Research Applications 159

Data Gathering
There has been an explosion in the range and scope of accessible data of
potential value to nursing researchers. Researchers use technology to man-
age the data gathering process. Facts (or data) originate with the patient.
Nurse researchers who seek to gather reliable and accurate facts should en-
sure that the data capture occurs as closely as possible to its source, i.e.,
the subject/patient. Technology can be helpful to the systematic collection,
management and transfer of accurate data. Nurse researchers are increas-
ingly using a variety of input devices including digital photography, biometric
probes and bar code generators and readers as well as hand held computers
and personal digital assistants (PDAs) for source data capture in nursing
research studies. (See Chapter 7 for more information on source data cap-
ture.) The archiving and transfer of digital and live images is a reality in prac-
tice and accessible to researchers (Blackmore et al., 2003; Moloney et al.,
2003).
The conduct of web-based research is becoming an acceptable method of
data collection, adding to the possibilities for direct input of research findings
prior to management and interpretation (Birnbaum, 2004). Research on
and through the Web is clearly a breakthrough in terms of reaching some
research participant populations; at the same time issues of data accuracy
and security are heightened and have created significant ethical issues and
debates (Cotton, 2003a; Ellett et al., 2004).
Increasingly, data are automatically and directly entered into a database
on a personal computer for analysis. There are far fewer opportunities for
coding or transcription errors with this method of data capture and transfer.
This is now an easily accessible option, as is direct input from patients or
clients themselves as well as practitioner input and access to relevant data
at the desk or bedside.
Principles of source data capture can also be applied to computer-assisted
interviewing methods. Computer-assisted interviewing methods allow the re-
searcher to capture the data immediately in the computer in a usable format.
Using these methods eliminates the step of data entry and has the potential
to improve data quality, as errors are commonly found in the transcription
from code sheet to computer. Computer-assisted interviewing can be accom-
plished either with the subject being physically present in the computer-base
interviewing room or through the use of Internet-based tools subjects can
use in the location of their choice (Read, 2004; Rew et al., 2004). There are
three types of computer-assisted interviewing.

r Computer-assisted self-interviewing (CASI): Research subjects answer

on-screen questions by selecting their response with a keyboard, light pen,
or touch screen. This method has been used in areas such as lifestyle risk
assessment, nutritional surveys, and health behavior studies.
160 Applications of Nursing Informatics

r Computer-assisted telephone interviewing (CATI): When using CATI, a

telephone interviewer reads each question from a computer screen. The
answer to the question is entered through the keyboard. The answer is
immediately placed in the correct preprogrammed row/column position.
The captured data are then already in the final form necessary for analysis.
r Computer-assisted personal interviewing (CAPI): Laptop computers al-
low the researcher to use the CATI process in a face-to-face setting. Ques-
tions are posed on the screen. Answers are entered immediately in a form
ready for analysis. Both open-ended and closed-ended questions can be
posed with these systems.

Advantages of Computer-Assisted Interviewing

r Automatic branching can be programmed, thereby decreasing errors that
result from incorrectly followed skip patterns.
r Text can be inserted into later questions. For example, if a current nursing
diagnosis or patient problem has been previously entered, a subsequent
question would replace “patient problem/nursing diagnosis” with the an-
swer given. This personalizes the interview.
r Question order and response categories can be automatically randomized.
When long lists of choices are given, particularly during telephone inter-
views, respondents tend to select from those at the end of the list. Random
reordering of the responses is one way to address this problem.
r On-line editing and consistency checking allow the interviewer to check
data captured while still interviewing. Many programs do not allow out-
of-scope answers to be recorded. This also increases the precision of the
data gathered.
r Typing is faster than writing when capturing answers to open-ended ques-
tions. Software resident spellcheck programs can then clean the captured
data. Content analysis of captured data is facilitated because the informa-
tion does not have to be entered from written notes.

Considerations When Using Computer-Assisted

Interviewing
r Each question is restricted to the size of the computer screen. If a question
scrolls to a second page, the speed of screen redisplay is important. Each
new screen must be immediately useful.
r Provision must be made for nonstandard movement through the question-
naire. The interviewer or respondent must be able to go back to a previous
question and check or change an answer.
r A major consideration is the up-front cost in both time and money to ac-
quire the hardware initially and develop the software and questionnaires.
 Research Applications 161

Use of Clinical Databases

Much clinical nursing research requires descriptive studies (i.e., initial gath-
ering of a database from which inferences and conclusions are drawn). With
the introduction of computerized information systems in healthcare insti-
tutions, nurses’ opportunity to access large databases of nursing practice
documentation has become a reality in many such institutions. Health and
hospital information system databases provide unique possibilities for retro-
spective studies generating nursing research questions and descriptive nurs-
ing research. However, not all systems are equally suitable for the storage or
manipulation of data relevant to nursing research, nor do all systems retain
on-line information for extended periods of time. From a nursing research
perspective, there are several considerations and problems associated with
the data currently being accumulated in many computerized hospital infor-
mation systems. Too often such data are formatted and retrievable merely as
patient record data rather than with any view to retrieval for research pur-
poses. The introduction of relational database management systems has been
most supportive of achieving the goal of simultaneously gathering clinical
documentation for the purposes of both legal records and nursing research.

Data Mining
With the advent of widespread use of source data capture and the elec-
tronic health record, healthcare clinical databases have grown exponen-
tially in both size and complexity. It has become increasingly difficult and
now nearly impossible for the researcher to manually analyze the massive
amounts of clinical data available from these large institutional or gov-
ernmental databases. Data mining, a step in the knowledge discovery in
databases (KDD) process, offers an approach to extracting useable and use-
ful information from large data sets. Data mining has been defined as “the
semiautomatic exploration and analysis of large quantities of data in or-
der to discover meaningful patterns and rules” (Berry and Linhoff, 1997,
p. 5). As the definition infers, data mining is generally focused on discovery,
looking for patterns in the vast amount of data available related to a partic-
ular question. For example, researchers Goodwin and Iannacchione (2002),
looking for factors that predict which women are at risk for preterm birth,
used data mining techniques to examine the relationship between gesta-
tional age at delivery and more than 4000 perinatal data variables. Manual
analysis could not accommodate such a large number of possible relation-
ships, but data mining identified seven key variables that could then be tested
further for their ability to predict the risk of preterm birth (Goodwin and
Iannachione, 2002).
There are challenges to using data mining techniques. The largest chal-
lenge arises from the lack of standardized data measurement and labeling.
162 Applications of Nursing Informatics

Clinical data require considerable preprocessing to standardize labels, re-

move redundant data, and complete necessary data transformations. For
example, “myocardial infarction” and “MI” refer to the same diagnosis, so
rules must be applied to account for multiple labels representing the same
category (Berger and Berger, 2004). Goodwin and Iannachione (2002) note
that data mining makes sense when there are large stores of data to be
searched, where the computing power is available to process the massive
analysis, and when the people exist to prepare and analyze both data and
output. Although computer systems complete the processing of the data sets,
knowledgeable domain experts, such as nurse researchers are required to
transform the resulting information into useful and understandable knowl-
edge to guide nursing practice (Berger and Berger, 2004).
Technology is now available to allow interfacing among computers within
a single institution as well as between computers in different institutions
or facilities. For example, it is possible to use the computer in one site via a
modem and telephone lines or cable or wireless connection to merge existing
data with data entered on, and processed by, a computer at another location.
This technology of intercomputer communication, or networking, allows
creation of larger, more diverse databases. Random sampling, large samples,
and control groups may be easier to delineate using the database linkage
provided by computer networking.
Furthermore, networking makes collaboration with colleagues in widely
separated geographic locations possible through the use of electronic mail
and other Internet-based collaboration tools. Researchers now have the
means at their disposal to collaborate with colleagues having similar re-
search interests and expertise, regardless of the fact that they may live and
work in locations that are widely separated geographically.
Using electronic means of communication, dialogue and exchange of
ideas, refinements in protocols, and interpretation of data occur in a timely
fashion. Previously, these interactions among investigators had not been pos-
sible unless the investigators lived and worked in close geographic proximity
to each other. The regular interactions and contact vital to the outcome of any
research study are fully available to all investigators working on a project,
independent of location. Thus, both data gathering and data analysis are
enhanced by the use of computer networking and telecommunications.
There are also concerns along with the benefits of technologically en-
hanced access including the potential for an overloading of communica-
tion and information—an explosion of data that can lead to paralysis of
sorts (Mathieson, 2003; Radner, 2004). As well, the emergence of viruses
that infect databases and e-mail transfers can corrupt the quality of ac-
cessible and reliable information for research and practice alike (Reid,
2002). It is essential to establish effective communication and information-
sharing protocols as well as to employ sophisticated virus protection
software.
 Research Applications 163

Data Analysis
A critical part of any research process involves analyzing data. Research data
can include numerical information of a quantitative or statistical nature or
take the form of narrative text providing qualitative information. Computer-
ized software packages can assist both types of data manipulation. As nurse
researchers work with others in increasingly multidisciplinary research and
practice teams, their own scope of research interest and analytical compe-
tencies grow.
Most experienced nurse researchers are familiar to a greater or lesser de-
gree with the use of computers in statistical analysis. There are hundreds of
software packages for use in carrying out statistical analysis on computers.
The best known and most widely used include BMDP (Biomedical Data Pro-
cessing), EPINFO (Epidemiological Information), SAS (Statistical Analysis
Software), and SPSS (Statistical Packages for the Social Sciences). Institu-
tions in which research is being conducted have these packages available
through their main computing facility or network. These particular software
packages are widely available internationally and on the Internet; they have
demonstrated consistency and stability, provide a wide variety of statisti-
cal treatments, and are fairly easy to learn and use. They are also powerful
enough to handle large volumes of data.
Statistical software packages are increasingly designed for use on personal
computers. Some packages, such as EPINFO, are available free of charge
on the Internet (www.cdc.gov/epiinfo/). Five fundamental criteria originally
identified by Francis (1981) have long been regarded as guidelines for novices
to use when evaluating the utility and quality of statistical programs: capa-
bilities, portability, ease of learning and use, reliability, and cost. Although
they are not as powerful as the statistical packages available on larger com-
puter systems or those linked from dedicated servers, researchers may, for
a variety of reasons, wish to carry out data analysis on a personal computer
(Anthony, 2004). If so, in addition to the criteria just mentioned, researchers
must consider the compatibility of their hardware and operating system with
what the software package requires, the quality of the documentation pro-
vided by the software distributor regarding how to use the system, and the
availability of technical support online or via telephone. Other important
considerations are limitations in the volume of data that can be manipulated
and stored as well as constraints regarding the number of statistical functions
that can be performed, although these capacity limitations are rapidly being
addressed in powerful microcomputers.
One of the more innovative applications of computers in data analysis is
the use of text editing programs in qualitative research (Wietzman, 2002).
Any researcher who has conducted qualitative studies is well aware that the
volume of field notes and interviews to be transcribed is enormous, costly,
and frequently overwhelming. Qualitative data analysis packages, such as
164 Applications of Nursing Informatics

Atlas/ti, Ethnograph, and NUDIST, provide a way to enter these data into
computer files. These programs then use computer technology to search the
text for occurrences of particular words or phrases indicative of data related
to a specific category or cluster (Morse and Richards, 2002). Using these
programs for qualitative research permits illustrative blocks of text to be
copied and moved easily into another file for use when composing the final
report.

Graphics
Remember the well-known phrase, “A picture is worth a thousand words”?
Before the advent of computer graphics, researchers were confronted with
mounds of paper containing the outcome of statistical processing of their
data. As they attempted to aggregate and interpret this mound of paper,
researchers often sketched graphs and charts of the results. These rough
sketches were useful when summarizing data and reducing it to a manageable
scale. Eventually, these sketches were refined and given to an artist, who
produced the formal published versions that were used in research reports
to illustrate the findings. Computers have the capacity to produce, rapidly
and inexpensively, a wide variety of graphs, scattergrams, histograms, and
charts simultaneously with the numerical data analysis. People can retain
only a limited number of figures in their heads at one time. These pictorial
representations greatly assist the investigator’s progress in interpreting the
data. At the same time, the use of computer graphics to prepare illustrations
to accompany research publications also is accelerating the rate and reducing
the cost at which findings can be prepared for publication.

Summary
The advantages of computers to researchers are speed, accuracy, and flexibil-
ity. In common with most researchers today, nurse researchers must know
how to use automated information systems to their advantage to provide
them with better information at all phases of the data gathering, data anal-
ysis, and communication of research findings. These computer applications
must be combined with well developed critical appraisal and research meth-
ods skills. This allows increased creativity and aids the development of the
body of scientific knowledge on which nursing theory, practice, and educa-
tion are based and through which nurses make important contributions to
wider health systems research. Nurse researchers and practicing nurses alike
must become proficient in the application and uses of computer technology
to forward the development and use of an empirical base for nursing prac-
tice. Nursing research plays a critical role in enhancing nursing practice and
 Research Applications 165

contributing to the wider body of clinical research necessary to patient care

and population health protection and improvement.

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Berry, M.J.A., & Linhoff, G. (1997). Data Mining Techniques for Marketing, Sales
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Cotton, A.H. (2003a). Ensnaring webs and nets: ethical issues in Internet-based
research. Contemporary Nursing 16(1–2):114–123.
Cotton, A.H. (2003b). The discursive field of Web-based health research: Implica-
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319.
Egger, M., Juni, P., Bartlett, C., Holenstein, F., & Sterne, J. (2003). How important are
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Ellett, M.L., Lane, L., & Keffer, J. (2004). Ethical and legal issues of conducting
nursing research via the Internet. Journal of Professional Nursing 20(1):68–74.
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Gillis, A., & Jackson, W. (2002). Research for Nurses: Methods and Interpretation.
Philadelphia: Davis.
Goodwin, L.K., & Iannachione, M.A. (2002). Data mining methods for improving
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Griffin-Sobel, J.P. (2003). Research in practice: the literature review. Gastroenterol-
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Helmer, D., Savoie, I., Green, C., & Kazanjian, A. (2001). Evidence-based practice:
Extending the search to find material for the systematic review. Bulletin of the
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Mathieson, S. (2003). E-novation. spam with everything. Health Service Journal 8
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Moloney, M.F., Dietrich, A.S., Strickland, O., & Myerburg, S. (2003). Using In-
ternet discussion boards as virtual focus groups. Advances in Nursing Science
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Morse, J., & Richards, L. (2002). Readme First for a User’s Guide to Qualitative
Methods. Thousands Oaks, CA: Sage.
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tered Dental Hygienist 23(9):78–81.
Polit, D.F., & Beck, C.T. (2004). Nursing Research: Principles and Methods. Philadel-
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mation overload. Journal of Asset Management 4(6):364.
Read, C.Y. (2004). Conducting a client-focused survey using email. CIN: Computers,
Informatics, Nursing 22(2):83–89.
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Additional Resources
Brink, P.J., & Wood, M.J. (2001). Basic Steps in Planning Nursing Research. Boston:
Jones & Bartlett.
Crombie, I.K. (1996). The Pocket Guide to Critical Appraisal. London: BMJ Publish-
ing Group.
Egger, M., Davery Smith, G., & Altman, D. (Eds.) (2001). Systematic Reviews in
Healthcare, 2nd ed. London: BMJ Books.
Garrand, J. (1999). Health Sciences Literature Review Made Easy. Gaithersburg, MD:
Aspen.
Gift, A.G. (1997). Clarifying Concepts in Nursing Research. New York: Springer.
Hulley, S.B., Cummings, S.R., & Browner, W.S., et al. (2001). Designing Clinical
Research. Philadelphia: Lippincott Williams & Wilkins.
Lakeman, R. (1997). Using the Internet for data collection in nursing. Computers in
Nursing 15(5):269–275.
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BMJ Publishing Group.
 Research Applications 167

Websites of Internet
CINAHLdirect: http//www.cinahl.com
International Healthcare Research Guide: http//www.health.ucalgary.ca/
National Institute of Nursing Research (NINR): http//www.nih.gov/ninr
National Institutes of Health: Scientific Resources: http://www.nih.gov/
science
Research Institutes: http//pie.org/E21224T3783
SVR Nursing Connections Links to Nursing E-Journals: http//homel.inet.
tele.dk/box4280/nursedk/journ.htm
Newsgroups: Usenet newsgroup:sci.research
Part IV
Infrastructure Elements of the
Informatics Environment
12
Nursing Data Standards

Nursing Values Related to Health Information

The initial systems for gathering minimum uniform health data can be traced
back to systems devised by Florence Nightingale over a century ago (Verney
1970). Nightingale (1859) asserted the need for nurses to use their powers
of memory and nonsubjective observation to track the condition of those
in their care. Subsequently (Nightingale 1863), she provided forms and def-
initions for the collection of uniform hospital statistics. In conclusion, she
wrote (Nightingale 1863):

I am fain to sum up with an urgent appeal for adopting this or some uniform system
of publishing the statistical records of hospitals. There is a growing conviction that in
all hospitals, even in those which are best conducted, there is a great and unnecessary
waste of life; . . . It is imperative that this impression should be either dissipated or
confirmed.
In attempting to arrive at the truth, I have applied everywhere for information,
but in scarcely an instance have I been able to obtain hospital records fit for any
purpose of comparison . . . if wisely used, these improved statistics would tell us more
of the relative value of particular operations and modes of treatment than we have
any means of obtaining at present. They would enable us, besides, to ascertain the
influence of the hospital . . . upon the general course of operations and diseases pass-
ing through its wards; and the truth thus ascertained would enable us to save life and
suffering, and to improve the treatment and management of the sick and maimed
poor.

The needs have not changed. Nurses must be able to manage and process
nursing data, information, and knowledge to support patient care delivery in
diverse care delivery settings (Graves and Corcoran, 1989). Ozbolt, (1999)
maintained that:

Standard terms and codes are needed to record as structured data the problems and
issues that nurses and other caregivers address; the actions they take to prevent,

171
172 Infrastructure Elements of the Informatics Environment

ameliorate, or resolve the problems; and the results of their care. Such data could be
used to increase the effectiveness of care and control costs.

There is an essential linkage among access to information, client outcomes

and patient safety. “As Lang has succinctly and aptly described the present
situation: If we cannot name it, we cannot control it, finance it, teach it,
research it or put it into public policy” (Clark and Lang, 1992). Access to
information about their practice arms nurses with evidence to support the
contribution of nursing to patient outcomes. Outcomes research is an essen-
tial foundation for evidence-based nursing practice. Evidence-based practice
is a means of promoting and enhancing patient safety.

Evolution of Nursing Information and

Nursing Data Elements
There are a variety of concepts that interlink when considering the
capture of nursing practice data. Figure 12.1 illustrates the derivation,
from nursing practice, of nursing classification, nursing terminology, min-
imum data sets, reference terminology models, and the resulting feedback
loop.

FIGURE 12.1. Relationships between nursing practice and classification, terminology,

minimum data sets, and reference terminology model.
 Nursing Data Standards 173

United States
Uniform Hospital Discharge Data Set
In the United States, the Uniform Hospital Discharge Data Set (UHDDS)
was developed over a 5-year period during the early 1970s. It identified the
minimum basic set of data elements to be collected from all hospital records
at the point of patient discharge from hospitals. In 1974, the UHDDS was
adopted and mandated by the Secretary of the Department of Health and
Human Services for collection by the U.S. National Committee on Vital and
Health Statistics (Abdellah, 1988; Pearce, 1988). The UHDDS provided the
model for the hospital discharge abstract that was subsequently developed
in Canada and ultimately evolved into the Discharge Abstract Database
(DAD), now maintained by the Canadian Institute for Health Information
(CIHI).
The care items included in the UHDDS focused on physician-derived
clinical data (specifically, medical diagnosis and procedures based on medical
treatments). There were absolutely no nursing clinical data included in this
data set. Patient care is not exclusively physician-directed; therefore, a data
set of this nature falls short of providing a complete, accurate representation
of information related to the operation of hospitals.

Nursing Minimum Data Set

In response to recognition of the information gap created by the exclusion
of nursing data elements from the Uniform Hospital Discharge Data Set,
Werley and colleagues developed the Nursing Minimum Data Set (NMDS)
through a consensus conference at the University of WisconsinMilwaukee
School of Nursing in 1985 (Werley and Lang 1988). The NMDS was defined
as “a minimum set of items of information with uniform definitions and
categories concerning the specific dimension of professional nursing, which
meets the information needs of multiple data users in the healthcare system”
(Werley and Lang 1988). There were five purposes of the NMDS.
r Establish comparability of nursing data across practice settings and geo-
graphic boundaries
r Capture descriptors reflecting the nursing care of clients and their families
in a variety of settings
r Project trends in nursing care needs and resource use according to health
problems
r Provide a database for nursing research
r Provide data about nursing care for consideration by individuals involved
in health policy decision-making
The NMDS consisted of nursing care elements, patient demographic ele-
ments, and service elements. The nursing care elements of nursing diagnosis,
nursing intervention, nursing outcome, and intensity of nursing care drew
174 Infrastructure Elements of the Informatics Environment

on the nursing process used by nurses to plan and provide patient care in any
setting. The patient demographic and service elements, except health record
number and the unique number of the nurse provider, are data elements con-
tained in the UHDDS and could be accessed through linkage with this data
set (Werley and Lang, 1988). Once the NMDS was agreed upon, uniform
definitions for each of the data elements and standard classification systems
were necessary for collection of uniform, accurate data to be feasible.

Classification Systems for NMDS Data Elements

The North American Nursing Diagnosis Association (NANDA) initiated the
development of labels for the clinical phenomena for which nurses provide
care (i.e. nursing diagnosis) in 1973. NANDA has defined nursing diagnosis
as “a clinical judgment about individual, family, or community responses to
actual and potential health problems and life processes. Nursing diagnoses
provide the basis for selection of nursing interventions to achieve outcomes
of which the nurse is accountable” (Carpenito, 1989).
The Visiting Nurses Association (VNA) of Omaha developed the problem
classification scheme, intervention scheme, and problem rating scale for out-
comes related to community health client problems and nursing problems
used for documenting community health nursing services. The Omaha classi-
fication system defined a problem as “a clinical judgment about environmen-
tal, psychosocial, physiologic and health related behavior data that is [sic] of
interest or concern to the client” (Martin, 1988; Martin and Scheet 1992).
The Home Healthcare Classification (HHCC) was developed at the
Georgetown University School of Nursing from 1988 to 1991 to assess and
classify home health Medicare clients for predicting their need for nursing
and other home care services as well as for measuring outcomes and data on
the resources employed (Saba, 1992). Nursing interventions were defined in
the HHCC: Nursing Interventions as a nursing service, with significant treat-
ment, intervention, or activity identified to carry out the medical or nursing
order (Saba, 1992). Nursing interventions were considered critical measures
of the resources used.
The Nursing Interventions Classification (NIC) and Nursing Outcomes
Classification System (NOC) were developed by a large research team (the
Iowa Intervention Project) led by McCloskey and Bulechek at the University
of Iowa. This team defined nursing interventions as “any treatment, based
upon clinical judgment and knowledge, that a nurse performs to enhance pa-
tient/client outcomes. Nursing interventions include both direct and indirect
care; both nurse-initiated, physician-initiated and other-provider-initiated
treatments”(McCloskey and Bulechek, 1996). NIC was coded to be consis-
tent with the Current Procedural Terminology, American Medical Associ-
ation, and the Healthcare Financing Administration’s Common Procedure
Coding System and was included in the Library of Medicine’s Metathesaurus
for a Unified Medical Language. Additionally, it has been endorsed by the
 Nursing Data Standards 175

American Nurses Association (ANA) for inclusion in the proposed Unified

Nursing Language System (McCloskey and Bulechek, 1996; McCormick
et al., 1994). NIC provides a standardized language that can be used across
settings and across healthcare disciplines (McCloskey and Bulechek, 1996).
Independent and collaborative interventions as well as basic and complex
interventions were included. A nursing outcomes classification (NOC) sys-
tem has also been developed in conjunction with the NIC through the Iowa
Intervention Project Johnson et al., 2000).
The Unified Medical Language System (UMLS) includes NANDA, the
Omaha System, the HHCC, and the NIC. The UMLS is a long-term research
project developed by the U.S. National Library of Medicine to integrate
clinical vocabularies from various sources so data from each can be cross-
referenced when needed. In addition all four of these classifications have
been incorporated into the International Classification for Nursing Practice
(ICNP).

International Classification for Nursing Practice (ICNP)

R

The International Council of Nurses (ICN), as a component of its commit-

ment to advance nursing thought the world, initiated a long-term project to
develop an international classification for nursing practice (ICNP) in 1990.
The motivation was to support the processes of nursing practice and to ad-
vance the knowledge necessary for cost-effective delivery of quality nursing
care (Ehnfors, 1999; Nielsen and Mortensen, 1999). The intent was to estab-
lish a common language about nursing practice that was capable of describing
nursing care, permitting comparison of nursing data, demonstrating or pro-
jecting tendencies, and stimulating nursing research (International Council
of Nurses, 1993, 1996, 1999). In 1993, a draft of the classification was pro-
posed that included virtually all of the nursing classification schemes that
had been developed internationally. The aim was to provide worldwide in-
put into the construction of a comprehensive classification scheme that could
eventually be used by nurses around the world. The Alpha Version was re-
leased for comment and critique in 1996, followed in 1999 by a Beta Version.
The Beta 2 version was published in 2002 (International Council of Nurses,
2002b) R
and Version 1 was released at the ICN Congress in 2005 (ICN 2005).
The ICNP R
is a classification of nursing phenomena, actions, and out-
comes. It provides a terminology for nursing practice that serves as a unify-
ing framework into which existing nursing vocabularies and classifications
can be cross-mapped to enable comparison of nursing data (International
Council of Nurses, 2002b).
The initial objectives of the ICNP R
were reviewed by the ICNP Evaluation
Committee in 2000. The objectives were revised to direct the aims of the
ICNP R
program.
r Establish a common language for describing nursing practice to improve
communication among nurses and between nurses and others
176 Infrastructure Elements of the Informatics Environment

r Represent concepts used in local practice across languages and specialty

areas
r Describe the nursing care of people (individuals, families, communities)
worldwide
r Enable comparison of nursing data across client populations, settings, ge-
ographic areas, and time
r Stimulate nursing research through links to data available in nursing and
health information systems
r Provide data about nursing practice to influence nursing education and
health policy
r Project trends in patient needs, provision of nursing treatments, resource
utilization, and outcomes of nursing care

Europe
Telenurse
European nurses also recognized that their health systems need to include
nursing data elements that are significant in the nursing decision-making
process. A research initiative entitled “A Concerted Action on Euro-
pean Classification for Nursing Practice with Special Regard to Patient
Problems/Nursing Diagnosis, Nursing Intervention, and Outcomes” (TE-
LENURSING) was launched in 1991. The objectives of TELENURSING
were to create a network of nurses interested in the classification of patient
problems/nursing diagnosis, nursing interventions, nursing outcomes; min-
imum data sets and healthcare informatics; raising the awareness among
nurses of standardization efforts in healthcare informatics; and linking the
technical approach of national groups and the professional approach of inter-
national groups with regard to the development of classifications of health-
care. The TELENURSING group established evidence of an interest in
developing data standards and a nursing minimum data set. The next step
was to promote standardization of definitions, classification, and coding of
data as initial work that may contribute to the development of internation-
ally comparable nursing minimum data sets (Mortensen et al., 1994). The
second phase of the project was TELENURSE, which stood for telematic
applications for nurses. TELENURSE was a dedicated effort to the follow-
ing goals (Mortensen, 1997).
r Disseminate and promote the ICNP in Europe in collaboration with the
ICN and the national member organization in Europe
r Build consensus among European nurses
r Demonstrate how comparative telematics-based nursing data could be
used in nursing modules of electronic patient records

The final phase, TELENENURSE ID, was the development, testing, and
evaluation of software products using the ICNP
R
in electronic health records.
 Nursing Data Standards 177

This phase also included translation of the alpha version of ICNP

R
into
14 European languages and collaboration with the ICN in the preparation
of the beta version of ICNP
R
(Mortensen, 1999).

European Standardization Committee

The European Standardization Committee (Comite European de Normal-
isatrion) Technical Committee 251 on Medical Informatics (CEN TC 251)
brought together the efforts of the ICNP program (Coenen et al., 2001;
Hardiker and Rector, 1998; Hardiker et al., 2000; Mortensen, 1997, 1999;
Nielsen and Mortensen, 1996; Ozbolt, 2000b), Telenurse ID (Mortensen,
1999; Nielsen and Mortensen, 1996), and other European efforts such as
nursing activities in the Galen projects (Hardiker and Rector 1998; Hardiker
et al., 2000) into a Prestandard—CEN prENV 14032 (Ozbolt, 2000b). The
CEN Prestandard broadly addresses categorical structures for nursing diag-
noses and nursing actions (ISO, 2002, 2003).

Canada
Nurses in Canada who were monitoring development of the NMDS in the
United States urged Canadian nurses to initiate similar activity. The Cana-
dian Nurses Association responded to a resolution calling for a national con-
sensus conference “to develop in Canada a standardized format (NMDS) for
purposes of ensuring entry, accessibility, and retrievability of nursing data”
(Canadian Nurses Association 1990). The NMDS conference was held in Ed-
monton, Canada in 1992. The overall objective of this working conference
was to develop an NMDS in Canada to ensure the availability and accessi-
bility of standardized nursing data. Because of recognition of the paucity of
dialogue that had taken place on the topic among Canadian nurses and the
inappropriateness of attempting to achieve consensus on the topic at such an
early stage, the invitational conference brought together those individuals
best able to formulate a plan for initiating the development of an NMDS in
Canada. The Canadian NMDS conference culminated in the identification
of five elements.
r Client status is broadly defined as a label for the set of indicators that re-
flect the phenomena for which nurses provide care relative to the health
status of clients (McGee, 1993). Although client status is similar to nurs-
ing diagnosis, the term client status was preferred because it represents a
broader spectrum of health and illness. The common label “client status” is
inclusive of input from all disciplines. The summative statements referring
to the phenomena for which nurses provide care (i.e., nursing diagnosis)
are merely one aspect of client status at a point in time, in the same way
as medical diagnosis.
r Nursing interventions refer to purposeful and deliberate health affecting
interventions (direct and indirect), based on assessment of client status,
178 Infrastructure Elements of the Informatics Environment

that are designed to bring about results that benefit clients (Alberta As-
sociation of Registered Nurses, 1994).
r Client outcome is defined as a “clients’ status at a defined point(s) fol-
lowing healthcare [affecting] intervention” (Marek and Lang, 1993). It is
influenced to varying degrees by the interventions of all care providers.
r Nursing intensity “refers to the amount and type of nursing resource used
to [provide] care” (O’Brien-Pallas and Giovannetti, 1993)
r Primary nurse identifier is a single unique lifetime identification number for
each individual nurse. This identifier is independent of geographic location
(province or territory), practice sector (e.g., acute care, community care,
public health), or employer.

Group deliberations on each of the data elements are summarized else-

where (Canadian Nurses Association, 1993a). These nursing data elements
were proposed for addition to existing national data sets as a next step toward
a cross sectoral, multidisciplinary, longitudinal national health database in
Canada (Canadian Nurses Association, 1993a). However, some individuals
and national organizations in Canada perceived the Canadian use of the
term “nursing minimum data set” to portray a stand-alone nursing data set
such as that in the United States. In Canada, this was not the intent. It is es-
sential in Canada that the nursing data elements constitute one component
of fully integrated health information data, such as the Canadian Institute
for Health Information (CIHI) discharge abstract data set (Canadian In-
stitute for Health Information, 2002) or an electronic health record (EHR)
such as that being developed under the leadership of Infoway. Therefore, the
five nursing data elements were identified collectively as the Nursing Com-
ponents of Health Information (Health Information: Nursing Components,
HI:NC) (Canadian Nurses Association, 1993b).
Following the Conference in 1992, CNA’s Working Group on the Nursing
Components of Health Information (HI:NC Working Group) continued to
build on the work that had been started. In 1997 a national consensus was
reached on three clinical nursing care data elements: client status, nursing
intervention, and client outcome as well as nursing resource intensity and
nurse identifier (Canadian Nurses Association, 2001a).
Identifying data elements that represent the most important aspects of
nursing care is only the first step. In Canada, nurses face an immediate
challenge to determine the most effective and efficient means to collect and
code data elements that reflect nursing practice. To collect the data reflecting
nursing contributions within the larger health information system, there is a
need for consistent data collection using standardized languages to aggregate
and compare data (Canadian Nurses Association, 1998).
In October 1999, a meeting was held at the CIHI in Toronto. Representa-
tives of CIHI and CNA, as well as nurse researchers and nursing informatics
specialists, from across the country discussed the gaps and opportunities for
nursing data in the national health databases held by CIHI. A number of
nursing informatics leaders representing CNA supported ICNP in principle
 Nursing Data Standards 179

as the most universal, generic, comprehensive foundational classification

system for nursing at the time. CIHI representatives committed to exploring
inclusion of the five data elements comprising the Nursing Components of
Health Information in their national databases. Regrettably, CIHI’s inves-
tigation of the version of ICNP available at the time (early beta version)
revealed that the lack of a coding structure was a significant barrier to im-
plementation at that time. This barrier has now been eliminated in Version 1.
Another barrier was the apparent lack of awareness and consensus among
nurses about the need for and importance of capturing nursing data nation-
ally. As discussed in the following paragraph, the second barrier has been
substantially reduced during the intervening 4 years since the CIHI analysis
of ICNP.
In March 2000, CNA completed a discussion paper (Canadian Nurses As-
sociation, 2000) proposing that registered nurses in Canada support ICNP
in principle as the foundational classification system for nursing practice in
Canada. Responses and feedback received from the consultation related
to this discussion paper indicated strong support from CNA’s member ju-
risdictions for investigating how ICNP might be adapted for use in Canada
(Canadian Nurses Association, 2001a). The result was a CNA position state-
ment (Canadian Nurses Association, 2001b).
In Canada, nurses have come to recognize the need to incorporate the
Nursing Components of Health Information into the national health infor-
mation infostructure (national data bases and EHRs) as federal and provin-
cial health information systems are being restructured. To ensure that nurs-
ing data are incorporated into the national health infostructure, nurses must
participate in the design, standards development, and pilot studies to ensure
capture of data that are essential to reflect the contribution of nursing to
healthcare in Canada.

Current State of Nursing Information in Clinical

Nursing Practice
Internationally
International Classification for Nursing Practice (ICNP)
R

Nursing information and specifically nursing data elements with their asso-
ciated definitions and classification systems evolved simultaneously in dis-
parate parts of the world. Efforts at consensus and convergence among these
classification systems led to the development of the ICNP R
by the ICN.

R
The beta 2 version of the ICNP was released in 2002. The differences be-
tween the beta and the beta 2 versions of the ICNP R
are mainly editorial

R
corrections. The ICNP Beta 2 provided a version for ongoing testing and
evaluation. Continuing development, revision, and updating based on re-
search and experience with ICNP R
resulted in the production and release of
ICNP Version 1 at the ICN Congress in Taiwan in 2005. ICNP

R R
Version 1 is
180 Infrastructure Elements of the Informatics Environment

a mature product with a level of stability that can provide vendors confidence
to encourage incorporation into software products. In addition to mainte-
nance and release of updated versions of the ICNP R
, the ICNP
R
program
established formal evaluation and review processes to advance the ongo-
ing maintenance and advancement of the ICNP R
(International Council of
Nurses, 2002c).
As shown in Table 12.1 the International Council of Nurses (2002a) has
identified work under way on developing and refining the ICNP R
in one
TABLE 12.1. ICNP
R
Projects registered with the ICN (International Council of
Nurses, 2005)
Country Project
Austria ICNP R
German Browser
Using ICNP R
in Hospital Information Systems
Botswana ICNP R
in Botswana (W.K. Kellogg/ICN)
Brazil A linguistic analysis of the ICNP R
Beta Version
Social violence: A case for classification as a sub-phenomenon of
community in the ICNP R

ICNP Project in Brazil (W.K. Kellogg/ICN)

Canada Authenticating the Voice of Nursing Through the Use of ICNP in
Capturing Nursing Data from Multiple Practice Settings
Collecting Data to Reflect Nursing Impact
The Use of the International Classification for Nursing Practice for
Capturing Community Health Nursing
Chile ICNP R
Project in Chile (W.K. Kellogg/ICN)
Colombia ICNP R
Project in Colombia (W.K. Kellogg/ICN)
Czech Republic ICNP R
User Group
Denmark Classificatory Review of the ICNP
ICNP R
Going Live in Nursing Homes
Estonia Implementation of the ICNP into nursing practice
European Union Telenurse ID
Germany Conceptual System Design and Implementation of a web-based
Classification-Browser for Documentation of Nursing Practice with
PHP and XML
Using the ICNP R
in Continuity of Care in the Osnabrück Region
Introduction and evaluation of nursing documentation systems
Nursing Classification system-practical use and integration in a clinical
information system (CIS) on the example of the ICNP R
Beta Version
Italy Testing of the International Classification for Nursing Practice to define
nursing diagnosis and procedures: usage in the electronic nursing
record and in the implementation of pressure ulcers prevention plan
Translation and Testing ICNP R
in Italy
International ISO—Integration of a Reference Terminology Model for Nursing
Japan Evaluation at Nine Months after the Establishment of Nursing Care
Support System with Reference to ICNP
Fundamental research on development of community nursing
assessment and evaluation for elderly people
Development of the Standardized Nursing Language System in Japan
Validation study of select ICNP R
terms
Nursing practice in transurethral ureterolithotripsy treatment
Korea Development of electronic nursing record model through application
and evaluation of ICNP R
in Nursing
 Nursing Data Standards 181

TABLE 12.1. (Continued)

Country Project
Mexico ICNP R
in Mexico (W.K. Kellogg/ICN)
Netherlands Cross-mapping ICNP R
and ICF
New Zealand An International Classification for Nursing Practice: Terms used by
Community-based Mental Health Nurses to Describe their Practice
Norway Evaluating the beta-version of the International Classification for Nursing
Practice (ICNP R
)
Pakistan Nursing Care Plan in Pakistan
Poland ICNP R
in Poland
Portugal Nursing Information Systems: Support, Structure and content-an action
research approach
Study about the cultural adequacy of ICNP concepts and definitions on an
hospital obstetric unit and content-an action research approach
Clinical evaluation of ICNP R
in a Portuguese perioperative nursing setting
Study about the relevance of nursing documentation for the continuity of
care along nursing shifts on a hospital unit
Study of the benefits for citizens, related with the implementation of an
automated articulation between hospitals and health centers by means of
nursing information systems
Study about the intensity of nursing care in primary health care
The ICNP Beta and the terms used by the Nurses of Madeira Autonomous
Region
Slovenia ICNP Browser in Slovenia
Translation and dissemination of the ICNP R
in Slovenia
South Africa ICNP and the electronic record
ICNP R
Project in South Africa (W.K. Kellogg/ICN)
Swaziland 
ICNP R in Swaziland (W.K. Kellogg/ICN)
Sweden Learning and Using the ICNP R
on the Web
Swedish Nursing Terminology Workgroup
Switzerland Deriving Nursing Workload Data from the Electronic Health Record
NURSING Data
German Speaking ICNP R
Development and Evaluation Project
Taiwan ICNP R
Validation Project in Taiwan
Development of Integrated Multi-modal Interface for Recording Nursing
Care Activities
Thailand A Study of Nursing Minimum Data Set in Inpatients Departments of
Queen Sawangwattana Memorial Hospital at Sriracha
Nursing Diagnosis Used in Nursing Practice among Professional Nurses at
Nan Hospital
RTG/WHO: Nursing Minimum Data Set and Preliminary Nursing
Classification
UK Testing Reference Terminology
USA A content coverage study: Coded terminologies and post acute care data
sets
Evaluation of the ICNP R

Multinational Validation Study of Dignified Dying

The International Study of Certified Nurses: Implications for the ICNP
International Nursing Minimum/Essential Data Set (i-NMDS)
Use of terminology tools to ease use of ICNP R
in selected American
graduate nursing schools
Zimbabwe ICNP R
in Zimbabwe (W.K. Kellogg/ICN)
182 Infrastructure Elements of the Informatics Environment

international project and 64 other projects in 30 countries. There does not

seem to be any country where the ICNP is being used nationwide in clinical
nursing practice.

International Standards Organization Technical Committee

on Health Informatics (ISO TC 215)
Nursing terminologies, in either paper-based or computer-based form, have
been designed as enumerated classifications and implemented as interface
terminologies at the point of care and as administrative terminologies to
examine nursing data across settings. As discussed in the previous sections,
many standardized terminologies exist and no single standardized terminol-
ogy is complete for the domain of nursing in terms of breadth or granularity.
The most comprehensive of the classifications systems is the ICNP.
Experts in the field of concept representation (Bakken and Mead, 1997;
Campbell et al., 1997; Ingenerf, 1995; Ozbolt, 2002) widely recognize that
classifications are useful to people as a means of communicating and un-
derstanding. However, classifications are not sufficiently granular or specific
for use in electronic information systems (Bakken and Mead, 1997; ISO,
2002, 2003). Such systems require a formal terminology that Ingenerf (1995)
defined as

based on concepts or units of thought, rather than on lexical expressions or terms.

Formal terminologies also have explicit rules for combining simple concepts into
sensible complex concepts. Finally, formal terminologies have a knowledge repre-
sentation scheme, or formalism, for depicting the relationships among the concepts.

The International Standards Organization Technical Committee 215 on

Health Informatics Standards (ISO TC 215) has facilitated an international
convergence and consensus-building process to develop a formal termino-
logical model for nursing. Currently the only concept-oriented terminology
that integrates the domain concepts of nursing in a manner suitable for com-
puter processing is the ISO’s International Standard 18104—“Integration
of a Reference Terminology Model for Nursing.” This international stan-
dard was accepted by the ISO member nations on December 15, 2003 (ISO,
2003). The Reference Terminology Model for Nursing (RTMN) is being re-
viewed and evaluated by each member nation for national adoption and use
in electronic information systems as the standard for linking nursing classi-
fication systems. It was approved as a national standard of Canada in March
2005.
The ISO’s International Standard 18104 (ISO, 2003) focuses specifically
on the conceptual structures that are represented in a reference terminol-
ogy model rather than in other types of information models. Moreover,
toward the goal of integration with other healthcare models, the reference
terminology models for nursing diagnoses and nursing actions in the ISO
international standard reflect harmonization with evolving terminology and
information model standards outside the domain of nursing (ISO, 2003).
 Nursing Data Standards 183

The stated purpose of International Standard 18104 (International

Standards Organization, 2003) is to establish a nursing reference terminology
model consistent with the goals and objectives of other specific health ter-
minology models in order to provide a more unified reference health model.
The International Standard 18104 (ISO, 2003) includes the development of
reference terminology models for nursing diagnoses and nursing actions and
relevant terminology and definitions for its implementation. The anticipated
uses (ISO, 2003) for the reference terminology model are the following.
r Support the intentional definition of nursing diagnosis and nursing action
concepts
r Facilitate the representation of nursing diagnosis and nursing action con-
cepts and their relationships in a manner suitable for computer processing
r Provide a framework for the generation of compositional expressions from
atomic concepts within a reference terminology
r Facilitate the construction of nursing terminologies in a regular form that
makes mapping among them easier
r Facilitate the mapping among nursing diagnosis and nursing action con-
cepts from various terminologies including those developed as interface
terminologies and statistical classifications
r Enable the systematic evaluation of terminologies and associated termi-
nology models for purposes of harmonization
r Provide a language to describe the structure of nursing diagnosis and nurs-
ing action concepts to enable appropriate integration with information
models (e.g., Health Level 7 Reference Information Model).
The ISO 18104 Reference Terminology Model for Nursing (ISO, 2003)
is already guiding the efforts of the team modeling nursing concepts and
relationships for SNOMED-CT. SNOMED-CT will contain the first real-
ization of a formal reference terminology for nursing. Because SNOMED-
CT will encompass virtually all of healthcare, nursing’s formal terminology
will be integrated de facto into a broad healthcare terminology (Bakken
et al., 2001). HL7 is beginning to register nursing vocabularies that sat-
isfy that organization’s standards for sending messages containing health-
care information (Ozbolt, 2002). In addition, LOINC (Logical Observations,
Identifiers, Names, and Codes) has adapted its standards to accept nursing
information and has added terms for nursing assessment data (Bakken et al.,
2000).

United States
The Nursing Terminology Summit began in 1999 and has been held annu-
ally at Vanderbilt University (Ozbolt, 2000a, 2000b, 2000c). These summits
bring together the developers of nursing vocabularies with leaders of pro-
fessional associations and standards developing organizations, developers
and vendors of healthcare information systems, and representatives of gov-
ernment agencies concerned with healthcare terminology standards. Efforts
184 Infrastructure Elements of the Informatics Environment

of this group have focused on contributing to the development of a formal,

concept-based terminology model for nursing to which the preceding classi-
fications as well as other sets of nursing terms could be mapped. The intent
is to resolve ambiguities among representations of nursing concepts and re-
lationships between evolving standards being produced by standards bodies
such as the International Standards Organization Technical Committe on
Health Informatics (ISO TC 215), Health Level 7 (HL7), and Logical Ob-
servations, Identifiers, Names, and Codes (LOINC) and incorporation of
the formal terminology into information systems. Over four years, the major
accomplishments of the Terminology Summit are:
r Identified the need for a formal, concept-based terminology for nursing
to which classifications and other sets of nursing terms could be mapped.
r Determined that the first step in developing a formal concept-based termi-
nology was to depict the model of nursing concepts and relationships that
would subsequently be populated by terms providing specific instances of
the concepts.
r Facilitated collaboration among participants toward developing a nursing
concept model.
r Reviewed, analyzed, and critiqued the European CEN TC 215 “Categor-
ical System for Nursing,” a model with characteristics approximating a
nomenclature.
r Supported a proposal to ISO TC 215 to create a formal reference ter-
minology model for nursing and to integrate it with other standards for
healthcare data. This proposal integrated previous efforts by the ter-
minology summit, European CEN TC 215, ICN, and the Nursing In-
formatics Group of the International Medical Informatics Association
(IMIA).
r Resolved ambiguities between the representation of nursing concepts and
relationships in the evolving ISO reference terminology model and their
representation in the reference information model (RIM) of the stan-
dards organization called HL7. As a result of summit collaboration, HL7
has begun to register nursing vocabularies that satisfy that organization’s
standards for sending messages containing healthcare information. Simi-
larly, the standards organization called LOINC has adapted its standards
to accept nursing information and has added terms for nursing assessment
data.
r Supported use of ISO’s Reference Terminology Model for Nursing to
guide the efforts of the team modeling nursing concepts and relationships
for SNOMED-CT. SNOMED-CT likely will contain the first realization of
a formal reference terminology for nursing. Because SNOMED-CT will
encompass virtually all of healthcare, nursing’s formal terminology will
perforce be integrated into a broad healthcare terminology.
r Initiated exploration of ways to incorporate the formal terminology into
information systems.
 Nursing Data Standards 185

Canada
The clinical data elements comprising the Nursing Components of Health In-
formation (i.e., client status, nursing interventions, client outcomes) are not
formally captured in a standardized terminology in any national database
or EHR. There is a paucity of Canadian research related to the clinical data
elements of the Nursing Components of Health Information. Only one com-
pleted Canadian study (Loewen, 1999) and two studies in progress (Kennedy,
2002; Pringle and White, 2002) were identified. The Nursing and Health
Outcomes Project (Ontario) aims to identify nursing-sensitive patient out-
comes and their attendant inputs and processes that could be entered on,
and abstracted from, patients’ charts or provided in other formats (Canadian
Institute for Health Information, 2002).

Summary
Much remains to be accomplished in research to continue to develop a for-
malized clinical nursing vocabulary common among nurses. Nurse educators
must become more aware of the importance of nursing data standards and
become familiar with the content and substance of standardized clinical
nursing vocabulary so they incorporate this knowledge throughout nursing
education curricula. Similarly, practicing nurses need to understand the im-
portance of nursing data standards for use in documenting clinical practice
in a fashion that enables data analysis of the nursing impact on patient out-
comes. Nurse managers need to become familiar with nursing data standards
and their role in providing evidence to substantiate the value of the nursing
contribution to patient care.

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13
Defining Information Management
Requirements
Jane Curry

The mantra of informatics is “getting the right information to the right people
at the right time.” The requirements definition phase is determining (and
making sure everyone agrees with) what is the right information, who are
the right people, and when is the right time. The most important decisions
require that everyone involved agree on the anticipated benefits and the
expected scope of information system use.
The use of computers has changed over the last 50-plus years. At first,
computers were used as fast calculating machines (hence the name). Later,
manual processes that involve moving pieces of paper from one person
to another were automated so the paper was replaced by electronic data
storage and screens, or printers were used to retrieve the information. Still
later, as computers and networks became more readily available and af-
fordable, information systems were used to enable communication between
people located across time and space. The newest use of computers is to
manage complexity—there are simply too many interdependent elements
in the health system for people to be able keep track of all of them and their
changes with sufficient reliability.
Introducing any kind of automated information system involves changing
the way people get their work done. Simply replacing paper with information
systems without understanding how the change affects the minute-to-minute
activities of the people involved cannot produce the benefits anticipated.
Rather than saving time and improving information quality and availability,
introducing information systems may increase people’s frustration and de-
crease the quality of information. This is especially true when adding yet an
other information system into an environment in which information systems
are already in use. Getting information systems to work effectively together
is an additional activity that usually takes more time and effort than antici-
pated. Making information systems truly useful requires that many activities
be done well. None of the technical activities can be effective without first
having a shared understanding of what the collection of information systems
is supposed to do to help people get their work done.

189
190 Infrastructure Elements of the Informatics Environment

Stages in System Development/Acquisition

Information systems are not introduced in a vacuum. What activities are
undertaken depends on what information systems already exist and how the
information systems are managed. The most successful organizations man-
age information systems as assets of the organization as a whole, with each
new information system or major change to an existing information sys-
tem being managed as an individual project. Managing all the information
systems together is often called “information systems architecture manage-
ment” and involves planning for change, setting standards, and keeping track
of all the information systems and the interdependence of their components.
Each information system project goes through a process that roughly falls
into the following stages.1
r Initiation: getting approval for the project, organizing the people affected,
clarifying the expected benefits, planning, and assembling a team to do the
project
r Elaboration: one or more iterations (or mini-phases), each verifying re-
quirements, identifying interdependencies among components, aligning
with industry and organizational standards, testing major technical as-
sumptions, analyzing and specifying component design details, and build-
ing core components
r Construction: refining information systems requirements, refining infor-
mation system design details, building and testing interdependent infor-
mation system components, piloting the resulting information system with
a small group
r Transition: introduce a new information system across all environments,
train people to use and support the information system, manage data
archiving and conversion, integrate with other information systems
r Production: support the information system, including ongoing training
and help support
r Retirement: ensuring information system is appropriately withdrawn from
the environment, archive and convert historical information
In general, the broader the expected scope of information system use,
the more attention that is needed during the earliest phases. Many infor-
mation systems being acquired or developed in healthcare organizations
today cross boundaries and are expected to be used by multiple disciplines,
across multiple organizational units, and spread across multiple sites and
even between multiple organizations operating in different jurisdictions.
Such projects require careful planning and coordination to be successful.

1 Although many information system development methodologies exist, emerging

industry best practices are being based on a methodology called “unified process.”
One proprietary source that supports a unified process within an enterprise manage-
ment approach is found at http://www.enterpriseunifiedprocess.info/.
 Defining Information Management Requirements 191

The details of what the information systems are expected to do must be de-
termined within a set of activities that includes providing ongoing communi-
cation to everyone affected and coordinating change to align activities, roles,
policies, and procedures to accompany the introduction of the information
system.

Requirements Definition
Requirements definition is the process of ensuring a common understanding
of just what an information system is supposed to do and how it fits into
the daily lives of the people expected to use it. The process is essentially
the same whether an information system project is expecting to acquire
a commercial information system, modify an existing information system,
develop an information system from scratch, or integrate many information
systems to work together.
People communicate with each other in a dialogue fashion, allowing each
individual to clarify meaning and intent and make sure the information pro-
vided is suitable to the purpose. This form of person-to-person communica-
tion is highly effective so long as all parties understand the same “language.”
Language is not just a matter of being able to speak and understand or to
read and write in a common human language such as English or French, it
also refers to the use of terms and a shared context. People use short cuts
in communicating all the time. Acronyms and jargon abound in healthcare,
and often clear understanding is local to a work setting among people in a
common discipline. People from different disciplines, or teams, must work
out a common language whether the form of communication is person to
person or person to paper to person.
People excel at clarifying ambiguity in language and can often understand
terms within a context without resorting to formal definitions. Computers
do not tolerate ambiguity. Information systems rely on extremely specific
instructions to do anything. The goal of the requirements definition is to
make sure enough details are known and accepted about what information
is required by whom at which point in time to accomplish the purpose of al-
lowing a computer to carry out the tasks necessary to make the information
system useful in the expected environment. Most information systems allow
at least some customization to accommodate the differences in the way peo-
ple work in different settings. The most challenging part of the requirements
definition is gaining agreement among groups of people who need to coop-
erate to be able to accomplish a common goal. The more an information
system is expected to do to make work more effective, the more important
it is to make sure the details are explicit and accepted by everyone who
needs to use the information system. Because it is not possible to ask every
person’s opinion in advance, it is especially important that the people who
are chosen for the requirements definition team of the information systems
192 Infrastructure Elements of the Informatics Environment

project can adequately delineate the interests of the group of people they
represent.
The suite of information systems supporting healthcare in a particular
setting are becoming increasingly complex. There are many combinations
of hardware and software components that exchange information to ac-
complish a stated purpose, and these combinations are changing all the
time as new information is required or old systems are retired. Keeping
track of these complex environments is a task that requires information
system support. Information system architecture management uses infor-
mation system tools to help make sure the suite of information systems sup-
porting the healthcare organization is as effective as possible with the least
cost.
Information system management tools are also being used to make sure
the details captured during the requirements definition are sufficiently spe-
cific and consistent. One of the most effective techniques in managing any-
thing highly complex with interdependent components is to show the compo-
nents and their relationship in a visual diagram. The analogy of a blueprint
used to build a building is often used to talk about what an information
system is supposed to do. The blueprint is made up of a series of related
diagrams each specifying details supporting a different discipline, such as
structural or mechanical engineering or carpentering. The advantage of us-
ing diagrams is that attention can be focused on one topic at a time until
it is sufficiently understood, with the information system management tool
keeping track of the details so no gaps or overlaps occur. Different views of
the blueprint are used to inform different audiences at different levels of de-
tail. Everyone has a different perspective and considers a complex topic with
a focus point representing what they care about. The center of the diagram
typically has many details about components and their relationships. The
edges of a diagram tend to be less detailed and relationships to components
exist but are not shown. Diagrams are supported by text to add further
clarity for people to read, as well as highly structured data that allow the
information system tool to manage the interdependence among views and
components.
The types of diagrams have evolved over time but are beginning to con-
verge around an information technology industry standard called the unified
modeling language.2 The following discussion of diagram types helps clarify
which diagram is used to capture the details of the information needed by
which people at the time to accomplish what purpose.
The purposes for information systems vary widely but must be explicitly
understood and accepted. This is particularly important when information
recorded for one purpose is made available to someone else to avoid their

2 Unified modeling language (UML) is an information technology standard man-

aged by the Object Management Group. More information can be found at

http://www.uml.org/.
 Defining Information Management Requirements 193

redundantly collecting information or to reuse information collected for one

purpose for a different purpose. Information quality, in terms of precision
of measure, timeliness, accuracy, and relevance, must be considered in the
context of both the circumstances under which it was initially recorded and
when it is subsequently used. Information sharing can improve the coordina-
tion of care and reduce the cost of maintaining information—but only when
the information’s quality is preserved. Examples of information recording
purposes include the following.
r Recording reminders to self
r Recording activities performed to demonstrate accountability for actions
r Recording requests for someone else to do something
r Recording direct observations or measures to monitor the condition of a
subject of interest
r Record the outcome of activities that affect the availability of resources,
such as money in an account, time spent by a specific human resource,
amount of time a specific piece of equipment was used
r Record the authorization to do something or acknowledge a decision
r Calculate new measures or summaries from information already available
Using diagrams during the requirements definition phase and recording
the resulting pictures in information system tools that support requirements
definition helps to maintain a clear linking of requirements to delivered infor-
mation systems over time. As information systems are added and changed,
the impact on other information systems or related activities can be pre-
dicted. Integration of the specific diagrams and the accompanying detailed
information into requirements definition tools ensures that each perspective
is adequately represented and that all the details are recorded that make up
the accurate specification of just what an information system is supposed to
do and how it is integrated into daily activities. Figure 13.1 represents how
people with different viewpoints would view a complex information system.
If each circle represents the scope of interest of a different perspective, it is
easy to see that complete understanding is impossible by considering only a
single perspective. Effective information systems need to be built from spec-
ifications that integrate the multiple perspectives into a congruent whole.
The ability to view different aspects individually, however, ensures that each
perspective is accommodated and allows the appropriate people to validate
that their needs have been met. The requirement definition tools also help
identify how the activities of people and the corresponding roles and re-
sponsibilities along with the organizational policies and procedures must
be adjusted to make the whole work environment more effective as new
information systems are implemented.
The following diagrams are often used during the requirements definition
phase. There are 13 types of diagram available in UML, each of which adds
clarity to some aspect of the requirements definition or component analysis,
design, and deployment management.
194 Infrastructure Elements of the Informatics Environment

FIGURE 13.1. Scope of interest of different perspectives.

Use Case Diagram

A use case diagram specifies which people use an information system to
accomplish what purposes. It shows the set of roles involved in using an
information system to achieve a purpose. People are represented by a stick
figure called an actor. The name of the actor is a specific role that has a
defined set of responsibilities and permissions to use an information system
to accomplish specific tasks, or use Cases. Use cases are represented by ovals
inside a box that represents the information system boundary. The use cases
can be specified at different levels of detail and may be related to each other.
This is a useful convention because exception processes can be understood
without distracting attention from the “mainline” processes typically used to
achieve the purpose. Figure 13.2 is an example of a simple use case diagram.
It shows that although both physicians and nurses have access to a clinical
information system, it is the nurse who is expected to record vital signs and
the physician who is expected to record medication prescriptions. Both are
expected to verify patient demographics.
 Defining Information Management Requirements 195

Clinical Information System

Record
Vital Signs

Nurse Verify
Patient
Demographics

Record
Prescription

Physician

FIGURE 13.2. Use case diagram.

Activity Diagram
An activity diagram specifies the responsibility for processes, the sequence
in which they are performed, and any decision points. These diagrams are
useful for clarifying how information systems are used across organizations,
disciplines, or systems. Sometimes called a “swim lane” diagram because the
processes are organized to show which actors (which may be information
systems) are responsible for what processes. This diagram is especially useful
for clarifying the “hand-off” of responsibility and can serve to focus attention
on aligning policies, responsibilities, and information definitions associated
with the performing cooperating processes. A simple example is depicted in
Figure 13.3.
In this example, a discharge planner is interacting with a placement system
to determine if a patient should be discharged home or to a long-term care
residence or if alternative arrangements are needed while the patient is on a
waitlist for transfer. The use case starts when the patient needs are assessed.
The placement system calculates a resource requirement and, based on the
outcome, arranges for patient transfer with the long-term care coordinator
if the patient needs that level of care and a place is available. Otherwise,
the patient is placed on a waitlist, or the discharge planner is notified that
long-term care is not suitable. The discharge planner arranges for discharge
home, transfer to long-term care or alternative arrangements, depending on
the outcome of decisions made. Note that this activity diagram would be used
to explore the responsibilities associated with each role, the rules required to
196 Infrastructure Elements of the Informatics Environment

Prepare
Assess Patient
Patient Discharge
Condition Arrange Prepare
Discharge to Home Alternative Patient for
Planner Care Discharge to
Long Term Care
Facility

Record
Patient Resource
Assessment Requirement
Suggests
Long Term Care
Placement?
Calculate
Placement Resource
System Requirement Place
Available?
Put Patient
Check on Waitlist
Availability
in
Long Term
Care Update
Facility Availability

Arrange
Patient
Transfer
Long Term
Care
Coordinator

FIGURE 13.3. Swim lane diagram.

determine placement, and any other policy or procedure alignment among

the organizations.

Information Model Diagram

Information is understood only in a specific context. However any infor-
mation has certain core subjects that correspond to real-world factors that
must be tracked over time. Information models are diagrams that depict
items and information about them that are required to support an organiza-
tion and all its information systems. Diagrams that visually display items and
the relationships among them have evolved over time but have always been
intended to help the user clearly understand what people, places, factors,
rules, and events are important to keep track of over time and the meaning
of their important characteristics and relationships.
 Defining Information Management Requirements 197

Diagrams of these “information classes” help specify the “right informa-

tion” that must be maintained by information systems. Information modeling
has often been represented as entity/relationship diagrams, although more
recently class diagrams have become more accepted. Understanding infor-
mation as descriptions of things whose characteristics change over time and
as they are affected by particular events, helps not only to design informa-
tion systems that are adaptable as circumstances change but also to help
organizations take on appropriate accountability for the quality of informa-
tion used to support many purposes. Not all information about classes can
be shown on a diagram. Accompanying definitions for each element in the
model are also required. For example, it is important to understand how
each characteristic can be expressed so an information system can process it
correctly and what would be considered valid content for each characteris-
tic. It is also important to determine how each class might change over time,
either through changes as processes effect a class or as part of a normal life
cycle. Additional considerations involve determining sensitive information
that must be protected with additional security and access permission. Such
additional details may be expressed in related diagrams or as narrative text
in a related glossary.
Figure 13.4 depicts a simple class diagram that helps clarify that it is im-
portant to understand a person as a unique individual and what the role of
patient really means in the context of a specific healthcare encounter. A box
represents a named class, with characteristics of interest appearing below
the line. The lines between the boxes represent key relationships and may
be named with notation on the ends indicating whether the relation is op-
tional and whether more than one relation of that type can exist between the
classes. The diagram in Figure 13.4 can be interpreted to mean that a person
can play the role of either a patient or a healthcare practitioner. A patient is
a person with a relation with a healthcare organization. A person in the role
of a patient participates as a subject during an encounter, whereas a person

Person Patient Subject

Identifier Identifier
Name Effective Time Mode Encounter
Birthdate
Identifier
Effective Time

Healthcare
Organization
Performer
Identifier Healthcare
Name Practitioner Mode

Identifier
Effective Time
Speciality

FIGURE 13.4. Class diagram.

198 Infrastructure Elements of the Informatics Environment

in the role of a healthcare practitioner participates as a performer during

the encounter. An encounter can be with more than one patient and involve
more than one healthcare practitioner who may be participating is different
modes: physically present or remotely.
This model is drawn from a health information standards development
organization, Health Level 7 (HL7),3 which has produced a reference infor-
mation model that is now being used across the world to help information
systems share information with the same meaning. Other standards devel-
opment organizations are working on developing common terminology to
be used by information systems. Having these health information standards
available during requirements definition helps people recognize that their
unique information needs can be met using a “common language” that is
sufficiently precise that computers can process it and expressive enough that
detailed requirements can still be met.

Summary
Participating in the requirements development phase of an information sys-
tems project is challenging but rewarding. It is an opportunity to help an
organization acquire the best possible information systems that support the
daily activities of the people who use them and help coordinate care over
time and across disciplines and organizations. Most of the effort is spent
working with other people to reach a consensus of just what the informa-
tion system is to do and making sure there is a common understanding of
the specific activities and the information captured and used to achieve the
stated purposes. One way to gain understanding is to tell specific stories of
just what the future would look like when the information system is in place.
Use the diagrams and accompanying detailed information as the “bones” of
the story, but flesh out the story and dress it up by using real-world examples
in reasonable detail. These stories carry over into the next phases of infor-
mation systems projects and can become test cases that help make sure that
the information systems do what they are supposed to do—before they are
implemented.

3 Health Level Seven has many activities focused on supporting information sharing

with the same meaning across information systems. More information is available at
http://www.hl7.org/.
14
Selection of Software and Hardware
With contributions by Eleanor Callahan Hunt, Sara
Breckenridge Sproat, and Rebecca Rutherford Kitzmiller

Selection Process and the Role of Nursing

The installation of a clinical information system does not just happen, nor is it
a mysterious process. The process starts with identifying a need, conducting
a feasibility analysis, creating a selection team who gathers information and
develops vision and goals, promoting executive buy-in and funding commit-
ments. After a clear vision and goals are identified, a request for proposal
(RFP) is sent out to the vendor field. Vendor responses are evaluated, site
visits and on-site vendor fairs are arranged, and the system selection deci-
sion is made. While the contract is being negotiated, funding is confirmed
and an implementation team is formed. The implementation team config-
ures the system, deploys it to users, and evaluates and maintains the sys-
tem. This entire process from initial idea to deployment is summarized in
Figure 14.1.
A clinical system implementation provides nursing the opportunity to help
clinical staff optimize their workflow and improve patient care by harness-
ing technology and using it to advantage. A system implementation project
marks its beginning from its earliest conception, perhaps a clinician with an
idea inspired to find a better way to solve workflow issues, reduce errors, or
improve patient outcomes. As the idea develops, buy-in from senior leader-
ship and the executive level formalizes the project. Although the selection
process may appear lengthy, it serves multiple purposes, such as engaging
all potential users, promoting buy-in and ensuring that all embrace the same
shared vision (Hunt et al., 2004). Depending on the experience level and
knowledge of the staff working on a particular implementation, this pro-
cess can be abbreviated for smaller projects (Hunt et al., 2004). Through
thoughtful, deliberate information gathering, analysis, and decision making,
a system that enhances clinician decision making, optimizes staff work, and
improves patient care will be selected and implemented. It is imperative that

The contents of this chapter are opinions of the authors only and do not reflect those
of the US Army Medical Department or the US Army.

199
200 Infrastructure Elements of the Informatics Environment

FIGURE 14.1. Hardware and software selection process. HIS, health information sys-
tem; RFI, request for information; RFPs, request for proposal.

nursing be actively involved at every stage of the process from beginning to

end (Hunt et al., 2004; Manning and McConnell, 1997; Mills, 1995).
Once the need for a system has been identified, the initial step is to form
a selection team to choose the solution. The formation of the selection
team committee depends on how the organization typically handles projects
and committees. This committee is usually composed of various department
heads or designates (including nursing) in the organization, but it can and
should include other disciplines as needed. It is important to identify all of the
organizational departments that will be affected by the system installation
and ensure that their interests are adequately represented. Membership can
include both permanent and ad hoc representation of the core group of users
(Hunt et al., 2004). Communication mechanisms must be made more formal
as the size of the group grows to ensure effective meetings and to keep the
 Selection of Software and Hardware 201

process moving along. Large groups require documented meeting agendas,

meeting minutes, assigned responsibilities, and subcommittees reporting
progress. Small groups could accomplish similar tasks with handwritten agen-
das, round-table discussion, and documentation only as decisions are made.
One of the first tasks addressed by the selection committee is to gather
detailed information and statistics about the organization. This baseline de-
scription includes information about the type of healthcare organization,
daily patient census and workload, number of staff, number of prescriptions
dispensed, specialty units, level of patient acuity, organizational design, ad-
ministrative structure, and geographic area served. Other tasks at this stage
are to complete a needs analysis; develop the vision, mission, and goals of the
project; determine how the system selection decision is to be made; identify
a budget range for system installation and maintenance; and create a broad
timeline. Information gathered is used for many purposes throughout the
life cycle; for the RFP it is used to compare and evaluate vendor propos-
als, implement the chosen system, and evaluate system effectiveness after
installation. The process of gathering information and arriving at common
goals provides the opportunity to gain buy-in of the user base and to culti-
vate appropriate user expectations. Obviously, during this phase the nursing
department has a great deal of information to provide as end-users of many
of the clinical systems installed in an organization.
It is wise to capture existing information flow, document additional data
needs, and examine data usage while gathering descriptive information about
the organization. Often, existing systems are cumbersome, inefficient, and
error-ridden, which is why the team is seeking a replacement. There is no
point in continuing such processes. Self-evaluation reveals areas and pro-
cesses needing minor improvements, modifications, or even major revisions.
Often immediate time and cost savings can be realized by simply refining
current information-handling procedures in preparation for installation of a
computerized information system. This self-evaluation and documentation
may be conducted by the selection committee, the information computer
services department, or a hired systems analysis consultant. Documenting
initial information handling provides a means by which one can evaluate
the final product of a computerized information system. In addition, this
self-evaluation phase facilitates early identification of gaps or inequities in
the existing information management methods. Such knowledge permits ini-
tiation of remedial action. For example, when patient care plans are to be
included in the computerized information system, the information analysis
may reveal that there is no standard format for patient care plans in the
organization or that there is a standard format but it is not used consistently
by all patient units. Consolidating or making practice consistent prior to the
start of an implementation makes deployment of the system easier. Imple-
menting a familiar documentation method in a new clinical system is easier
than implementing a new documentation method in a new clinical system,
and it will meet less resistance (Hunt et al., 2004).
202 Infrastructure Elements of the Informatics Environment

The Request for Information (RFI)

Members of the selection team or the manager of information services dis-
tributes a request for information (RFI) to as many vendors as possible.
An RFI provides demographic information about the organization, such
as size and mission, and requests a general response from vendors regard-
ing the types of products they manufacture and market. The RFI addresses
the basic system description, desired capabilities, and scope of the intended
project. It is usually the first contact with a vendor and is used to obtain
vital information about the products and services offered by the company.
An RFI announces to vendors that the organization is in the preliminary
phase of considering installation of a system and provides the organization
with a quick, albeit superficial, educational overview of what is commercially
available. The RFI also narrows down options and eliminates vendors that
cannot meet basic requirements. Once the vendor field has been whittled
down, vendors are asked to respond to the more detailed RFP.
An alternative to sending out an RFI is attending a clinical conference
that has a large clinical system vendor presence. Conferences are valuable
for the sessions on implementing clinical systems as well as providing op-
portunities to see and touch the systems, network with colleagues evaluating
similar systems, and selecting pertinent literature to share with the rest of
the selection team.

The Request for Proposal (RFP)

The RFP is the way the selection team gets detailed information from ven-
dors. An RFP is prepared from the information received from evaluating
RFI materials returned by vendors, as well as organizational summaries of
the site, technology infrastructure, existing and desired information use, and
flow (see Chapter 13). An RFP is sent to selected vendors, inviting them
to submit a detailed response or proposal describing how they would meet
the needs of the organization. Be aware that it is expensive for a vendor
to prepare a thorough RFP, and it is costly to evaluate RFPs returned. It is
important to narrow the list of vendors sent RFPs to those that are likely to
meet an organization’s needs.
The RFP may be assembled by the chief executive officer, a project of-
ficer, the information systems department, a nurse informaticist, or an in-
dependent consultant. It reflects decisions and specifications provided by
the selection committee. Each member of the committee reviews the final
document before it is issued, further reinforcing the team’s effort and input.
The format for an RFP varies depending on the organization and the au-
thor(s). Appendix I contains a detailed example of an RFP for an inpatient
clinical system. The RFP should give vendors enough detailed information
to respond to the questions asked in the RFP. The format of the RFP may
vary from one organization to another and in the level of detail provided.
 Selection of Software and Hardware 203

If written well and unambiguously, the RFP elicits accurate responses from
vendors. Vendors do not mistakenly indicate that their system can meet the
requirement when it does not, nor do they misinform the system selection
committee. RFP questions must be phrased so the vendor can answer most
questions with one of four answers: yes; yes, with customization; yes, avail-
able in the future; or No. An area should be left for comments if explanation
is needed (Hunt et al., 2004). Clearly, the nursing perspective at this point
in the process is crucial. “It is the nurse who must integrate and collate all
the information into a logical format and develop a comprehensive plan of
care for the individual patient. Information the nurse collates is captured by
registration, medical records, physicians, laboratory, pharmacy, radiology,
physical therapy, dietary, and many other departments” (Jenkins, 2000).
Although it is helpful to start with an example, vendors naturally have a
strong self-interest in this process, and therefore organizations should not
accept any vendor’s offer of assistance with the preparation of an RFP, no
matter how apparently innocent and well intentioned the offer. (It is likely
that the RFP would request system features the vendor’s system would be
able to provide.) The high cost of preparing an RFP rests in the cost of
gathering and compiling information. Care should also be taken to ensure
that if an outside consultant prepares the RFP there is also no bias toward
a particular vendor in final selection.
Vendors interested in competing for the opportunity to sell their product
to the organization then submit proposals and costs estimates in response to
the RFP. These documents specify the vendor’s proposed means of meeting
the specifications outlined in the RFP. Details include hardware and software
descriptions, including number, type, location, and specifications; installation
information, including location, wiring, delivery times; staff training require-
ments; and a multiplicity of other specifications, including travel expenses
(Hunt et al., 2004).
When all the proposals have been received from the vendors, the organi-
zation must select vendors whose proposals they wish to pursue. The propos-
als from the competing vendors are reviewed and evaluated by the selection
committee. It is imperative that nursing representatives on the committee
are knowledgeable about nursing’s processes and issues and are empow-
ered to make decisions. Some (among many) criteria considered during the
evaluation process are as follows.

r Timeliness of response. Did the proposal meet the deadline for submis-
sion? If not, what is the assurance that the vendor will meet other deadlines
and internal milestones?
r Degree to which the proposed solutions for each area meet the evaluation
criteria stipulated in the RFP. Are there many “No” or “Available in the
future” answers?
r Compliance with system specifications stated in the RFP.
r Soundness of the vendor’s technical approach.
204 Infrastructure Elements of the Informatics Environment

r Past and current experience of the vendor with similar installations. Ask
for references and visit or call those sites that are organizationally similar
in size and mission.
r Qualifications of proposed implementation staff and consultants to be
provided by the vendor.
r Financial stability or business health of the vendor.
r Cost-benefit ratio to include total system costs over the expected system
lifetime.

Incorporating the established criteria into a grading tool can greatly assist
the selection team when documenting their evaluation. The tool also serves
as a reminder of the agreed-upon decision-making process at the beginning
of the process when determining the overarching goal(s) of the project.
Existing tools can be found in the literature on total quality management
(TQM) and continuous quality improvement (CQI) and are easily adapted
to technology projects (Hunt et al., 2004).
The effectiveness of an information system depends on nursing input and
use along with satisfaction with the system from patient care, clinical, and
administrative perspectives. Input during the RFP evaluations is crucial.
The outcome of the evaluation process is a consensus on rank ordering of
all proposals based on comparisons across all the evaluation criteria. This
rank ordering identifies the two to four vendors whose solutions seem most
acceptable on paper. They are often comprise the “short list” of vendors
competing for the business.

Vendor Demos and Site Visits

While the list of vendors is being whittled down and top choices become
apparent, arrange vendor fairs and site visits to locations where computer
systems similar to the one being proposed by the vendor are installed and
operational. The purpose of site visits is to see systems under consideration
in operation and being used by clinicians. The importance of nursing’s rep-
resentation on these site visit teams cannot be understated. Each member of
the site-visiting team is visiting with a different perspective, with interview
questions developed before departure and after input from the total selec-
tion committee. Manning and McDonnell (1997) and Hunt et al., (2004) have
provided lists of questions and guidelines about need, safety and security,
effectiveness, efficiency, and the economic and social impact. The purposes
of these site visits are to see the system, clarify understanding of the system,
and verify vendor claims. The site-visiting team is optimally small, composed
of four to six members chosen from among senior administrators and end-
users who are also members of the selection committee. Site-visit locations
are suggested by the vendor, but contacts and scheduling of visits are usually
arranged directly between the prospective purchaser and the organization
to be visited. Site visits should conform to a predetermined structure so each
 Selection of Software and Hardware 205

system function or lack of function is exposed and allowed fair evaluation

across vendors (Staggers and Repko, 1996). In addition to looking for spe-
cific functional criteria, the team should try to gain a general opinion of the
system.
In addition to arranging site visits where the systems are functioning,
many consider inviting vendors to set up a training environment in their
organization to demonstrate their product to the selection team and larger
groups of users if appropriate. The vendor should use a functional system
with ‘live’ data, with a “script” developed by the selection team to demon-
strate the functionality described in the RFP. It is most important to structure
these vendor visits and utilize the same criteria for all vendors (Staggers and
Repko, 1996). If the team does not control demonstration sessions, each
vendor may discuss different aspects of a system and few comparisons can
be made between vendors, making evaluation difficult. Each representative
should be encouraged to point out unique features of his or her product, but
the overall format should be similar (Hunt et al., 2004).
There is always a trade-off between the number of companies under con-
sideration and the depth to which each product can be investigated. A large
number of vendor companies involved at the beginning preclude a detailed
investigation of each. As the field is narrowed and decisions must be made on
an increasingly detailed level; in-depth demonstrations of selected systems
can provide greater detail and assist with prioritizing the short list.
Here are some things to watch for or do during site visits.

r Observe the general state of cleanliness and order around the terminals:
a smooth running system tends not to have dozens of little “helpful hints”
notes stuck to the walls or terminal.
r Observe the response time of the system, particularly when it is busy.
r Observe whether all staff use the system or just selected staff (e.g., clerks).
r Ask the staff if they would prefer to go back to a “traditional” method.
r What aspects of care has the system improved? What is the best feature?
r Attempt to speak to staff other than the ones the vendor has arranged for
you to see.
r Ask the staff what they do when the system “goes down” or stops working.
What you want to hear is “the system rarely goes down.”
r Ask “who fixes the system when it stops working.” This can illuminate how
many people really support the system.
r This is also the time to ask about training. How long did it take the staff
to learn the system and who trained them?
r How responsive is the vendor? How easily and quickly are customizations
made?

The final selection of the vendor is based on information presented in the

proposal and on the site visit. A contract is negotiated between the vendor
and the organization; the system is installed and evaluated.
206 Infrastructure Elements of the Informatics Environment

Developing a Short List of Vendors

Below is a suggested phased approach aimed at minimizing the time re-
quired to evaluate lengthy RFPs and providing a structured means for all
participants to contribute.
r Phase I: narrowing process. Eliminate vendor proposals that fail to meet
all mandatory requirements or that arrive late (unless contacted prior to
deadline). Distribute the remaining responses to the RFP to all committee
members. Each member should review the responses and decide whether
the proposal addresses essential requirements. Utilize a tracking tool to
keep members focused and to organize responses. The idea is to reduce
the number of proposals to a workable number, such as three to five.
Then correlate the team’s findings. Discuss the areas of the proposal where
members held different views.
r Phase II: telephone survey and site visits. A telephone survey can help de-
termine what sites might be visited. Call those suggested by the vendor as
well as organizations that may not be suggested by the vendor to gain a
better overall, unbiased picture of the system. Ask each location specific
questions about the system: Does it meet their needs, why did they choose
a particular vendor, what type of computer hardware and software is re-
quired to use the system, would they be willing to have a visit? Site visits
help minimize the risk of a wrong choice of vendor or system and allow
valuable observations of the system in use. Use them wisely but also be
aware that some organizations charge for such visits.
r Phase III: vendor demonstrations. Bring the top vendors in for a demon-
stration. Provide the vendor with a scripted demo of typical scenarios in
advance. (Note: these scenarios are also useful during the system test-
ing phase.) Consider inviting a broader group of users and have them fill
out evaluation surveys. Collect and evaluate the data submitted on these
surveys to see if the selection committee is representing the user base
appropriately.
r Phase IV: decision making. Using the decision-making criteria determined
at the start of the selection process, choose the factors that are important to
the success of the system in your organization. Assign a weight, or “score,”
to each vendor’s response for their system (Hunt et al., 2004). For example,
response and stability may be more important to your organization than a
flashy graphical user interface (GUI) front end that your users may desire.
Being able to rank certain areas of the RFP with more “points” provides
more accurate scoring of the RFPs.
r Phase V: technical analysis. An organization’s information services de-
partment needs to evaluate vendor offerings to ensure that the proposed
system integrates easily in the existing technical infrastructure and can
be supported after installation. If additional infrastructure must be pur-
chased or incorporated into planning to allow the purchased system to be
 Selection of Software and Hardware 207

installed, the cost must be incorporated into the financial analysis of the
final vendors.
r Phase VI: financial analysis. Remember to consider all the financial costs.
There can be front-end costs: installation, conversions from old systems,
interfaces to existing systems, renovations to facilities, hardware and soft-
ware, training. Operating costs include hardware and software mainte-
nance, insurance, supplies, ongoing training, and staffing. The goal is to
try to compare the proposals objectively and consistently. Bring together
the entire package of price versus performance combined with financial
information. Identify the vendor or system that gives the most results for
the least investment. However, keep in mind that price should not be the
overriding consideration: It just happens to be one that is foremost in
everyone’s mind.

Contract Negotiations
The definitive legal document that defines the relationship with a consultant
or the purchase of hospital information systems or stand-alone computer
systems in the nursing department, laboratory, or pharmacy is a contract.
A successful contract represents a “win-win” solution and leaves both par-
ties feeling positive (Marreel and McLellan, 1999). The contract is the legal
umbrella that defines a mutually acceptable set of understandings and com-
mitments between a vendor and an organization. Generally, the contract
outlines the products purchased, required data gathering for planning, the
implementation plan and timeline, and evaluation criteria. Given the im-
portance of this document and potential consequences, it follows that the
contract must be precise, comprehensive, and reviewed by legal advisors and
contract experts because it serves both user and vendor for the duration of
their relationship (Hunt et al., 2004).
The points discussed here are broad in nature and are meant only to
kindle awareness in the reader regarding the importance and consequent
implications of a computer contract. The objective of this section is to point
out the need for an effective legal document and importance of accurate
advice before contract signing. The following is a list of items to help the first-
time purchaser of computerized healthcare systems. These tips are offered
to avoid major problems that have been encountered.
r Involve an attorney at the beginning of the contract negotiation—not just
any lawyer but a lawyer who understands healthcare and technology.
r Ensure that you have the authority to sign a contract and obligate your
organization. Often this power or ability resides in certain individuals in the
organization who tend to be experts in contracts and should be consulted
early in the contracting process (Hunt et al., 2004).
208 Infrastructure Elements of the Informatics Environment

r Be a firm negotiator but not unreasonable. Be demanding of special items

your organization has defined as essential while you negotiate the contract
with the vendor.
r “It is not so much that the buyer beware but that the buyer should always
be aware.”
r Avoid signing a vendor’s standard contract. It is their contract and is pri-
marily protecting the vendor’s interest, not that of the organization.
r Make sure everything is in writing; do not accept verbal promises.
r Read the fine print.

Several key steps can be taken before entering into a contractual relation-
ship.

r Prepare the RFP as clearly as possible, paying specific attention to the fact
that those requirements stated in the RFP will become part of the final
contract.
r Request that vendors include any additional contractual requirements to
their response to the RFP.
r When comparing systems and while doing the final systems evaluations,
keep in mind that decisions about modifications to the existing system
must be a major part of the final contract.
r A reference check on vendor performance and a check on the financial
stability of the vendor(s) being considered is crucial.

The user or purchaser must have some notion of how to negotiate a con-
tract. Certainly, the overall purpose of a contract is to have a comprehensive
document that provides the decision-makers with the flexibility to monitor
the performance of the vendor. It is extremely important to remember that
the final contract must be signed before the actual purchase of the system.
If the hardware or software is installed before contract signing, additional
problems are introduced.
It is to the buyer’s disadvantage if only one vendor is being considered dur-
ing the final negotiation period. At least two vendors should be considered
until the contract is signed. The contract is also much more effective if top-
level management from both organizations are present in the final phases
of contract negotiations. By this time, the hospital, including the nursing de-
partment, should have clearly defined its needs and be able to document its
requirements in the contract.
Ask your legal counsel to define the element of profit for the vendor.
What will the effect be on the vendor of having you as a user? Consider the
time and other resources invested in the proposal preparation, site visits,
and demonstrations by the vendor. Is the vendor strictly a provider of the
healthcare computer services you need, or is it a larger company marketing
many healthcare or even general computer services? This information gives
you some idea as to how the vendor values your business.
 Selection of Software and Hardware 209

All these points can help develop a strong negotiation strategy. A few
more logistical points are of interest.
r It is advantageous for the buyer to maintain control over what is being
negotiated and how it is being negotiated.
r The buyer should have an agenda and set the times and locations of nego-
tiation.
r The buyer should decide the chronological order of items to be negotiated.
r A healthy two-way negotiation of give and take should be established to
reach desired goals.
r The buyers should always have a set of alternatives, but it is essential that
a position statement be developed from which no compromise is possible
(the bottom line).
r To draw an analogy, when bidding at an auction, the buyer has a set price
on each item over which he or she will not bid. Working with a contract is
similar. There must always be limits, or the game is lost before you start.

The ultimate purpose of contract negotiation, however, is to produce a

workable arrangement that satisfies the buyer and can be carried out by the
vendor. Compromise is almost essential even on key issues of importance
to the buyer. The buyer must remember that if the contract becomes too
restrictive or burdensome for the vendor, the relationship can end up in
legal friction to the point of nonperformance. Negotiation is an art; in a
good contract, both parties believe they have won.
A sensible contract differs according to the objectives of the purchaser.
One basic similarity remains: A contract is the written document of mutual
consent made between the buyer and seller or vendor. The contract stands
as the written testament of the legal obligations of both parties. It should be
written to anticipate problems and should establish an ordered mechanism
as to how these problems will be remedied. In addition, the contract should
deal with the following (Hunt et al., 2004).
r Specific hardware and software being purchased and when (if spread over
several fiscal years)
r Financing or a payment plan if tied to vendor deliverables or systems
acceptance
r Implementation schedules and major milestones
r Configuration, software modifications, upgrades
r Acceptance criteria
r Ownership of software source code
r Warranties and liabilities
r Detailed set of descriptions of responsibility for both parties, including
software, maintenance, and support functions
r Remedies for nonperformance and default of warranties; technical and
legal standards to measure success or failure of the implementation
r Vendor presence during deployment
210 Infrastructure Elements of the Informatics Environment

Using a Consultant
All nursing directors or administrators during the course of their admin-
istrative responsibilities must at times make the decision to consider vari-
ous forms of assistance. Although system implementation is relatively new
in comparison to the history of nursing in general, there are still lessons
learned and captured in current literature that can be used as tools. The
intent of this textbook is to provide nurses with a means for learning about
computers and information systems and to provide further references for
information. However, not all nurses need to be computer experts. Those
nurses in decision-making positions may choose to seek advice from a nurs-
ing informatics or healthcare informatics consultant.
When choosing a nursing informatics or healthcare informatics consultant,
a nursing director or administrator should be aware of the available options.
One option is an internal consultant who is a member of the organization and
who is most knowledgeable in a certain aspect of the organization (e.g., pa-
tient care, nursing education, information services). The second option is to
tap into the expertise of a similar healthcare system or an informatics expert
in academia. The third option is an independent professional consultant.
In many cases, an internal consultant can serve as a liaison with a consultant
brought in from the outside, as internal consultants are more intimately
involved and knowledgeable about the organization. There is no doubt that
there is a place for each of the three types of consultants, but it is up to each
nursing director or administrator to choose from the various alternatives on
the basis of need, expertise offered, and financial resources.

When Is a Healthcare Computer Consultant Needed?

Employing a competent healthcare information systems consultant should
be considered when computerized patient information systems are under
consideration. The organization greatly benefits from one or two people who
have experience facilitating successful use of information systems. For what
amounts to a minimal financial commitment, the organization thus engages
someone with an unbiased, broad perspective that specifically addresses its
defined needs. However, as with any type of advice, administrators must
use the advice of healthcare information systems consultants with discre-
tion; after all, consultants do not have to live with their proposed solutions.
Consultants’ advice must always be tempered by the administrator’s com-
mon sense, intimate knowledge of the organization, and a deep and abiding
faith in personal knowledge of the nursing discipline. There are a num-
ber of specific reasons for bringing in additional assistance in the form of
consultants.

r Need advice and support of an outside consultant to justify or modify the

current operation of a department.
 Selection of Software and Hardware 211

r Need advice on a specific management or technical problem requiring an

expert opinion of a specialized nature.
r Offer an outside, unbiased opinion on major equipment decisions, reorga-
nizations, and financial commitments and assist in decision-making.
r Provide an overview of the current healthcare, hospital, or clinic situation
with a view toward developing a long-range strategic plan for the organi-
zation.
r To provide a state-of-the-art evaluation of the current information systems.
This can often focus and/or reduce the time it takes an organization to
develop an RFP.
r To analyze current operations with the intent of providing recommenda-
tions for improvement.
r To perform a rescue operation, usually at the request of the board of
trustees, in the areas of management replacement or cost reductions. This
reason is applicable when drastic action is required.
It is important to note that an effective consultant seldom makes definitive
decisions but, rather, develops and presents a set of viable alternatives for
the client. The role of the consultant can be viewed in the broad context, not
only as a specialist who might be called on for specific advice but also as a
generalist to whom the nursing department can turn to at regular intervals
for the purpose of addressing unanticipated problems.

What Is a Qualified Healthcare Informatics

Consultant?
One of the most difficult tasks for the nursing administrator or director is
defining what a qualified healthcare informatics consultant is. Often the best
person for this position is a nurse informaticist who meets the following
criteria (Welebob, 2000).
r Relevant professional preparation
r Significant experience with more than one type of information system
r Recognition in the field
r Recommendations tailored to needs of the client
r Reports delivered on time and within budget
r Ability to accomplish change
r Effective communication skills

Where Can a Healthcare Informatics Consultant

Be Found?
One of the best ways to ensure competent consulting assistance is to check
with colleagues who have already worked with a consultant and can make a
recommendation. Second, the prospective employer should check the cre-
dentials of computer healthcare consulting firms. Another avenue is to work
212 Infrastructure Elements of the Informatics Environment

through various national professional organizations, which are often willing

to suggest several private consultants who might be in business for them-
selves or who are affiliated with major universities. It is important to iden-
tify whether a consultant or their agency has arrangements with a particular
vendor(s). Having an affiliation with a particular vendor may be acceptable
after a system has been chosen but having an affiliation during system selec-
tion may lead to a conflict of interest, with the risk of having a system chosen
that may or may not meet an organization’s needs.
At this time, it is relevant to point out that it is up to the individual who
is hiring the consultant to define precisely the parameters of the consultant
contract. It is often most valuable to have a preliminary meeting with the
consultant in question. At that time, financial compensation and the du-
ration of the consultant’s employment should be discussed. In addition, a
written agreement about expected outcomes is mandatory. In the overall
consideration, employers should be aware of what can and cannot be ex-
pected from a consultant. A competent healthcare informatics consultant is
able to review the present information system and anticipate future needs;
usually suggests alternative solutions for various organizational, technical,
and system problems; offers advice about how the system can be integrated
with other information systems in the organization; and assists with contract
negotiations.
One might think that a consultant can solve all the problems encoun-
tered in the organization. However, a consultant cannot, or at least should
not, make basic decisions for the administrator. A healthcare informatics
consultant cannot assist in fighting private, internal political battles or be
expected to solve fundamental management or organization problems. This
is a job for a management consultant.

Linking Nursing and Healthcare Information Systems

The object of this section is to impart an understanding and recognition of
the importance of nurses being educated about computer systems as a way
of ensuring the success of such information systems. One of the essential as-
pects of a successful information system projectlies is establishing effective
communication between and among the various professionals, technicians,
consultants, and administrators in a healthcare organization. This section
emphasizes a few basic rules that have been effective in closing the communi-
cation gap between nurses and the information technology (IT) department.
In other chapters, basic computer concepts and details of information sys-
tems have been expanded upon, but the emphasis here is to make the reader
aware of the importance of establishing a basic conceptual understanding
between these two professional groups.
Hostility toward technology produces definite obstacles in the course of
system implementation. It is therefore vital that nursing management be
 Selection of Software and Hardware 213

fully committed to the changeover, thereby making the transition smooth

and sustaining the morale of the nursing staff. Given the fullest commitment
by all parties, it is still difficult to implement technology solutions. One of the
most glaring problems encountered is the gap in communication between the
nurses and the IT professionals. Most tasks in the healthcare computing field
require the expertise of both disciplines. An effective working relationship
is a prerequisite for the accomplishment of these complex tasks.
The basic characteristics of the average IT professional are that he or she
is energetic, is anxious to help the user, wants to be creative, is convinced that
the computer can help solve problems, and is totally unaware of the user’s
real problem. The willingness and technical capabilities of these individuals
must not be underestimated. How, then, can the health professional best
utilize these highly motivated, specially trained individuals who are eager to
lend their talents to improving the delivery of healthcare?
To work effectively with clinical information systems, it is essential to rec-
ognize the principles and methods of modern information processing. One
should look forward to this learning opportunity. Nurses can learn or gain
command of basic concepts, such as design of computer-compatible records
and transformation of plain English statements into logical computer-
compatible systems, and recognize the benefits and risks of electronic storage
of medical information. On the other hand, to achieve a mutually beneficial
working relationship, the computer professional must learn the terminology
and practice of modern nursing. The following suggestions are helpful for
integrating computer systems into the various areas of nursing practice.

1. Have the workflow or operation of the department well defined. One

must know what is happening in the department before undertaking
the task of implementing a system that computerizes it. All activities
of the operation must be documented, and the sources and recipient of
all transactions must be identified (see Chapter 13). The smallest detail
must be explainable. If you do not know what is going on, there is no
way to make the computer help you. If anything, you would then have
a more serious problem on your hands. You must precisely define the
input to the new system to begin the task of developing a useful tool.
2. Know what you want to do. One must know what is desired as output—
the end result must be well defined. If you want nurses’ notes in a certain
format, be able to articulate to the IT professional why you want it that
way. Do not worry at the design stage about how the data are manip-
ulated by the computer; be more concerned with what you want to get
out of the system. Draw a detailed picture of your desired report’s data
elements. Realize that appearances can be changed so it is the content
that needs to be captured accurately and communicated (Hunt et al.,
2004).
3. Be aware of all the exception conditions. An exception condition is
any statement where the user says, “this is true except when . . . .” For
214 Infrastructure Elements of the Informatics Environment

example, temperature is expressed in Fahrenheit degrees except on the

pediatrics unit, where it is expressed as Celsius degrees. This is the most
difficult part of designing, configuring, and implementing any system.
Discovering and satisfying all the exceptions that can arise during the
implementation of a new system eliminates most of the traumatic sit-
uations that might occur. The more precise the identification of excep-
tion conditions during the design/configuration phase of the project, the
smoother and more well accepted is the final system.
4. Ask questions. No one enjoys talking about his or her work more than a
dedicated IT professional. Get explanations about the purpose of each
device your application is using. “Oh, you wouldn’t understand” is a
response that should not be accepted; convince the IT professional to
be your teacher. Build a relationship and learn what you can about their
field, as they learn about yours. Unless you understand what facilities the
computer has available and what their functions are, the mystique of Do
not fold, spindle, or mutilate will inhibit you from taking full advantage of
the computer’s capabilities. It is wise to remember that a little knowledge
is dangerous. Make sure you understand the answers to your questions.
5. Obtain explanations of the computer solution. The computer user must
understand how the computer is maintaining the data for the system.
Nurses must be able to compare the computer workflow with the work-
flow that occurs in the current system. The IT professional typically
thinks logically, and many of the techniques implemented in a computer
system could also be valuable if adapted to the manual system. It has
been said that the best method of developing a good manual system is
to plan for a computerized one. Develop a complete computer system
and design a manual backup system that emulates the computer system;
then install the manual backup system. This may be a bit extreme, but
it emphasizes the fact that much can be learned by comprehending the
computer solution to your problem. This can be done prior to actual im-
plementation, and it is especially recommended if the workflow is going
to change dramatically.
6. If you are not getting what you need, speak up. Once the computer
system is installed and running, keep the data processing or IT support
personnel informed about what they need to do to make the system
better fit the requirements. If all you do is complain to your coworkers
about how bad the computer is, it will never work satisfactorily. You
have to tell the people who can do something about it. A good system
is never quite complete and must be evaluated and enhanced to stay up
to date with current clinical practice.
7. Make constructive suggestions. Do not limit your criticism of the com-
puter system to “that dumb computer does not work.” Tell the computer
programmer or analyst, specify the problem, and participate in problem-
solving. A successful well received computer system is a partnership be-
tween the end-users and the data-processing people who implement the
 Selection of Software and Hardware 215

system (Clough, 1997). Effective communication between these groups

is essential for the realization of a successful system.
8. Do not be overly impatient. It took a long time for your system to evolve
to the point at which it was decided to use a computer. Computer sys-
tems are not created in a day. Extensive work must be done in system
design, programming, and interfacing to have a current operational sys-
tem. Ask the IT staff for time estimates to implement the enhancements
and respect these estimates. Add in extra time because configurations of-
ten take longer than estimated—but never shorten the estimates. If you
force a “quick and dirty implementation,” the system will not be what
you want and will require a great deal of your time to correct or work
around. Instead, consider phased approaches if something is absolutely
time-boxed for a particular date.
9. Be considerate of the IT professional’s problems. Computer profession-
als are humans too and therefore have all the emotional conflicts, prob-
lems, and stresses to which any other person is subject. A family member
may get sick or other priorities arise, all of which can affect implementa-
tion schedules. They endure similar frustrations of everyday workdays.
Treat the IT staff as you would any other valued clinician, and the world
will be more pleasant for everyone involved.
10. Understand the system’s limitations. After you have a functioning sys-
tem, it is easy to escalate your desire to the unattainable. One must
understand restrictions well enough to not make impossible requests.
There are many reasons a computer cannot fulfill all workflow requests
or scenarios. Talk to the IT systems people about this aspect; perhaps
there is an intermediate solution. Try to keep your dreams realistic and
stay within reasonable demands. On the other hand, do not settle for
inconvenient workaround steps because the IT staff is too busy. Ask for
time estimates, options for phasing in components you want and can use,
and hold the IT staff accountable for the dates provided.

The entire organization can derive significant benefits by the early es-
tablishment of several IT and user committees. These committees should
represent every department of the healthcare organization and focus on
particular priorities. For example, an IT steering committee may look into
the future for IT planning versus only one project or solution. Find out what
committees your organization has and who the nursing members are on
those committees.

Summary
There are incredible opportunities when selecting a clinical system. Of ut-
most importance is that it helps clinicians provide quality patient care. This
chapter has considered various aspects of the preparation required when
216 Selection of Software and Hardware

selecting computer applications for patient care settings. The focus has been
on selections that meet the needs of clinical applications, but the same prin-
ciples apply for administrative, educational, or research applications. System
selection is also the time to start encouraging change, getting end users ex-
cited about the new system, and establishing appropriate user expectations,
thereby improving eventual system implementation success.
The following “common sense” guidelines might be of help during the
selection process.
r Understand the process.
r Write down what is not clear.
r If you do not understand something, say so.
r Keep documents simple, write for clarity, and be concise. Do not try to
“snow” others.
r Realize you cannot know it all.
r Assign responsibility for tasks.
r If someone else drops the ball, pick it up.
r Be proactive and head off trouble before it occurs.
r Two heads are sometimes better than one.
r Avoid distractions.
r Isolate tasks; do things one step at a time; use a time line.
r Be patient; involved problems take time to solve.
r Be willing to follow up.
r Do not be afraid to fail; we all learn from our mistakes.
r Do not hesitate to ask questions.
r Do not hesitate to ask for outside opinions.
r Know that what you do will make a difference.

To prepare nurses for the widespread use of information systems in health-

care, there is a strong need for continuing education, in-service education,
and undergraduate education programs that provide nurses with general
knowledge about information systems. Informatics nurses obtain more ad-
vanced education about information systems to enable them to maintain
their nursing focus and serve as interpreters between information systems
people and nurse users of information systems. This preparation makes the
nurse knowledgeable about both nursing and information system science.
When asked, all nurses are responsible for full participation and representa-
tion of nursing in the selection, development, implementation, or evaluation
of clinical information systems.

References
Clough, G.C. (1997). Getting the right system: The CHIPS experience. In: Gerdin, U.,
M. Tallberg, & P. Wainwright (eds.) Nursing Informatics: The Impact of Nursing
Knowledge on Healthcare Informatics. Amsterdam: IOS Press, p. 569.
 Selection of Software and Hardware 217

Hunt, E., Breckenridge-Sproat, S., & Kitzmiller R. (2004). The Nursing Informatics
Implementation Guide. New York: Springer-Verlag.
Jenkins, S. (2000). Nurses’ responsibilities in the implementation of information sys-
tems. In: Ball, M.J., Hannah, K.J., Newbold, S.K., & Douglas, J.V. (eds.) Nursing
Informatics: Where Caring and Technology Meet, 3rd ed. New York: Springer-
Verlag, p. 211.
Manning, J., & McConnell, E.A. (1997). Technology assessment: A framework for
generating questions useful in evaluating nursing information systems. Computers
in Nursing 15(3):141–146.
Marreel, R.D., & McLellan, J.M. (1999). Information Management in Healthcare.
Albany, NY: Delmar Publishers, Inc.
Mills, M.E. (1995). Nursing participation in the selection of HIS. In: Ball, M.J., K.J.
Hannah, S.K. Newbold, & J.V. Douglas (eds.) Nursing Informatics: Where Caring
and Technology Meet, 2nd ed. New York: Springer, pp. 233–240.
Staggers, N., & Repko, K.B. (1996). Strategies for successful clinical information
system selection. Computers in Nursing 14(3):146–147, 155.
Welebob, E.M. (2000). Nursing informatics consultancy: how to select a nursing
informatics consultant. In: Ball, M.J., K.J. Hannah, S.K. Newbold, & J.V. Douglas
(eds.) Nursing Informatics: Where Caring and Technology Meet, 2nd ed. New York:
Springer, pp. 179–180.
15
Data Protection

The issue of privacy is difficult. The individual has the inherent right to
control personal information. However, to provide the best possible care and
service to the individual, the public, and private organizations must know
some of that information. The issue is further complicated because “privacy”
has not been defined in a way that is widely and generally accepted. Actions
such as collecting and storing unnecessary personal data, disclosing data to
individuals or organizations that do not have a genuine need for it, or using
private information for something other than the original purpose could be
considered intrusive.
Since the 1960s, the widespread use of computers has led to concern about
the large mass of data collected through sophisticated data linkage capabil-
ities. The following sociolegal concerns are widespread among the public.
r How and what information is collected
r How the collected information will be used; who will have access to it
r How the collected information can be reviewed and, if necessary, corrected

Within the nursing community, concern over data protection has always
been present. The power provided by technologies such as computers and
the Internet has heightened the concern of nurses for these reasons.
r More data and information are available.
r More possibilities exist for errors in the data.
r Organizations rely on information systems for essential functions.
r More data are shared between disciplines and organizations/institutions/
facilities.
r Public concern over possible abuse of information and privacy is strong.

Until recently, terminology in the area of data protection has not been uni-
form. However, a standard is emerging, based on the headings used by Work-
ing Group 4 of the International Medical Informatics Association (IMIA)
(Hoy, 1997). In the area of data protection, then, data security is the overar-
ching concept, with three subareas.

218
 Data Protection 219

r Usage integrity, more commonly called confidentiality

r Data or program integrity
r Availability

This chapter provides a foundational understanding of the concepts con-

tained in usage integrity (confidentiality), data or program integrity, and
availability. The major focus has been on addressing usage integrity (confi-
dentiality). As approaches to data usage integrity have been identified and
implemented, more attention has been focused on data/program integrity
and availability.

Usage Integrity (Confidentiality)

Exchange of information is a cornerstone of the provision of healthcare.
Nurses are continually asking patients to share information relating to their
health, including work, home, and social life. When a patient shares some-
thing with the expectation that the information is for a limited audience only,
it is called confidentiality. The formal definition for confidentiality is respect
for the privacy of information being disclosed and ethical usage of that in-
formation only for the original purpose. Privacy is the right of individuals
and organizations to decide for themselves when, how, and to what extent
information about them is transmitted to others.
Some degree of anonymity in the environment is necessary for mental
and physical well-being. On the other hand, the needs of society often su-
persede the individual’s right to privacy. As computer databanks proliferate,
the public’s concern rises. In a 1994 survey, 52% of respondents thought that
computer records were more secure than written records. Surprisingly, when
the same survey was conducted in 1995, only 42% thought this (McKenzie,
1996). The increased use of automated personal data systems creates a seri-
ous potential for abuse and for “invasion of privacy.” Today, systems abstract
a uniform data set from medical records at the hospital level and forward it
to local, state, and federal organizations. The exchange of medical records
information between hospitals and third parties has been made easier by
computers. This exchange will increase in the future.
To date, these exchanges usually have the personal identifying data re-
moved. The main problem with automated medical records is the potential
for breach of privacy. Many health professionals, citizen groups, and other
individuals directly affected by such systems consider them to threaten the
basic rights of the individual. Underlying these attitudes is a deep concern
for confidentiality.
Data collection did not originate with the use of computers. In 1918, physi-
cians began, as a matter of practice, to record information in a medical record.
Today, the record is the vehicle for communicating information among
healthcare professionals. A health team administering comprehensive care
220 Infrastructure Elements of the Informatics Environment

to the patient develops and uses the patient record. Healthcare professionals
assume that patients fully disclose all information related to their condition
so proper care and treatment can be given. For an effective relationship
to exist between the healthcare professional and the patient, the patient
must believe that all information provided will be treated confidentially. Un-
less patients feel assured that the highly sensitive personal information they
share with healthcare professionals will remain confidential, they may with-
hold information critical to their treatment. This need for assurance existed
before computerized records. However, the introduction of computerized
healthcare records has brought the issue of confidentiality and security to
the forefront.
The capabilities of modern technology have created a public awareness
regarding the loss of confidentiality inherent in the systems being devel-
oped and installed. People other than the direct caregivers have become
responsible for the storage and safekeeping of records. Other uses of in-
dividual information—for accounting, administrative decision making, and
biomedical and healthcare research—are being explored now because the
information is easy to retrieve. The flowchart in Figure 15.1 suggests the
multitude of possible uses for healthcare data. The ability of computers to
match data from diverse sources, to handle large quantities of data, and to
maintain records over time has resulted in an unprecedented risk to personal
privacy. Record keeping and record protection (i.e., data security) are only
parts of the problem. It is access to records for “secondary” purposes that
poses the major risk to maintaining confidentiality.
Demands for computerized patient data in the healthcare setting, other
than for the actual administration and delivery of an individual’s medical
care, include the following.

r Utilization of facilities and standards reviews

r Epidemiological studies
r Program evaluation
r Biomedical, behavioral, and health services research
r Financial/billing purposes

Putting private and personal information to “secondary” uses poses a ma-

jor threat to patient privacy and creates complex social and ethical dilemmas
in healthcare. Examples of misuse of confidential information—from old
medical files left in the trash to identification left on computerized health
databases—are readily found in the newspapers. This sort of abuse does
little to reassure the public. Possible linking of various databases and fast re-
trieval and distribution capabilities have increased concern over how private
this information might truly be. The need of users (i.e., physicians, nurses,
police, insurers) to have easy access to medical information systems must be
balanced with the need of the individual for privacy.
 Data Protection 221

FIGURE 15.1. Possible uses of healthcare data.

Data Security Breaches

There are many outcomes that can occur as a result of breaches in data
security (Barber, 1977, p. 62).

r Public embarrassment or loss of public confidence

r Question of personal safety
r Infringement of personal privacy
222 Infrastructure Elements of the Informatics Environment

r Failure to meet legal obligations

r Question of commercial confidentiality
r Financial loss
r Disrupted activities

Damage to patients is of vital concern; however, other types of damage

are also important. Legal cases, financial loss, and loss of public confidence
can cause great damage to organizations. To address these concerns before
problems occur, it is essential that nurses be involved in formulating specific,
documented policies related to data security. When such policies are in place,
nurses are not left in the dangerous situation of having to make judgments
about use of data without any regulations to assist them. The three areas
identified here must be considered when defining data protection policies.
Data protection policies will contribute to an overall organizational disaster
plan, as discussed in Chapter 17.

Protecting Data Usage Integrity

Three approaches to protecting data usage integrity are suggested: hardware,
software, and organizational.

Hardware Approach
Hardware security is concerned with the protective features that are part of
the architectural characteristics of the data-processing equipment. It also in-
cludes the support and control procedures necessary to maintain operational
integrity of those features. Hardware security features include hardware
identification, isolation features, access control, surveillance, and integrity.
Specific protection could include physical barriers such as special doors, locks
on individual machines, and control over the use of communication links to
the system.

Software Approach
Software security requires the operating system to provide the same features
as the hardware security system. It must be able to identify and authenticate,
to isolate, to control access, and to have surveillance and integrity features.
Security mechanisms designed to protect patient confidentiality generally
rely on some combination of authentication, authorization, and auditing
(Bowen et al., 1997).
Authentication refers to the methods by which a system verifies the identity
of a user, usually based on passwords or physical tokens. Passwords, although
a useful approach, have many inherent problems. Users exchange passwords,
 Data Protection 223

passwords are left written down by the computer, common words are used,
and passwords are not changed on a regular basis.
Authorization denotes access controls or other means used to provide
specific information to a given user. Systems that implement authorization
procedures generally attempt to determine whether a given user has a need
to know the requested information. Some of the dimensions considered
when formulating mechanisms for making such decisions include user roles,
types of database interaction, and the purpose for which the information
will be used. Commercial programs exist to aid this process.
Auditing is used to record and review a user’s interaction with the system.
These user records create an audit trail. Depending on the system, auditing
may be unapparent to the user. Audit records can then be used to identify
unauthorized attempts at access and patterns of access. The threat of sanc-
tions is often sufficient to deter abuse of information access. However, such
systems depend on users being aware of and sensitive to the consequences
of abuse. Another problem associated with the use of auditing as a secu-
rity approach is that it is retrospective (Bowen et al., 1997). Depending on
the design of the processes to review auditing records, much time can pass,
with the result of having continued information security breaches before the
unauthorized usage is detected and confronted.

Organizational Approach
The procedural considerations that bring together computing equipment,
software, and data in an operational electronic data-processing environment
are collectively called operations security. These procedures must provide for
secure processing during data input, processing, storage, and output. The ad-
ministrative and organizational component of privacy protection involves
the development and dissemination of policies, procedures, and practices
related to privacy of patient information. Administrative policies and pro-
cedures must be put in place to protect the privacy and confidentiality of
patient information. Such measures include disciplinary action for violation.
An initial concern is the question of which individuals or categories of work-
ers should have access to what information in a hospital information system.
These are difficult decisions. Each user’s or department’s needs must be con-
sidered, along with those of the patient. The committee who makes these
decisions and the information systems staff most likely know how best to ac-
cess the entire patient record. Yet even then there is potential for violation
of confidentiality. For example, some institutions employ data entry clerks
to enter previously written data. These employees have access to the entire
patient chart while the data are being entered but are not bound by a “code
of ethics” as are other healthcare personnel. This could be a strong argument
against using these employees to enter data. It might be better to have all
professionals enter and retrieve their own data. Other considerations include
where terminals, printers, and data storage are located. Portable computers
224 Infrastructure Elements of the Informatics Environment

and bedside terminals are liable to theft and may allow the patient or visi-
tors unauthorized access to the system. The organizational decisions about
ways in which physical items are sited influence the hardware and software
approaches to security that must be taken.

Data/Program Integrity
Data must be collected, stored, and transmitted in a manner that preserves
the integrity of the data. Accurate collection of data along with mechanisms
for reviewing and correcting specific information are essential for preserv-
ing data integrity. The use of source data capture technologies enhances the
probability of collecting accurate data (see Chapter 6). A key concern of
consumers is the ability to view personal data and correct it as required. Ac-
curacy is the foundation for data integrity. Arduously protecting the storage
and transmission of that which is fundamentally flawed is a strong possibility
if attention is not paid to all three aspects of data integrity.
There has always been concern about protecting the storage of data. In
times past, the primary threat was from natural disasters such as fires, floods,
tornadoes, or earthquakes. Electronically stored data are also open to these
threats. However, the more common threats to data and storage integrity
come from system malfunctions, either accidental or malicious. Computer
viruses that corrupt individual data or entire system are a major threat to the
security and integrity of data storage. The viruses are commonly introduced
into an organization’s information system by users transferring infected files
between their personal computers and the organization’s computers. An-
other threat to the secure storage of data is the ability of users to copy data
files onto personal computers to work at home. Confidential patient infor-
mation may be left on a CD-ROM that is then partially copied over and
given to someone else, with identifiable data remaining accessible. As part
of an overall data security plan, organizations must develop and enforce
policies related to the transfer of information between the organization’s
information system and an individual user’s personal computer.
The transmission of electronic data within an organization and with out-
side agencies provides another significant opportunity for exposure to se-
curity threats. Many organizations have developed policies to deal with the
security of data transmitted within the organization (e.g., between depart-
ments). However, the exponential growth of the use of the Internet for secure
data transmission requires a fresh look at transmission policies. The level of
concern about Internet security depends on how an organization is using
the Internet. Even organizations that have not connected their networks to
the Internet are at risk as staff members use the organization’s systems and
networks to connect to the Internet using their personal subscriptions. Or-
ganizational use of the Internet can be roughly divided into three categories,
each with specific data transmission security concerns (Miller, 1996).
 Data Protection 225

1. Using the Internet as an information resource or on-line library includes

searching the CINALHDirect database or other on-line databases for ar-
ticles and downloading articles from a website. The risk here is not from
inappropriate transmission of secure data but of downloading a virus
along with the article. The installation and maintenance of antivirus soft-
ware should protect data from corruption from an Internet connection.
2. Using the Internet as a communication vehicle. Sending and receiving
e-mail, participating in mailing lists or discussion groups, and making in-
formation available to the public through a website are examples of the
Internet’s use as a communication tool. As a communications tool, the
Internet should not be considered secure. Messages may be read by many
other persons in addition to the intended recipient. The message may be
stored on a variety of computers before delivery, or the recipient may
make copies or forward the message to any number of people. Transmit-
ting electronic patient data to other healthcare professionals via e-mail,
for either consultation or research, must also be regulated for the reasons
stated above. Communicating with patients via e-mail may pose risks to
the patient’s privacy and data security, especially if the e-mail is directed
to the patient’s employment e-mail address. Policies must be developed
to govern communication using the Internet so as to preserve data trans-
mission integrity.
3. Use of the Internet as an extension of the organization’s network, includ-
ing linking your computer systems to another organization’s computer
systems (e.g., to participate in a joint research project) or providing re-
mote access for staff members or transfer of files to other organizations.
File transfers should be used with caution. When files are transferred into
an organization, there is a risk of downloading software in violation of
copyright or infecting the organization’s computers with viruses. Transfer-
ring files outside the organization runs the risk of disclosing confidential
patient or proprietary information either in the file transfer itself or as
a result of the way in which the information is handled in the receiving
organization. Research and policy discussions about the secure transmis-
sion of electronic patient information are accelerating as the electronic
health record becomes a reality in many jurisdictions.

System Availability
A system must be available in the right place at the right time. Overload-
ing may slow down a system’s response, and other, more serious problems
may shut it down altogether. All computer users live in fear of their system
becoming unusable because of failure of the machine or its power supply.
Solutions may involve uninterruptible power supplies and backup hardware
on standby and certainly should include backup of patient data on a regu-
lar basis to ensure that no information is lost if a system problem occurs.
226 Infrastructure Elements of the Informatics Environment

Buildings that house computer equipment require precautions against natu-

ral and manmade hazards. Chapter 17 contains detailed information related
to disaster recovery planning.

Legislation and Standards

As healthcare institutions use computerized medical records in more ways
and as demands for personal data increase, public concern will continue to
rise unless fears regarding potential abuse of information are addressed. In
an effort to strike a balance between institutional objectives and public con-
cerns, legislators have proposed or enacted policies to control and regulate
the creation and use of large databases. However, many of these proposals
have created legal conundrums because of their conflict with existing laws
or through the resulting division of power between the various levels of gov-
ernment. Because of these problems, there has been greater emphasis on
the voluntary establishment of standards and codes of ethics within the data
processing and medical record management communities. Internationally,
the Organization for Economic Cooperation and Development (OECD)
(1981) held that

although national laws and policies may differ, member countries have a common
interest in protecting privacy and individual liberties, and in reconciling fundamental
but competing values such as privacy and the free flow of information.

This belief led to the adoption by member countries of a set of guidelines

that should be minimum standards for handling personal data relating to
an identifiable individual. The Guidelines on the Protection of Privacy and
Transborder Flows of Personal Data, adopted in 1980, continue to represent
the international consensus on general guidance concerning the collection
and management of personal information: http://www.oecd.org/document/
20/0,2340,en 2649 201185 15589524 1 1 1 1,00.html (OECD, 1980). The
eight guidelines are as follows.

1. Collection Limitation Principle. Collection of personal data should be

limited. It must be done through lawful and fair means and, whenever
possible, with the knowledge and consent of the subject.
2. Data Quality Principle. Data should be relevant to the proposed usage,
accurate, and complete; and it should be kept up to date.
3. Purpose Specification Principle. The intended use of data should be stated
at the time of collection, and subsequent usage should be limited to that
purpose or such other that is not materially different from the stated
intended purpose.
4. Use Limitation Principle. Data should not be disclosed, made available,
or used for purposes other than those specified without the consent of the
subject or unless authorized by law.
 Data Protection 227

5. Security Safeguards Principle. Personal data should be protected by rea-

sonable security safeguards against such risks as loss or unauthorized
access, destruction, use, modification, or disclosure of data.
6. Openness Principle. A general policy of openness should exist about de-
velopments, practices, and policies with respect to personal data. Means
should be readily available for establishing the existence and nature of
collected personal data and the main purpose of their use, as well as the
identity of the collector of the data.
7. Individual Participation Principle. An individual should have the follow-
ing rights.
r Be able to obtain confirmation as to whether data relating to himself or
herself exists
r Be able to have data relating to him or her made available within a
reasonable time, at a reasonable cost, in a reasonable manner, and in a
form that is readily intelligible
r Be given reasons for refusal of a request made under the first two rights
r Be able to challenge data relating to him or her and, if successful, to
have the data erased, rectified, completed, or amended
8. Accountability Principle. A data controller should be accountable for
complying with measures that give effect to these principles as just stated.

The principles embodied in the OECD guidelines are evident in many

privacy-related laws passed in member countries and in principles and guide-
lines adopted by national professional organizations.
In the United States, the Health Insurance Portability and Accountability
Act (HIPAA) of 1996 was enacted to allow employees and their families to
transfer insurance benefits from one employer to another or to extend cover-
age if the employee was terminated or left the job (portability) and to protect
the way electronic health information is stored and exchanged (accountabil-
ity) (Follansbee, 2002; Trossman, 2003). Although there are nursing impli-
cations related to portability, the major implications of HIPAA in the area
of accountability are addressed here. The Administration Simplification ad-
dresses accountability through “The Privacy Rule” and “The Security Rule.”

In response to the HIPAA mandate, HHS published a final regulation in the form
of the Privacy Rule in December 2000, which became effective on April 14, 2001.
This Rule set national standards for the protection of health information, as applied
to the three types of covered entities: health plans, healthcare clearinghouses, and
healthcare providers who conduct certain healthcare transactions electronically. By
the compliance date of April 14, 2003 (April 14, 2004, for small health plans), covered
entities must implement standards to protect and guard against the misuse of indi-
vidually identifiable health information. Failure to timely implement these standards
may, under certain circumstances, trigger the imposition of civil or criminal penalties.
[http://www.hhs.gov/ocr/hipaa/guidelines/overview.pdf]
Under the Privacy Rule, health plans, healthcare clearinghouses, and certain
healthcare providers must guard against misuse of individuals’ identifiable health
228 Infrastructure Elements of the Informatics Environment

information and limit the sharing of such information, and consumers are afforded
significant new rights to enable them to understand and control how their health in-
formation is used and disclosed. [http://www.cms.hhs.gov/hipaa/hipaa2/regulations/
privacy/finalrule/privrulepd.pdf]

HIPAA places comprehensive restriction on the use and disclosure of

individual health information in any form including computer diskette or
CD-ROM, storage on a computer server, e-mail, voice recordings, and other
similar media as well as anything derived from these sources (Follansbee,
2002). “Covered entities” include health insurance plans, healthcare clearing
houses, and healthcare providers. Specifically, the HIPAA Privacy Rule may
be summarized as follows.
r It requires that patients receive a clear written explanation of how their
health information is used, kept, and disclosed.
r It requires that patients be permitted to see and obtain copies of their
records and to request amendments to those records. Also, a history of
disclosures of their records must be accessible to the patients.
r It specifies that patient consent is required before sharing protected health
information for treatment, payment, or healthcare operations purposes. In
addition,“authorization” is required when the healthcare information is to
be used for nonroutine and most nonhealthcare purposes.
r It specifies that, except for uses or disclosures for purposes of treatment,
payment, or healthcare operations, patient consent to use and disclosure
of protected health information may not be required and must not be
coerced by providers and health plans.
r It provides patients with recourse in the event of HIPAA violations.

The security standards . . . define administrative, physical, and technical safeguards

to protect the confidentiality (safe from wrongful access), integrity (safe from alter-
ation), and availability (safe from loss) of electronic protected health information.
The standards require covered entities to implement basic safeguards to protect elec-
tronic protected health information from unauthorized access, alteration, deletion,
and transmission. The Privacy Rule, by contrast, sets standards for how protected
health information should be controlled by setting forth what uses and disclosures are
authorized or required and what rights patients have with respect to their health in-
formation. [http://www.cms.hhs.gov/hipaa/hipaa2/regulations/security/03-3877.pdf]

The HIPAA Security Rule applies only to electronic data, which includes
storage media (hard drives, magnetic disks and tapes, optical disks) and trans-
mission media (Internet, dial-up lines) (McCartney, 2003). The Security Rule
includes the administrative policy and physical and technical requirements
summarized below (McCartney, 2003).
Required administrative policies include the following.
r Security management
r Security official
r Risk analysis
r Identification and response to a security incident
 Data Protection 229

r Sanction policy
r Information system activity review (audit)
r Contingency plan for data backup, system failure, environmental disaster
recovery, and emergency situations (includes requirement to create and
store retrievable exact copies of electronic patient data)
r Procedures to authorize access to protected health information
r Security training

Required physical safeguards include these items.

r Policies that limit physical access to the facility, workstations, electronic
devices, and media
r Policy that details the movement and disposal of any electronic protected
health information
Required technical safeguards include the following
r Each user has a unique user name or number for identification and au-
thentication of permission to access protected health information.
r Activity, in an electronic file, of any user must be permanently recorded,
able to be examined at a later date, and be nonrepudiatable (individual
cannot deny accessing the information).
r Automatic logoff is in place.
r Encryption is part of the system.
r Integrity safeguards ensure that electronic protected health information
are clearly represented in the original format, complete, correctly iden-
tified, retrievable, and have not been altered, destroyed or wrongfully
transmitted.
r Corroboration (evidence that protected health information has not been
altered) is built into the system.
Nurses must be knowledgeable about HIPPA and how it relates to their
individual practice. Organizations and institutions have developed policies
and procedures specific to their situation. If you are not aware of the policies
and procedures related to protected health information in your work setting,
contact the nursing administration in your institution.
In Canada, the federal government and all provinces have passed free-
dom of information and protection of privacy legislation to protect personal
information in the public sector. Common provisions in these laws include
guidelines for the collection, use, and disclosure of personal information.
Four provinces have passed legislation specific to health information. There
is a federal initiative to develop national legislation to deal specifically with
the privacy, confidentiality and security requirements of the electronic health
record. Additionally, the Canadian Organization for the Advancement of
Computers in Health (COACH) has published Guidelines for the Protec-
tion of Health Information (2004). These guidelines provide an overview of
key issues related to the development and implementation of security and
privacy programs for healthcare organization and legislators.
230 Infrastructure Elements of the Informatics Environment

The European Union passed a data protection directive, Directive

95/46/EC, in 1995 (http://europa.eu.int/comm/internal market/privacy/
index en.htm). The Directive covers the processing of personal data and
free movement of the data. Several countries have moved to supplement
this broad legislation with laws that provide strict privacy safeguards for
medical data. In the United Kingdom, the Data Protection Act, passed in
1998 (http://www.hmso.gov.uk/acts/acts1998/19980029.htm), categorizes in-
formation relating to an individual’s physical or mental health as sensitive
data, requiring special efforts to protect its privacy.

Nursing Responsibilities
The components of privacy protection in a healthcare information system are
not mutually exclusive but are highly interrelated and interactive. As patient
advocates, nurses must be vigilant in protecting patient privacy. Nurses must
initiate and participate in the evaluation of the privacy protection in new or
existing computerized patient information systems. The following questions
might be useful in guiding such an evaluation.
r What is the mechanism for restricting entry to main computer system
areas?
r How are the terminals “locked”—that is, by card, key, or password?
r What security is provided for media storage areas? Will a librarian be
available to control access? Will stored materials ever be allowed to leave
the storage area?
r What provision is made to protect data in the event of fire, destruction of
the area, and the like?
r What control is used to establish who can view, enter, or alter data?
r Are certain terminals designated for access to specific data sets only (e.g.,
dietary)?
r Is the sign-on done by department, unit, or individual? Are codes a com-
bination of alphanumeric symbols?
r Is an audit trail available through a transaction log to process the time and
identification code of each log-on?
r What mechanism(s) exists for encrypting personal data?
r Is there a mechanism whereby a terminal is identified before information
goes out?
r Do statistical reports identify individuals in any way?
r Is an oath of secrecy or a signed statement on ethical position necessary
for staff members who are not governed by a code of ethics (e.g., those
who process and store the data)?
r Does the duty of confidentiality transfer from direct caregivers to data
processors?
r How are data-processing personnel screened for jobs? How is their re-
sponsibility for confidentiality emphasized? What are the consequences
for inappropriate release of data?
 Data Protection 231

r When personnel leave, what happens to their password?

r What agency is used to test the security of the system?
r How are security breaches reported (by whom, to whom)? Who has au-
thority to take disciplinary action when security breaches occur?
r Who has overall responsibility in the institution for confidentiality of in-
formation?
r Who is responsible for keeping the public informed of the purpose, use,
and existence of computerized records?
r Who is responsible for establishing, updating, and enforcing written poli-
cies and procedures?
Knowledgeable nurses advocate their institution’s or organization’s com-
pliance with the following criteria, which the literature identifies in relation
to both new and existing computerized health information systems.
r The use of passwords and identification codes is essential. Controlled ter-
minal access can be used in conjunction with the measures described here;
by itself, however, it does not appear to be adequate. Passwords should be
changed at regular intervals and as necessary. The same password should
not be repeated to eliminate the employees using old passwords to gain
access to wrong information.
r Limits on the collection and recording of information must be established.
Individual institutions will formulate policies in this regard. As individuals,
nurses need to assess the relevance of the information they record.
r When entering data, we need to ensure that the information is accurate.
This has always been essential; but because of the qualities of automated
records, the potential harm of inaccurate charting currently has an even
greater impact on the patient.
r When developing policies regarding privacy, confidentiality, and a system’s
security, the patient must be the prime concern. To facilitate this objective,
a patients’ rights representative is a great asset.
r Informing the public when implementing a new hospital information sys-
tem is important. Part of the public awareness campaign should include its
impact on privacy. This method may cause unwarranted concern, but the
public is now aware of the system’s implementation and potential, both
positive and negative aspects. Also, the more introductory information
given to the public about the system, the more likely it is to accepted.
r Before the input of an individual’s data into a system, the patient must
be informed that computerized medical records are operational in the
institution. To withhold this fact from a person is an invasion of the patient’s
privacy.
r When using information for research, a consent is absolutely essential.
Information should not be identifiable.
r The system and its controls must be reviewed at regular intervals, and
audits must be performed by an independent party.
r At present in Canada, medical records are the property of the hospital.
A study on personal privacy performed in the United States recommends
232 Data Protection

that patients have a right to see their own records and, furthermore, be able
to make amendments as necessary to maintain their accuracy. Legislation
is necessary to change this policy. Making the medical record the prop-
erty of the individual allows patients to have access to their own medical
records. Access to the record should be available anytime and anywhere.
The patient could then assess its accuracy. Provisions would have to be
made enabling the individual to make amendments to the record. Patient
ownership of records is an issue in itself but is beyond the scope of this
section and is not being addressed further.
r With the implementation of computerized medical records, an entire new
department of staff has access to the patient’s record. These are the in-
formation systems personnel. A “code of ethics” should be formulated
for them regarding privacy and confidentiality of the information. The
document should be signed by each employee to obtain its full impact in
maintaining confidentiality.
r Government legislation is necessary in the area of database linkages to
control data transfer from one system to another and to control data uses.
As previously stated, because of the potential harm to the individual and
the institution, strict policies need to be enforced for governing both the
access and use of information.
r Education of all personnel in the area of patient privacy and confiden-
tiality is imperative. It is especially important for persons who are new
to the healthcare system and involved with patient care records for the
first time (e.g., information systems personnel). Education is an essential
part of the maintenance of privacy and confidentiality. Professionals who
are traditionally critical of automated medical records accept the system
more readily if they are educated about how security is maintained. Reg-
ular intervals of inservice must be carried out to inform the staff of new
developments in this area.

References
Barber, B. (1997). Security and confidentiality issues from a national perspective.
In: Patient Privacy, Confidentiality and Data Security: Papers from the British
Computer Society Nursing Specialist Group Annual Conference. Lincolnshire, UK:
British Computer Society, pp. 61–72.
Bowen, J.W., Klimczak, C., Ruiz, M., & Barnes, M. Design of access control methods
for protecting the confidentiality of patient information systems in networked
systems. Journal of the American Medical Informatics Association: Symposium
Supplement. Nashville: Haanlley & Belfus, 1997:46–50.
COACH—Canada’s Health Informatics Organization. (2004). Guidelines for the
Protection of Health Information. Toronto: COACH.
Data Protection Act. (1998). http://www.hmso.gov.uk/acts/acts1998/19980029.htm.
European Data Protection Directive. (1995). http://europa.eu.int/comm/internal
market/privacy/index en.htm.
 Data Protection 233

Follansbee, N. (2002). Implications of the Health Information Portability and Ac-

countability Act. Journal of Nursing Administration 32(1):42–47.
Health Information Portability and Accountability Act. (1996). http://www.hhs.gov/
ocr/hipaa/.
Hoy, D. (1997). Protecting the individual: Confidentiality, security and the growth of
information systems. In: Sharing Information: Key Issues for the Nursing Profes-
sion. Lincolnshire, UK: British Computer Society, pp. 78–87.
McCartney, P.R. (2003). HIPAA and electronic health information security. The
American Journal of Maternal Child Nursing, 28(5):333–334.
McKenzie, D.J.P. (1996). Healthcare trend improves security practices. In Confi-
dence., May/June, pp 1–3. http://www.ahima.org/publications/1a/May-June.inconf.
html.
Miller, D.W. Internet security: What health information managers should know.
Journal of AHIMA. 1996, September, 4 pg. Online. Available: http://www.ahimma.
org/publications/2f/sept.focus.html.
Organization for Economic Cooperation and Development (OECD). (1980). Guide-
lines on the Protection of Privacy and Transborder Flows of Personal Data. Paris:
OECD.
Personal Information Protection and Electronic Documents Act. (1980). http://www.
privcom.gc.ca/legislation/02 06 01 e.asp.
Trossman, S. (2003). Protecting patient information: healthcare facilities gear up for
privacy regulations. American Journal of Nursing 103(2):65–67.

Additional Resources
DiBenedetto, D. (2004). AAOHN and CMSA develop joint position paper on
HIPAA and confidentiality. Case Management 9(2):106–108.
Mills, M.E. (1997). Data privacy and confidentiality in the public arena. Journal of
the American Medical Informatics Association: Symposium Supplement. Nashville,
TN: Hanley & Belfus, pp. 42–45.
Muller, L. (2004). HIPAA: Demonstrating compliance. Case Management 9(1):27–
31.
Murray, P.J. (1997). “It’ll never happen to me”: Revisiting some computer security
issues. Computers in Nursing 15(2):65–66, 70.
Olsen, D.P. (2003). HIPAA privacy regulations and nursing research. Nursing Re-
search 52(5):344–348.
Roberts, D.W. (2003). Privacy and confidentiality: The Health Insurance Portability
and Accountability Act in critical care nursing. AACN Clinical Issues: Advanced
Practice in Acute Critical Care 14(5):302–309.

Websites of Interest
American National Standards Institute Home Page: http://www.ansi.org
Canada Health Infoway: http://www.infoway-inforoute.ca/home.php?lang=
en
Canadian Institute for Health Information: http://www.cihi.ca
United States Privacy Laws by State: http://www.epic.org
16
Ergonomics

A major concern for nursing informatics is ergonomics. The word

“ergonomics” comes from the Greek words ergo, meaning work, and nomos,
meaning law. Ergonomics, a relatively new science, looks at the application
of physiological, psychological, and engineering principles to interactions
between people and machines. Ergonomics attempts to define working con-
ditions that enhance individual health, safety, comfort, and productivity. This
can be done by recognizing three things: the physiological, anatomical, and
psychological capabilities and limitations of people; the tools they use; and
the environments in which they function.
As the use of computerized nursing information systems increases, er-
gonomics is of increasing interest to nurses in their dual role as users of com-
puters and as healthcare providers. Nurses are concerned with how computer
workstations or handheld computers affect the provision of patient care (see
Chapters 7 and 8) and the nurse as an individual. These concerns include
the physiological aspects (i.e., physical comfort), cognitive aspects (i.e., com-
prehension of displayed information), and practical aspects (i.e., infection
control when using computers at the bedside). Ergonomics standards play
a key role in improving the usability of systems and addressing many of
the concerns identified here. The standards provide guidance to decision
makers in the procurement of systems and systems components that can be
used effectively, efficiently, safely, and comfortably. Ergonomics standards
themselves do not guarantee good, design, but they do provide a means of
identifying interface quality in design, procurement, and operational use.
International standards for display screen equipment are being developed
by the International Organization for Standardization (ISO). The ISO rec-
ommendations are developed by working groups whose members are rep-
resentatives of the national standards bodies of member countries. There
are 17 parts to the standard related to work with visual display terminals
(VDTs). Many of these parts are still works in progress. More information
regarding ISO standards can be obtained at http://www.iso.ch (for a fee) or
at www.usabilitynet.org/tools/r international.htm.

234
 Ergonomics 235

The following is a list of the various parts of ISO 9241 Ergonomics Re-
quirements for Office Work with Visual Display Terminals (VDTs).
r Part 1: General introduction
r Part 2: Guidance on task requirements
r Part 3: Visual display requirements
r Part 4: Keyboard requirements
r Part 5: Workstation layout and postural requirements
r Part 6: Environmental requirements
r Part 7: Display requirements with reflections
r Part 8: Requirements for displayed colors
r Part 9: Requirements for nonkeyboard input devices
r Part 10: Dialogue principles
r Part 11: Guidance on usability specification and measures
r Part 12: Presentation of information
r Part 13: User guidance
r Part 14: Menu dialogues
r Part 15: Command dialogues
r Part 16: Direct manipulation dialogues
r Part 17: Form-filling dialogues

There is work in progress to develop ISO AWI 18789 (Ergonomic re-

quirements and measurement for electronic visual display), which will
revise and replace ISO 9241 Parts 3, 7, and 8 and ISO 13406 (Er-
gonomic requirement for work with visual displays based on flat panels
(www.usabilitynet.org/tools/r international.htm).
Detailed discussion of ergonomics and the ISO standards is beyond the
scope of this text, but the next section addresses selected areas directly re-
lated to nurses.

Nursing Computer Workstation

The nursing computer workstation has two components: hardware (the phys-
ical equipment) and software (the programs required to enter, retrieve, and
process information). Both components affect the quality of patient care
and the physical and psychological comfort of the nurse. The hardware nor-
mally has a way to enter data and commands and a way to display data
and results. How this is accomplished primarily affects the physical com-
fort of the nurse. The quality of patient care is determined by how accu-
rately data can be entered and how easily retrieved information can be
interpreted and comprehended by the nurse. The effect of the presence of
bedside terminals on the patient–nurse relationship has not been well doc-
umented.
236 Infrastructure Elements of the Informatics Environment

Video display terminals are the usual point of contact between the nurse
and most computerized nursing information systems. VDTs are the de-
vices that show both input to, and output from, the central processing unit.
Information is typed on the keyboard and presented on the display screen
for verification by the operator before being transmitted to the computer.
Output from the computer is presented to the operator in the same fashion,
that is, as an image generated on the display screen.

Physiological Concerns
Much research has been done regarding the physiological aspects of VDT
workstations. The terms VDT, video display unit (VDU), video matrix
terminal (VMT), cathode ray terminal (CRT), and monitor are synony-
mous. Some users of VDTs complain of ergonomic shortcomings such as
strained postures, poor photometric display characteristics, and inadequate
lighting conditions. Others claim that the complaints are symptoms of a
health hazard requiring immediate measures to protect the health of oper-
ators. The National Institute for Safety and Health (NIOSH) in the United
States has sponsored extensive research concerning a variety of ergonomics-
related topics. These reports are available through the NIOSH website
(http://www.cdc.gov/niosh/homepage.html). Additional reference articles,
current journal listings, and related conferences can be accessed at the
ERGOWEB site (http://www.ergoweb.com). A VDT workstation check-
list is available at the ERGOWEB site that is useful for nurses and em-
ployers to evaluate the ergonomics of fixed workstations. The following
sections provide an overview of ergonomic concerns related to nursing
informatics.

Eye Strain
Screen Resolution
The displayed size of the characters on the screen can contribute to eyestrain.
The character’s image is generated on the display screen by a cathode ray
tube. The cathode ray tube used in computer terminals is identical to those
found in television sets. It is essentially a glass vacuum tube encased in a
lead seal with an electron gun in opposition to a phosphor-coated screen.
High-voltage electricity is used by the electron gun to generate a stream of
electrons that can be directed to any display screen location. This electrical
excitation of the phosphors eliminates the point on the screen at which the
slender beam of electrons is being focused. A scanning mechanism generates
letters and characters using a dot matrix pattern. The number of horizontal
and vertical dots, called pixels, in the matrix determines the resolution of
the character. The ranges for high-, medium-, and low-resolution screens
continue to change with each advance in technology.
 Ergonomics 237

Flicker
Flicker on the screen also causes eyestrain. Two characteristics of the screen
play a crucial role in reducing flicker: persistence and refresh rate. Persis-
tence is the length of time the phosphors remain illuminated after being
electrically excited. The refresh rate is the frequency with which each point
on the surface of the screen is reilluminated by electrical excitation. The
refresh rate must be frequent enough so persistence of the phosphor is sus-
tained; otherwise, the displayed characters seem to fade away. Flicker occurs
when the refresh rate is too low. The operator then notices the decay in the
phosphor’s illumination before it is reexcited. In this case, the operator can
identify pulsating luminescence in the display. The presence of flicker causes
eye and mental fatigue for operators. Refresh rates of 70 Hz (cycles per sec-
ond) are usually sufficient to prevent perceptible flicker on screens having
light characters on a dark background, thereby reducing eye strain (ISO,
9241, Part 3, 1996).

Color
The color of the display does not seem to be a major physiological factor.
The choice of the phosphor to be used in the screen is determined by the
phosphor’s grain, its luminescence, its color, and its persistence (rate of de-
cay). There is considerable disagreement whether amber or green phosphors
provide better legibility and color contrast. Generally, it is agreed that light-
ing conditions determine which is best in specific situations. Usually, green
is preferred for highly illuminated rooms and amber for less well lit areas.
Often the choice of color is more a matter of personal preference than of
scientific determination considering the lighting conditions in most work
environments.

Glare
Glare also contributes to eyestrain among users. Although lighting condi-
tions do not appear to influence the choice of screen phosphor color, they
are of considerable ergonomic significance in relation to glare. Glare oc-
curs when the range of luminances in the visual field is too great (e.g., when
bright sources of luminares, windows, or their refracted images fall within
the field of vision). Glare causes distractions, visual discomfort, reduced leg-
ibility, and reduced visual acuity. Engineers have attempted to reduce glare
on display screens using three methods: etched glass and filters, optical coat-
ings, and position of the screen. Etched glass and filters do reduce glare but
also tend to simultaneously reduce legibility by defocusing the characters
and reducing character brightness. In fact, some filters have been found to
increase the operator’s awareness of screen reflections. Optical coating of
the screen glass has been found to be an effective but expensive solution for
glare. The most effective, least expensive means of reducing glare is simply
238 Infrastructure Elements of the Informatics Environment

to make sure that the screen can be moved and positioned so reflections are
no longer visible. This can be accomplished by placing the screen at right
angles to the source of light and by ensuring that the display screen is an
independent, adjustable unit.

Contrast
Contrast examines how the use of color compatibility affects human perfor-
mance under the effect of reflected glare. Performance may be improved
by selecting proper color combinations. Most displays use light characters
on a darker background (negative presentation). In general, white on black,
white on blue, or amber on black is preferable to using black on white or
white on yellow. Such displays appear to flicker less but suffer from reduced
contrast between characters and background as a result of high ambient light
levels. The contrast between the brightness of the image and the brightness
of the background is a key factor in determining the legibility of images on
a VDT. It is recommended that the contrast ratio of characters and back-
ground on CRT screens be large, at least 3:1 and up to 15:1 (ISO, 9241, Part
3, 1996). As individual preferences for both brightness and contrast vary, the
controls for these components should be effective over the range of lighting
and environmental conditions experienced at the workstation.

Posture
The presence of rotating, tilt, and swivel mechanisms to allow adjustment of
the screen is also important in helping the operator maintain proper posture.
As illustrated in Figure 16.1, NIOSH recommended that the keyboard be
29 to 31 inches from the floor. The center of the display screen should be 10 to
20 degrees below the user’s vertical eye level. The angle between the upper
and lower arm should be between 80 and 120 degrees. The user’s wrist angle
in using the keyboard should be less than 10 degrees, and ample leg room
must be available. It has also been found that swivel chairs with adjustable
seat height and independent back support are helpful. Compliance with
these criteria reduces or prevents the pain or stiffness in the neck, shoulders,
and lower back that results from poor posture at the workstation.
The user’s workspace should be arranged so the eye to display screen
viewing distance is between 17 and 25 inches (see Fig. 16.1), depending of
course on the user’s eyesight. To reduce eye strain induced by eye refocusing,
the screen, keyboard, any any text that is being copied should be at the same
distance from the operator’s eyes. Another factor that has been shown to
create itching, burning, and dry and irritated eyes is the warm airflow created
by floppy disk drives and terminal fans which often seems to be aimed at the
user’s face.
The previously described postural concerns relate solely to seated work-
stations. Little research has been reported relating to clinical workstations.
 Ergonomics 239

FIGURE 16.1. National Institute for Occupational Safety and Health (NIOSH) spec-
ifications for visual display terminal (VDT) use show (1) height of keys at 29–31
inches; (2) optimal viewing distance 17–25 inches; (3) screen center 10–20 degrees
below the plane of the operator’s eye height; (4) angle between upper and lower arm
80–120 degrees; (5) wrist angle less than 10 degrees; (6) keyboard at or below elbow
height; (7) ample leg room. (From Computers Medicine 2, no. 5, September 1982,
with permission.)

Although general laptop guidelines have been articulated, there is no report-

ing of the ergonomic considerations of their use in clinical settings. Addition-
ally, there is no research related to the ergonomic aspects of personal digital
assistant (PDA) use (Nielsen and Trinkoff, 2003). Ergonomic concerns aris-
ing from bedside or notebook technology have also not been described in
the literature.
Cumulative trauma disorder (CTD), also know as repetitive stress injury
(RSI) is a major concern for nurses as the amount of time spent working on
computers increases (Berner and Jacobs, 2002: Nielsen and Trinkoff, 2003).
Interventions can be put into place in both work flow process development
and workstation engineering to limit the risk of injury to nurses from their
work with computers.

Other Health Concerns

The major debate surrounding cathode ray terminals is the question of poten-
tial radiation hazards. In North America, extensive testing was undertaken
by NIOSH: measurements of ionizing and nonionizing radiation, analysis
of workroom air for contaminants, administration of a questionnaire on
health complaints to employees, and evaluation of ergonomic aspects in the
workplaces. On the basis of this study, Murray et al. (1981) stated that “the
results of these tests demonstrated that the VDT operators included in this
240 Infrastructure Elements of the Informatics Environment

investigation were not exposed to hazardous levels of radiation or chemical

agents.” NIOSH further concluded that routine monitoring of VDTs was
unjustified. A similar position has been adopted by the Consumer and Clin-
ical Radiation Hazards Division, Health and Welfare Canada (Charboneau,
1982). Since these landmark studies, the literature has been largely silent on
this issue.
Responsible nurses monitor the literature and exercise a judicious use
of caution and informed professional decision making to recognize media-
generated hysteria and rebuttal by parties with vested interest.

Psychological Concerns
The psychological aspects of computer ergonomics have been much less thor-
oughly researched and studied than the physiologic aspects. To some extent,
this situation is to be expected because physiologic aspects are more easily
measured and quantified than are the psychological aspects of computer use.
However, as hardware costs decrease, as more software is developed, and
as the physiologic aspects of ergonomics are addressed, greater attention
is being directed toward the psychological aspects of ergonomics (Helander
and Tham, 2003: Riva, 2003). Unfortunately, the psychological aspects of the
human–machine interface continue to be approached in a highly subjective,
emotional, and personal fashion.

Human–Machine Interface
The latest techniques in computer program development consider the user’s
cognitive abilities, including memory load, visual scanning, and formulation
of mental models. These techniques make it easier for the user to enter
data and comprehend information. These techniques address the following
issues.

r Dialogue design: intelligent or adaptive interfaces

r Input methods: windows, icons, mouse, and pointer environments
r Screen design: graphical–user interfaces
r Attention-getting techniques: use of color
r Consistency in the appearance of screen information, error messages, and
system usage

Also, these techniques meet the subjective criteria by which their advocates
evaluate them. However, further research is required to determine if they
meet the psychological ergonomic needs of other users.
 Ergonomics 241

Variety of Input/Output Media

There has been a move away from total reliance on the keyboard for input
and the monochrome display for output. Individuals can use speech for both
input and output, color graphics, physiologic probes, and computer mice to
facilitate keyboard use. There are also touch screens used for data entry.
Pen-based notebook systems offer yet another form of a more naturalistic
input device. Moreover, natural speech recognition programs offer another
naturalistic approach to input and output. Many users new to the computing
environment find a greater degree of psychological comfort in using input
devices not requiring keyboarding/typing skills (see Chapter 2 for a descrip-
tion of these input media).

Research Needs/Opportunities
A psychological aspect of computing ergonomics that remains largely un-
studied is the impact of a computerized workstation on individuals’ behavior
within an organization. We simply do not yet know the full effects on peo-
ple when they work in a highly automated environment and, subsequently,
have less need and opportunity for human contact. Interpersonal relation-
ships, group dynamics, personal stress levels, anxiety levels, and productivity
among personnel in such organizations are unexplored. It is imperative that
this kind of information be sought without delay.
The potential of bedside systems to affect the nurse–patient relationship
must also be researched. As new technology is developed, there is an ongoing
need to evaluate not only the effectiveness of the technology but also the
ergonomic effects on both nurses and patients.

References
Berner, K., & Jacobs, K. (2002). The gap between exposure and implementation of
computer workstation ergonomics in the workplace. Work 19:193–199.
Charbonneau, L. (1982). The VDT controversy. The Canadian Nurse October:30.
Helander, M., & Tham, M.P. (2003). Hedonomics—affective human factors design.
Ergonomics 46(13/14): 1269–1272.
Murray, W.E., Cox, C., Moss, C., & Parr, W. A. (1981). Radiation and Industrial Hy-
giene Survey of Video Display Terminal Operation. Cincinnati: National Institute
of Occupational Safety and Health.
Nielsen, K., & Trinkoff, A. (2003). Applying ergonomics to nurse computer work-
stations: Review and recommendations. CIN: Computers, Informatics, Nursing
21(3):150–157.
Riva, G. (2003). Ambient intelligence in health care. CyberPsychology & Behavior
6(3):295–297.
242 Infrastructure Elements of the Informatics Environment

Additional Resources
Croasmun, J. (2003). Taking the oxymoron out of ergonomic laptops. Ergonomics
Today September 19, 2003.
Piccoli, B. (2003). A critical appraisal of current knowledge and future directions of
ergophthamology: Consensus document of the ICOH Committee on “Work and
Vision.” Ergonomics 46(4):384–406.
Seghers, J., Jochem, A. & Spaepen, A. (2003). Posture, muscle activity and muscle
fatigue in prolonged VDT work at different screen height settings. Ergonomics
46(7):714–730.
17
Disaster Recovery Planning

Disaster recovery planning (DRP) is many things to many people. To some,

it is planning how to recover or replace damaged computer systems in or-
ganizations that range from a single nurse practitioner’s office practice to
a multisite hospital group. To others, it is planning how to maintain critical
hospital/nursing functions during interruptions in computer service. To still
others it is planning how to avoid those interruptions, and to yet others it is
planning an organization’s response to any emergency or crisis situation.
Disaster recovery planning is, of course, all these things and more. In
its broadest sense, DRP encompasses all measures taken to ensure orga-
nizational survival in the event of a natural or manmade calamity and to
minimize the impact of such an event on the organization’s staff, patients,
and bottom line. Disaster recovery planners are faced with an intimidating
array of terms, techniques, and technologies: hot sites, cold sites, warm sites,
mobile recovery, off-site storage, electronic vaulting, uninterrupted power
supply, T1 links, Megastream, satellite transmission (see Glossary). What
does this have to do with nursing informatics?
In this examination of DRP, the focus is on data, both paper-based and
electronic, while recognizing the many other areas required of a comprehen-
sive contingency plan. Nursing has traditionally not been involved in DRP.
However, as nurses come to depend more and more on information tech-
nology, they must become involved in developing disaster recovery plans
to safeguard patient care (Simpson, 2001). The disaster recovery plan is an
extensive, inclusive statement of actions to be taken before, during, and after
a disaster. The plan must be regularly tested and updated to ensure the con-
tinuity of operations and the availability of critical data and processes in
the event of a disaster. The goal of the planning process is to minimize the
disruption of operations and ensure a measure of organizational stability
and orderly recovery after a disaster (Simpson, 2001). In all organizations or
facilities, a formal planning method is needed to ensure quality, consistency,
and comprehensiveness of disaster recovery contingency plans. Informal,
ad hoc, and (worst of all) “it will never happen to us” approaches must
absolutely be avoided. It should also be noted that DRP is not a one-time,

243
244 Infrastructure Elements of the Informatics Environment

finished product but a process that must continually be used to update the
contingency plans as elements in the organization change.
In the United States, the Health Insurance Portability and Accountabil-
ity Act (HIPAA) of 1996 final security rule that must be implemented
by April 2005 requires that every health organization implement docu-
mented policies and procedures addressing disaster recovery and contin-
gency planning (http://www.hipaadvisory.com/action/security/disasterrecov.
htm) (Lucas and Adams, 2004). Healthcare organizations are also required
to test the plan to ensure that it promotes restoration of systems, networks,
and data following a disaster (Simpson, 2001).

Planning Process
The disaster recovery contingency planning process includes these steps.
r Risk identification: Which problems might occur?
r Risk analysis: What would be their impact?
r Risk prioritization: Which problems are the most critical?
r Risk reduction: How can I reduce the impact of the problems?
r Risk management planning: How will I apply this to the project?
r Risk monitoring and testing: How effective is our risk control?
The interaction of these activities is shown in the flowchart in Figure 17.1.

Planning Team
A fundamental premise of all types of planning applies to DRP: Plans are
best developed by those who must implement them in the event of a dis-
aster. A planning committee, including representatives from all functional
areas of the organization, the operations manager, and the data-processing
manager should oversee the development and implementation of the plan.
Many organizations additionally appoint a contingency planner to work with
a planning committee. Developing such a plan can be done completely in-
house with assistance from an external specialized disaster software or stor-
age vendor or by hiring an external disaster planning consultant. Often a
combination of these strategies provides the best value during the planning
process. There are numerous software products available to guide a plan-
ning committee through the process. There are also national and regional
professional organizations of disaster recovery consultants that can provide
guidance to novice planners. Access to a variety of disaster planning infor-
mation, terminology, conference announcements, sample plans, and links to
other related organizations is available at the websites of the Disaster Re-
covery Journal (http://www.drj.com) and the Disaster Recovery Information
Exchange (www.drie.org).
 Disaster Recovery Planning 245

FIGURE 17.1. Disaster recovery contingency planning process.

Risk Identification
Many risk assessments start with a group of project personnel gathering
together to make a list of potential risks. In general, this is not an effective
starting point for risk identification. It constrains the identified risks to those
that each individual thought was worth raising at the time. Many issues that
are not considered as risks are not raised, but such issues can combine in
complex ways and develop into critical risks. The way to avoid this trap is to
“brainstorm” the issues surrounding the project.
Obvious risks may be extracted from the list of issues produced. The
remaining issues are kept for analysis. Further risks may be identified from
analysis of project plans. Other techniques such as decision drivers exist. This
method looks at the major decision points in the project and is intended to
identify when the decision may be driven by inappropriate influences. Appli-
cation of these techniques should ensure that most of the risks surrounding
the project are identified, including all the critical risks. The following haz-
ard analysis checklist identifies some potential sources of risk that users of
nursing information technology should consider (Simpson, 2001; Wold and
Shriver, 1997).
246 Infrastructure Elements of the Informatics Environment

Possible Sources of Hazards

Natural Threats
r Climate: Which materials in your collection are the most sensitive to ex-
tremes and fluctuations in temperature? Do you get heavy or prolonged
snowfall, rainfall, or severe storms?
r Topography: Is your building beside a lake or river? Is your basement
below water table level? Is your area prone to avalanches, landslides, or
earthquakes?

Technical Threats
r Building structures: Has the roof a skylight, roof access, and drains? Are
there water pipes running through the records area?
r Dangerous goods: Are there any gas cylinders, solvents, or paints stored
near the records? Are staff trained in the correct handling of dangerous
goods?
r Internal services: Are plumbing, electrical wiring, fire detectors, fire extin-
guishers, and security measures regularly inspected and maintained? Are
there up-to-date plans and drawings of them? Are duplicates stored safely
somewhere else?
r Utility services: For which ones are you responsible? How about sewers
and telephones? Have you up-to-date plans of their locations, including
master switches? Is there a backup? What about power outages? Does the
facility have an uninterruptible power system (UPS)? Is water pressure
adequate for fighting fire?
r Information systems: Are there alternate systems available if there is a
malfunction or failure of the CPU? Failure of system software? Failure of
application software?

Human Threats
r Is unauthorized access possible to either the physical site or information
systems?
r What safeguards are in place related to bomb threats, extortion, burglary,
work stoppage, termination or resignation, or computer crime?

Risk Analysis
Records
When performing the risk analysis, consider the value of the records, both
paper and electronic, that need to be protected. Several factors affect the
value of a record. Consider the following.
 Disaster Recovery Planning 247

1. How much did it cost to create that record in the first place? What would
it cost to recreate it now?
2. Does the information protect the rights of individuals, research, or the
business interests of the agency?
3. Is the information complete, or would other documents be necessary if
action had to be taken.
4. How available is it? If the information could be obtained from another
source without too much delay, its value is reduced.
When assessing the value of your essential records for insurance purposes,
there are two approaches.
r Recreating the information: Calculate the cost of gathering the informa-
tion from scratch (e.g., by research, surveys, drafting) and then the cost
of producing and reproducing it. This is estimated by the number of man-
hours × $/hour for the project.
r Reproducing only: Calculate the cost of duplicating your essential records
now for off-site storage, or the cost of reproducing your off-site records for
use after a disaster. The most visible form of information is paper, closely
followed by magnetic and film records.
One thing is certain: It would cost much less to duplicate now than to
recreate later, after the information has been destroyed. For example, if
you were to lose 100 cubic feet of records, it might cost $10,000 to recreate
the information. If you have off-site backup copies, however, the only ad-
ditional cost is for transportation. It is necessary to keep reproduction to a
minimum and to use the most reasonable means of reproduction consistent
with the purpose or use of the information on the records. Remember, it is
the information you are insuring, not the media. Before any reproduction is
undertaken, consider the following questions.
1. Could the original record be stored at a safer location without causing
great inconvenience?
2. Is the record available elsewhere, in a field office, in another department,
or with the government, for example?
3. Would an extract or synopsis of the records meet the need, rather than a
copy of the entire original record?
4. Does a summary type of record fulfill the need, or is the original record
necessary? For example, using personal history cards instead of the per-
sonal file.
5. Are the records available now in printed or prepared form, such as annual
reports, machine-run or extra typed or printed copies?

Processing
There is also a need to analyze the risk related to delivery of service in
the event of a computer-related disaster. Computers are involved in the
248 Infrastructure Elements of the Informatics Environment

automatic delivery of intravenous medications, delivery of supplies through-

out many hospitals, and even regulating everything from lights and heating to
elevators. The risk exposure of all these systems must be considered during
contingency planning. From a nursing perspective, there is extensive expe-
rience of the disruption caused when even one computerized intravenous
delivery system malfunctions. Project the impact of a large-scale electrical
or computer technology problem in an intensive care unit if thorough con-
tingency planning has not taken place.

Risk Prioritizing
Risk prioritization is all about determining “risk exposure” (Baxter, 1991).
Risk exposure = (probability of unsatisfactory outcome)
× (loss, if outcome is unsatisfactory)
The components of “unsatisfactory outcome” may be cost, schedule, per-
formance, and support; the problems may even relate to system evolution.
Determining risk exposure provides the disaster planning project manager
with a prioritized list of risks. Those near the top require immediate action,
whereas the bottom part of the list consists of risks that would be costly but
unlikely to occur, or risks likely to occur but would cause little loss. The type
of risk reduction strategies used depend on the type of risk analysis per-
formed. Where quantitative analysis has been used, a range of parameter
values may be investigated so the project manager can select an appropriate
“level” of risk for a given likely outcome.
In all cases, the cost of reducing the risks must also be considered. A ratio
may be calculated that is known as the “risk reduction leverage.” This ratio
assesses the risk exposure before and after the risk reduction processes have
been carried out and compares them with the cost of those processes. A
relative cost–benefit measure can then be achieved when it is applied to the
prioritized risk list. This helps with planning risk reduction activities and
may lead to a decision to “live with some risks.”

Risk Reduction
Physical Prevention
Physical prevention requires a thorough audit of all facilities to identify
areas where paper-based or electronic data are created and stored. The audit
reviews the presence or absence of factors such as those listed as natural
or technical treats. For example, identifying where water lines are found
in relation to the organizations’ computer servers is important to prevent
flooding from broken water pipes. Installing and maintaining fire detection
and extinguishing systems act to reduce the spread of fire. A risk reduction
 Disaster Recovery Planning 249

audit must be comprehensive and intentional if a disaster recovery plan is

to be well informed and therefore well formed.

Procedural Prevention
Procedural prevention includes activities relating to security and recovery,
performed on a day-to-day, month-to-month, or annual basis. Examples in-
clude maintaining up-to-date backup copies of all computer files; annual
verification of User IDs and passwords; maintaining a system for storing
backup copies in a place discrete from the source computer; and schedul-
ing inspections and testing of smoke detectors, sprinkler systems, and fire
extinguishers.
Procedural prevention also includes an examination of human resources
policies. Procedures to remove the user accounts of terminated employees
prevents retribution. Additionally, resignations must be handled in a similar
way to ensure that no one who is not a current employee has access to an
organization’s data. The goal of procedural prevention is to define activities
necessary to prevent various disasters and ensure that these activities are
performed as required.

Recovery Options
Before a plan can be formalized, the planning committee must evaluate all
the available recovery options. Such options include the following.
r Off-site data storage at hot sites, warm sites, or cold sites
r Reciprocal agreements for data storage with other organizations
r Multiple data centers and multiple computers
r Consortium arrangements with many organizations sharing data storage

The key to evaluating recovery strategies is to identify the strategy that works
best for your organization rather than opting for the newest and latest rage in
recovery technology that does not provide a best match for your operations.

Disaster Recovery Plan

Document a written plan. DRP involves more than off-site storage and
backup processing. Organizations must develop written, comprehensive dis-
aster recovery plans that address all its critical operations and functions. It
is essential that nurses are involved in this process so the data-processing
needs related to patient care in whatever setting are represented.
With the growth in complexity of organizations and the threats to those
organizations, DRP has become increasingly complicated. Many organiza-
tions find it necessary to devote a separate department to this task or to hire
250 Infrastructure Elements of the Informatics Environment

outside consultants to work with them to develop and maintain a disaster

recovery plan.
A disaster recovery plan should contain all the information necessary to
maintain the plan and execute its action steps. Use of a standard format for
all departmental planning allows easy access to information and ongoing
maintenance of the plan. The following areas should be considered when
developing a disaster recovery plan.

Part 1: Introduction and statement of purpose: State why the plan has been
written and what it intends to achieve. You should say something about
who developed it and how it is to be kept current.
Part 2: Authority: Document the authority for the preparation of the plan
and subsequent action. In this part, you also designate who is to be re-
sponsible for the records during the emergency (i.e., who will coordinate
the execution of the plan and the line of succession).
Part 3: Scope of the plan: This part generally has three sections.
r Events planned for: Itemize each type of emergency event dealt with
in the plan. For each, indicate the circumstances under which the event
might occur and indicate what its expected impact on the department
could be. List the most serious or most likely events first.
r Locations planned for: If the department’s records are located only at
one site, this section may not be required. However, if more than one site
or building is involved, indicate here which sites are covered by the plan
and the circumstances under which the plan might or might not apply
to each site. Alternatively, if it is more practical, separate plans can be
developed for each site or building. The following equipment should be
considered: mainframe computer system, personal computers, bedside
systems, data communications, and voice communications.
r Relationship to other plans: If the organization has other action plans,
such as a medical emergency plan or a fire reaction plan, it is usually a
good idea to describe how all plans relate to and supplement each other
and to indicate the circumstances under which they may be executed
individually or simultaneously.
Part 4: Emergency procedures: Business resumption planning theory usually
suggests that vital records be backed up and stored off-site. However,
in practice, there are always documents too bulky or too valuable to be
copied. There are also documents where only the original will do, and
then there is always work in progress. To be realistic, contingency plans
should address the probability of having to retrieve vital material from an
evacuated site. Other contents of this section includes these points.
r Note is to put the plan into action, under what circumstances the plan is
to be fully or partially executed, and how all the actions will be carried
out.
r The location of the emergency operations center (EOC) is specified. It
is a predetermined meeting site for the disaster action team.
 Disaster Recovery Planning 251

r A floor plan showing the locations of the essential records for all sites
must be included.
r Detailed procedures for contingency processing at an alternate site (i.e.,
fixed location hot site, mobile facility) must be in place and written down.
r Detailed procedures for establishing voice and data communications
with the alternate processing site must be in place.
r Sample testing schedules and procedures, including types of tests, test
participants, team test responsibilities, and test forms are included.
r Include maintenance procedures for keeping the plan current.

The disaster recover plan should also address the following questions.
r Storage: Are vital documents stored in a fireproof room/vault/cabinet? Is
the fire rating sufficient? Is it rated for magnetic media? Is it waterproof?
r Security: Will the room/vault/cabinet be closed in an emergency? How can
you secure documents if they have been retrieved?
r Access: How can you arrange access to a cordoned off building? Who
would be assigned to retrieve the material?
r Identification: If you were allowed to retrieve only one box of material,
how would you identify the most urgent or critical one?
r Restoration: If your documents are charred or soaked, do you know how
to restore them?

Appendices
Use as many appendices as may be needed to include information vital to
the success of the plan. These may change so often, however, as to make its
inclusion in Parts 1 to 4 impractical. Suggested subjects follow.
r A staffing chart of the department, an organization chart showing the
department’s relationship to other departments (e.g., city government or
other outside governing authority), and a chart illustrating the disaster
control organization within the department. Other organizational charts
may illustrate the department’s relation to local civil preparedness author-
ities and to disaster and welfare agencies, including the Red Cross.
r Call-up lists of key personnel who are valuable to execution of the plan;
include name, title, address, telephone numbers, and the duties assigned
to each.
r Instructions for contacting outside organizations, such as the fire depart-
ment; the police department; local electric, gas, water, and telephone com-
panies; hospitals and ambulance services; plumbers; electricians; lock-
smiths; glass companies, guard and janitorial services; exterminators;
attorneys; and any other key people or agencies that might be of assis-
tance. State why each is to be called and what service each is expected
to render. It is critical to keep these lists current; review them at regular
intervals (at least annually).
252 Infrastructure Elements of the Informatics Environment

r An inventory of essential records and the priorities for their protection.

The estimated cost of creating or reproducing valuable records for off-site
storage.
r A summary of the arrangements that have been made for relocating the
records. It includes the names of persons to be contacted when tempo-
rary space is needed and information about alternative space in case the
primary space is suffering from the same disaster.
r Instructions for ensuring the emergency operation of the building’s utilities
and for service and operation of vital building support systems.
r Probably the most important appendix is a list of resources that might
be needed in an emergency. There should also be a list of local suppliers.
Record the supplies and materials you would need, what they are to be
used for, who is to buy them, who is to use them, and where they can
be found. Record your arrangements for borrowing materials, equipment,
and personnel from other departments, how to transport items, and whom
to call. List specialists who can be called on for assistance in preserving
damaged record materials.
r The final appendix should be a glossary of special terms that are used in
the plan so all its users are speaking the same language.

Plan Testing and Maintenance

After all the effort taken to develop a disaster recovery plan, many orga-
nizations make the mistake of thinking that the process is “finished.” The
contingency plan must be audited and tested on a regular basis to know that
proposed processes serve the purpose of protecting the data and processes
of the organization should a real disaster occur.
Because organizations change continually, disaster recovery plans must
also be dynamic. A process must be included for regularly updating the
plan. Most disaster recovery plans require a complete review of all proce-
dures every 5 years that focuses on refining the requirements, exploiting
new technology, and using a fresh approach to consider new solutions to
old problems. With regular testing and an annual audit, the plan should be
effective in processing critical data after a catastrophe occurs.

Summary
Disasters such as fires, earthquakes, hurricanes, power blackouts, and floods
will continue to occur. Less dramatic disasters, such as power “bumps”
or broken water pipes, also claim data vital to patient care. To minimize
losses, hospitals, clinics and individual practitioner’s offices must establish
and maintain effective data recovery contingency plans. Healthcare agen-
cies should identify the most suitable plan for their organization, obtain
 Disaster Recovery Planning 253

management’s commitment to the plan, and then implement the plan. Nurs-
ing must ensure that information vital to patient care is considered during
DRP.
It is truly rare when a facility must implement its disaster recovery plan.
However, maintaining a current reliable and tested plan gives an organiza-
tion the best possible response when calamity does strike.

References
Baxter, K. (1991). Avoiding the inevitable. The British Journal of Health Care Com-
puting 8(2):33–34.
Lucas, B., & Adams, S. (2004). Roadmap to HIPAA: Keeping occupational health
nurses on track. AAOHN Journal 52(4):169–178.
Simpson, R. (2001). What to do before disaster strikes. Nursing Management
32(11):13–14.
Wold, G.H., & Shriver, R.F. (1997). Risk analysis techniques. Disaster Recovery Jour-
nal 7(3):1–8 (http://www.drj.com/new2dr/w3 030.htm).

Additional Reading
Anonymous, (2002). Calm during crisis. Health Management Technology
23(11):42–44.
Barnes, J. (2004). The business continuity planning cube. Disaster Recovery Journal
17(2) (http://www.drj.com/articles/spr04/1702-16p.html).
Hensel, J. (1999). Hurricane and earthquake planning. Occupational Health and
Safety 68(10):222–224.
Huser, T. (2003). Flaming car in lobby tests hospital plans, employees. Disaster
Recovery Journal 16(1) (http://www.drj.com/articles/win03/1601-11.html).
Lewis, S. (2003). Disaster recovery planning for information technology functions.
Nursing Homes 52(2):50.
McCartney, P.R. (2003). HIPAA and electronic health information security. The
American Journal of Maternal Child Nursing 28(5):333.
Reinert, J. (2004). Data recovery completes disaster recovery. Disaster Recovery
Journal 17(2) (http://www.drj.com/articles/spr04/1702-15p.html).
Roden, K. (2004). Building a business case for disaster recovery planning. Disaster
Recovery Journal 17(3) (http://www.drj.com/articles/sum04/1703-19.html).
Vecchio, A. (2000). Plan for the worst before disaster strikes. Health Management
Technology 21(6):28–30.

Websites of Interest
Disaster Recovery Information Exchange: www.drie.org Information
Systems Security Association: www.issa.org
18
Implementation Concerns
With Contributions by Eleanor Callahan Hunt, Sara
Breckenridge Sproat, and Rebecca Rutherford Kitzmiller

Successful implementation of a clinical information system depends on a

variety of factors, but the two most important issues are not related to the
technology but to organizational and people issues (Lorenzi et al., 2004).
This chapter focuses on improving and responding to organizational and
people issues. Promoting user acceptance by identifying and responding
to resistance against information systems, optimizing communication, and
managing change effectively mitigate both of these issues.

Resistance to Information Systems and Computers

in Healthcare
The adoption of technology requires users to change how they work. Orga-
nizational change places great demands on staff members. Change creates
uncomfortable situations where staff faces the unknown and where their cop-
ing skills may not be effective. In 1982 Ball and Snelbecker examined the
reasons why healthcare professionals—nurses, physicians, and technologists
alike—have been slow in adopting computers and information technology.
Their research resulted in identification of the following major factors con-
tributing to resistance: oversell by vendors, unrealistic expectations, chang-
ing traditional practices, insufficient nursing involvement, fear of embracing
new approaches, and fear of the unknown. The results of this classic study
continue to be applicable in today’s healthcare environment (Adderly et al.,
1997; Despont-Gros et al., 2004; Doyle and Kowba, 1997; FitzHenry and
Snyder, 1996; Lorenzi et al., 2004; Marasovic et al., 1997).

Oversell by Vendors
The first general reason for resistance to innovative technology is a tendency
of some vendors to overstate the capabilities of or to oversell their product.

The contents of this chapter are opinions of the authors only and do not reflect those
of the US Army Medical Department or the US Army.

254
 Implementation Concerns 255

Of course, not every vendor or salesman oversells every time. Nonetheless,

this general statement describes vendor conduct in dealing with some clients
in the healthcare field. All too often the computer has been presented
as a panacea for all healthcare’s organizational and overall management
problems.
Until recently, healthcare professionals were unschooled in computer use
and tended to believe naively that the vendor had the perfect solution to
all problems. Often health professionals who were either too trusting or too
overwhelmed by technology turned decision-making power over to informa-
tion systems personnel, who knew little of the health professionals’ informa-
tion needs and work flow. This practice typically has led to serious commu-
nication problems between technology vendors, end-users, and those who
assume responsibility for the design and implementation of these systems.
This breakdown in communication impairs the potential quality of the sys-
tem and hampers future progress in the basic use of computers in healthcare.

Unrealistic Expectations
A second source of resistance stems from unrealistic expectations regarding
the capability potential of computer systems. This attitude is unfortunate
because it leads to inappropriate goals for what computer systems can do.
At other times, it tends to mask otherwise desirable and feasible contribu-
tions. For example, the computer may be viewed as a universal remedy for
administrative or political problems—a method to decrease the number of
errors and improve patient outcomes. When promises and expectations of
the system do not magically fix processes or procedural problems, health-
care professionals are disappointed and blame the computer system. Often
problems are not related to the technology but to issues that may be deeply
engrained in the organization and have nothing to do with automation. In
some cases, however, a 40% to 60% solution may have been achieved, which
in itself should be viewed as a monumental advance. However, healthcare
professionals who may have been promised an unrealistic 100% solution
are then blinded to the benefits and are disappointed and disillusioned with
the technology. As a consequence, the entire project may be discontinued,
the 40% to 60% success abandoned, and future projects not even attempted.
Inappropriate expectations of a system include the following (Hunt et al.,
2004).
r Solutions to ancient procedural problems
r Technology will make the organization profitable
r Magically improve the quality of care
r Provide the data to justify staff
r Reduce the patients’ length of stay in hospital
r Reduce the staff
r Ensure regulatory compliance
256 Infrastructure Elements of the Informatics Environment

Many hospital organizations struggle with processes surrounding verbal

or telephone orders. In general, a verbal/telephone order is given to a nurse
from a licensed, independent provider. The nurse then writes the order onto
an order document. As a safety measure, the provider or its designate re-
views the order within 24 hours to ensure that is was accurately recorded and
co-signs the document. The Joint Commission on Accreditation of Hospital
Organizations (JCAHO) evaluates this safety process. Healthcare organi-
zations have looked to computerized provider order entry as a means to
decrease or eliminate verbal/telephone orders or to provide a mechanism to
remind providers to co-sign the order within 24 hours. Unfortunately, these
same organizations often fail to address the healthcare processes, which
promote the use of verbal/telephone orders in the first place and as a result
fail to see a benefit from an installed system. For example, a way to im-
prove this process is to provide or improve access in areas where verbal and
telephone orders flourish. This includes using handheld wireless devices at
patient bedsides or in the emergency department or allowing providers to
access the system when outside of the organization, in their homes or offices.
Promoting and facilitating use of the system at the place and point in time
when care decisions are being made decrease the use of telephone orders.
Users’ unrealistic expectations typically lead to mixed feelings and resis-
tance concerning computer technology. If clinicians and hospital administra-
tors have little experience with selecting, configuring, installing, and maxi-
mizing the use of computers and information technology, they may relinquish
control to a systems specialist. Although a systems specialist may be expert
in using and installing computerized information systems, they are likely to
be inexperienced in understanding the care process and helping users rec-
ognize processes that must change and in working through those changes.
Failing to develop a partnership between clinical experts and technology
experts promotes a situation in which users do not buy into the system’s use
and thus implementation fails.

Changes in Traditional Procedures

It is difficult to move an organization forward with current technology and
trends. Many are reluctant to move beyond the decade in which they were
schooled. For example, clinicians who are used to viewing themselves as
experts and are asked to learn new processes and skills may be uncom-
fortably pushed into a situation in which they are not the expert and they
resist. However, today’s healthcare environment with complex patient care
demands high-tech, integrated healthcare systems to manage the data and
demands that clinicians reevaluate their healthcare processes (Hunt et al.,
2004). Nursing has a traditional set of rules, laws, ethics, and codes of confi-
dentiality. Computers and information technology can pose threats to long-
established, sound procedures in nursing. Computerization has an impact on
all of this, just as all types of innovations appear to pose a major threat when
 Implementation Concerns 257

first introduced. The key here is to leverage the positive uses of technology
and limit negative influences.
For nurses, skepticism is a most desirable professional trait. Nurses are en-
trusted with the welfare of their patients; and in that context, being skeptical
about new fads and resistance to change in one’s mode of practice is well
founded. The nurse may perceive that the patient is endangered by the use of
a clinical system when they lack confidence in its use. To counter this percep-
tion, involving nursing users at the beginning can educate them and identify
potential problems. This combination is powerful in that it “buys in” the
nursing users as well as developing a mutual level of trust. Just as nursing
implements best care practices based on demonstrated evidence and effi-
cacy, clinical information systems are coming to represent “best practice,”
and nurses are recognizing this as an advantage and embracing it.
The use and early adoption of advanced technology has created a per-
ceived generational gap among healthcare providers. The older generation
is seen to be technophobic, leading to a lack of integrated vision and inte-
grated systems (Tan, 2001). Despite the general acceptance of technology
into all aspects of our lives, fear of technological change does persist in our
workplace. As healthcare providers become increasingly overwhelmed by
information and demands on their time to provide quality care to patients,
they are looking for solutions. Addressing technophobic fears is vital to suc-
cess. Technophobia is not the only fear the project team should anticipate.
Consider these five concerns, which lead to resistant behavior among staff
members (Tan, 2001).
r As the organization expects to become more efficient when using automa-
tion, staff members may fear losing their jobs.
r Information systems impact both formal and informal communication pat-
terns.
r Peer pressure and previous experience with system implementation can
also influence the organizational climate, promoting success.
r Individual reaction to system implementation depends on the individual’s
overall personality and cultural background.
r Management techniques used to implement systems directly affect users’
perceptions.
Involving nursing users throughout the selection and implementation pro-
cess mitigates potentially resistant behaviors.

Insufficient Involvement of Nurses

It is absolutely imperative to insist on clinical involvement at every step of
healthcare information system installation. Each clinical user group has a
role to play in the selection, implementation, and successful use of an infor-
mation system. Administrators and nurses need to be adequately and consis-
tently involved in critical decisions about the use of information technology.
258 Infrastructure Elements of the Informatics Environment

Only involving hospital top management in new information technology

choices has proven detrimental to the success of computer installations in
health centers. Ensure appropriate representation and involvement from all
users when developing short and long range plans for selection and installa-
tion of information systems.
In the past, management has treated implementation of a patient or hos-
pital information system the same as installation of a telephone system or
an air conditioning system. There was a gap in understanding of the po-
tential impact to the whole organization. Now, decision-makers realize the
major responsibility in deciding how technology tools are deployed. With-
out nursing and clinician involvement combined with competent consultants,
accurate vendor contracts, responsible systems analysis, and an involved ad-
ministration, the potential of technological systems cannot be fully realized.
The ongoing nursing shortage has made it more difficult to obtain access to
nursing end-users at a time when it is becoming imperative to install technol-
ogy that affects those very same end-users. As a result, involvement has to
become more creative instead of allowing nurses to be cut out of the loop be-
cause of time commitments. One method for overcoming this time demand
is that, instead of requiring attendance at committee meetings, leverage the
technology to create web portals that allow links, distribution of documenta-
tion, access to power point presentations, and interactive discussion boards
to elicit information without tying up clinicians’ time. Nurses must recog-
nize that input may need to be provided outside of normal working hours
and is just as important as reading healthcare literature outside of working
hours to stay on top of healthcare trends. Include technology as part of your
continuous learning and self-education.

Embracing New Approaches

In many cases resistance occurs when personnel insist on holding onto what
they know and existing systems, rather than exploring new technologies.
Although “new” is not necessarily better, such resistance can preclude ad-
vances in nursing and patient care. A common tendency is to view a partic-
ular function solely in terms of existing systems characteristics rather than
to recognize alternative ways of how patient care may be improved. It is not
adequate to use new technologies simply to complete old tasks faster (see
Chapter 13). Instead, technology is being used to transform the entire care-
giving process.
The problem of managing and accessing medical records provides a typ-
ical illustration. The medical record is designed to provide a single loca-
tion where clinicians can document the care they provide and use the in-
formation from other clinicians to make decisions. Unfortunately, most of
this documentation remains on paper, posing many problems: sizable stor-
age challenges, expensive maintenance and reproduction costs, inaccessibil-
ity to all care venues in which a clinician makes decisions. Expanding the
paper-based system has not solved these issues. Computerized information
 Implementation Concerns 259

systems as a communications controller and file manager provides greater

flexibility in the functions and use of medical record systems. However, com-
puter technology should also aid in finding the best means for maintaining
and gaining access to needed information.
The objective of any medical record is to document information about
the care of patients. It is ideally accessible to all of the healthcare team who
collaboratively provide high-quality care. Such collaboration and communi-
cation require data storage, access, and retrieval among a number of health
professionals on the team. Unfortunately, traditional medical records sys-
tems operation is sometimes dictated by existing legacy systems, which deter-
mine how information can be stored and retrieved. Computerized methods
bring invaluable patient data to the physician and nurse at the point where
decisions are being made, resulting in better care. Through the paradigm
shift of documenting at the point of care, it is now possible for computer
technology to provide healthcare providers with information about patients
when and where it is needed. Having electronically captured data has elim-
inated the need for eight different members of the care team each to ask
patients the same questions for medical histories, allergies, and demograph-
ics. It has allowed nurses to use standards-based objectives to chart, reducing
the overall time required to document the care provided.

Fear of Leaving Paper and of the Unknown

Another form of resistance is linked to the traditional, time-tested reliance
and trust of printed material. We sometimes fail to recognize that the printed
word has limitations. Paper-based records are available to only one person
at a time, they are not up-to-the-minute accurate, data are not backed up,
and what is written is only as good as the person’s memory and handwriting.
This affects healthcare providers by limiting their ability to review current,
necessary patient care documentation when making decisions. Computer-
based information systems not only provide storage and retrieval of infor-
mation, they afford new opportunities for increasing knowledge and research
through data mining and data collection. It is through quality training, con-
sistent use, and positive reinforcement that clinicians will move from paper
to electrons to chart a patient’s course.
Duplication of effort is one of the most expensive yet least measured
cost expenditures in healthcare organizations. When working with customers
who are considering doing away with paper, ask the following questions
(Kriegel and Brandt, 1996).

r Does the paper provide value to the client in terms of improving quality
or service?
r Does the paper improve productivity or cut costs?
r Does anybody read it? More important, does anyone use it to make a
decision?
260 Infrastructure Elements of the Informatics Environment

The answers to these questions should unite and guide users to recognize
how to streamline paper processes. Streamlining provides users with addi-
tional resources to accomplish their critical missions. This may be enough to
motivate support of an automated system (Hunt et al., 2004).
Seldom has an individual given a more concise analysis of the acceptance
or acknowledgment of change within a traditional system or discipline than
did Machiavelli in 1513. His analysis on the establishment of new systems is
as follows.

It must be remembered that there is nothing more difficult to plan, more doubtful
of success, nor more dangerous to manage, than the creation of a new system. For
the initiator has the enmity of all who would profit by the preservation of the old
institutions and merely lukewarm defenders in those who would gain by the new
ones.

Change fails because of people, plain and simple. Change brings people
face to face with their biggest fears: failure, humiliation, ridicule. Change is
uncomfortable, it is unpredictable, and in a healthcare setting it is viewed
as risky. Recognize that fear is an incredibly strong motivator (Hunt et al.,
2004; Kriegal and Brandt 1996). Once recognized, however, it can be used
to assist in the change process.

Management of Change
After all other sources of resistance have been identified and mitigated, the
focus shifts toward change management. There is a tremendous amount of
research, stories, and journal articles that address change management in
the healthcare and business literature. This section touches on a few change
management theories, describing their application in clinical system imple-
mentation.
It is important to recognize that an organization is like any other social
system and change—where everything and everybody’s actions are interre-
lated (Hunt et al., 2004). All departments in an organization are integrated
and interdependent. Implementing change in one department affects the
function of another. It is also likely that change, although embraced in one
department, may be completely resisted by another. Additionally, there may
be other changes occurring within the organization that affect or will be af-
fected by the proposed system implementation. Managers must completely
assess the effects of change on the entire organization and develop a plan to
motivate each department to participate in the implementation and adapt to
change (Hunt et al., 2004). Roger’s theory of diffusion of innovation suggests
that some never adopt the change (Hilz, 2000). Where you need to concern
yourself is if the active resistor(s), or laggard(s), is in an area of influence or
a management position. Otherwise, once enough areas and users are using
 Implementation Concerns 261

the system, the rest naturally follow. Reaching that tipping point is key to
implementing change successfully (Gladwell, 2000).
One way to reach this tipping point, where the rest of the implementation
follows with less resistance, is to foster a collaborative relationship among
nurses, physicians, other health professionals, and information technology
(IT) professionals. This relationship can be developed while selecting, de-
signing, and configuring the system and can be continued through maintain-
ing the system. The common goal that all want to achieve is to be able to
deliver cost-efficient, high quality patient care.
The team can motivate each group affected by the system by identifying
how the system benefits them and fulfills personal and organizational goals.
This is critical to creating motivated team members, users, and stakeholders;
and it obtains the “buy-in” that is crucial to user system acceptance. Moti-
vation for change is the key to overcoming resistance. Tapping into users’
feelings that “there must be a better way”and educating and involving the
users leads to users who are motivated to participate in the change. When
people burn with enthusiasm, they take risks, go the extra mile, and fully
commit themselves to change (Kreigel and Brandt, 1996). Failure to com-
municate is the greatest threat to the success of any project, especially IT
projects (Lorenzi et al., 2004).
Another major aspect to collaboration between key team members is to
communicate effectively a plan that includes the positive effects offered by
the change as well as the dire circumstances should the status quo prevail.
This may mean that the “sacred cow” must be addressed. A sacred cow
(a term used in business) is an outmoded belief, assumption, practice, policy,
system, or strategy that inhibits change and prevents responsiveness to new
opportunities. A sacred cow uses valuable resources and limits productivity,
innovative thinking, and creativity, thus hampering an organization’s ability
to respond to changing market conditions. According to Kriegel and Brandt
(1996),
If it doesn’t
r Add value to the customer
r Increase productivity
r Improve morale
. . . . It “moos”!

While anticipating the broad scale implementation of computerized infor-

mation systems in healthcare institutions and agencies, it is fast becoming
clear that such transformation is frequently complex and always accompa-
nied by a shift in values and priorities that can conflict with vested interests.
Can you think of a few sacred cows that are alive in your organizations,
schools of nursing, and other workplaces? Implementing a clinical system
without recognizing and addressing at least a few of these sacred cows puts
your implementation at risk.
262 Infrastructure Elements of the Informatics Environment

FIGURE 18.1. Lewin’s dynamic balance of forces.

Most IT-related degree programs have many technical requirements but

few require courses in communication, psychology, and organizational be-
havior. As a result, communication is not necessarily in the forefront of the
IT staff’s skills, but it is high among nursing skills. This is one of the reasons
nurses make such great project leaders—they are trained to collaborate,
communicate, multitask, and document. Combine effective technical skills
with strong communication skills when working on IT projects, as individuals
need all these characteristics to be successful (Hunt et al., 2004; Schwalbe,
2002).
Another theory that is applicable when implementing change is Lewin’s
(1969) classic work suggesting that behavior in an institutional setting is not
a static habit or pattern but a dynamic balance of forces working in opposite
directions within the social-psychological space of the institution (Fig. 18.1).
Lewin identified three stages for accomplishing changes in behavior: un-
freezing the existing equilibrium, moving toward a new equilibrium, and re-
freezing the new equilibrium. To initiate the unfreezing of the equilibrium,
there are three strategies.
r Increase the number of driving forces
r Decrease the number of resisting forces
r A combination of the two preceding factors

The nursing profession is beginning to experience the profound impact com-

puters and information systems ultimately will have on nursing practice and
patient care. Previously, nurses were faced with the possibility of having
change thrust on them from others outside of the profession. Resistance
to change brought on by the introduction of healthcare information sys-
tems merely results in increasing the resisting forces that produce conse-
quential increase in the driving forces (e.g., societal trends, government,
and administration). Ultimately, because the driving forces in this case also
have the power and authority, change would be instituted but probably be
 Implementation Concerns 263

accompanied by increased tension, instability, and unpredictability. This is

unacceptable to nurses who, as patient advocates, are committed to using
every means at their disposal to ensure the highest quality care for patients.
Computers and information systems are only one tool to be used to achieve
this goal. No longer is the question “Should the nursing profession resist au-
tomation?” Given present societal, governmental, and technical trends, the
change to and expansion of computerized information systems in healthcare
agencies is inevitable. The question now becomes one of coping with the re-
sisting forces within and among the profession so the end result is a stable,
predictable, rational approach to improving the quality of nursing practice
and thus the quality of patient care.
Nursing is the single largest group of care providers in any healthcare or-
ganization. The ability to influence the entire organization positively when
choosing and installing computer-based systems is a major factor in im-
plementation success. Consider the historical roots of the nursing profes-
sion. Nursing’s roots in the military and hierarchical religious nursing orders
meant change was by command rather than cooperation. This approach is
still seen in many community practices but is slowly changing as today’s
nurses, who are academically prepared professionals, are establishing col-
laborative relationships with the rest of the care team. The impact this has
on implementation is that nurses no longer accept change simply on the
basis of position authority. They now expect to have input and demand to
know the business and scientific bases for the change. Also expected is that
change is based on knowledge, logic, and research rather than on whim and
emotion. Nurses expect greater sophistication from their leaders in the use
of skills and strategies for introducing change that affect nursing practice.
Numerous nursing authors have reported their strategies and experiences
in implementing such change. Repeatedly, the importance of the following
factors is identified (Adderly et al., 1997; Despont-Gros, et al., 2004; Doyle
and Kowba, 1997; FitzHenry and Snyder, 1996; Hostgaard and Nohr, 2004;
Hunt et al., 2004; Lorenzi et al., 2004; Marasovic et al., 1997).

r Involve nursing early in planning change that affects all departments.

r Involve users actively in planning.
r Designate a person in the nursing department at the senior management
level to coordinate the implementation process in the nursing department.
r Designate the nursing implementation coordinator as liaison between the
nursing department and other departments.
r Establish a user committee in the nursing department chaired by the nurs-
ing implementation coordinator; include the enthusiastic, the uncommit-
ted, and the mildly negative on the committee.
r Make resource people available as consultants to the nursing implemen-
tation coordinator.
r Develop a training program that includes an explanation of the rationale
for computerization, nurses’ responsibilities related to the new system, the
264 Implementation Concerns

expected effect of the system on nurses and nursing care in the organization
as well as actual use of the system.
r Use professional colleagues and peers to train others (i.e., a core group of
trained nursing users train nursing staff to use the system).
r Time the training to occur just before the new system goes “on-line”; allow
sufficient learning time; provide training time to all shifts.

Summary
Computers and information systems are as much a part of nursing prac-
tice today as the stethoscope. Resistance to change is normal for humans
but can be easily overcome if health personnel and IT specialists launch a
collaborative effort. Through early cooperation and free exchange of ideas,
information systems technology can facilitate major advances in improving
patient care, and nurses are showing that they willingly embrace it.

References
Adderly, D., Hyde, C., & Mauseth, P. (1997). The computer age impacts nurses.
Computers in Nursing 15(1):43–46.
Ball, M.J., & Snelbecker, G.E. (1982). Overcoming resistances to telecommunications
innovations in medicine and continuing medical education. Computers in Hospitals
3(4):40–45.
Despont-Gros, C. Fabry, P., Muller, H., Geissbuhler, A., & Lovis, C. (2004). User
acceptance of clinical information systems: A methodological approach to iden-
tify the key dimensions allowing a reliable evaluation framework. Medinfo 2004,
pp. 1038–1042.
Doyle, K., & Kowba, M. (1997). Managing the human side of change to automation.
Computers in Nursing 15(2):67–68.
Gladwell, M. (2000). The Tipping Point: How Little Things Can Make a Big Differ-
ence. Boston: Little Brown.
FitzHenry, F., & Snyder, J. (1996). Improving organizational processes for gains dur-
ing implementation. Computers in Nursing 14(3):171–180.
Hilz, L.M. (2000). The informatics nurse specialist as change agent: Application of
innovation-diffusion theory. Computers in Nursing 18(6):272–281.
Hostgaard, A.M., & Nohr, C. (2004). Dealing with organizational change when im-
plementing EHR systems. Medinfo 2004, pp. 631–634.
Hunt, E, Breckenridge-Sproat, S., & Kitzmiller R. (2004). The Nursing Informatics
Implementation Guide. New York: Springer.
Kriegel R, & Brandt D. (1996). Sacred Cows Make the Best Burgers: Paradigm-
Busting Strategies for Developing Change-Ready People and Organizations. New
York: Warner Books.
Lewin, K. (1969). Quasi-stationary social equilibria and the problem of permanent
change. In: Bennis, W.G., K.D. Benne, & R. Chin (eds.) The Planning of Change.
New York: Holt, Reinhart, pp. 235–238.
 Implementation Concerns 265

Lorenzi, N., Smith, J., Conner, S., & Campion, T. (2004). The success factor profile
for clinical computer innovation. Medinfo 2004, pp. 1077–1080.
Machiavelli, N. (1513). The Prince. Translated by George Bull (1961). New York:
Penguin.
Marasovic, C., Kenney, C., Elliott, D., & Sindhusake, D. (1997). Attitudes of
Australian nurses toward the implementation of a clinical information system.
Computers in Nursing 15(2):91–98.
Schwalbe, K. (2002). Information Technology Project Management, 2nd ed. Boston:
Course Technology.
Tan, J.K.H. (2001). Health Management Information Systems: Methods and Practical
Applications, 2nd ed. Gaithersburg, MD: Aspen.
19
A Process Redesign Approach to
Successful IT Implementation
Paul E. Pancoast
With contributions by Carole Stephens, Diana Domonkos,
and Lee Lavergne

There is nothing more difficult to take in hand, more perilous to conduct,

or more uncertain in its success, than to take the lead in the introduction of
a new order of things, because the innovator has for enemies all those who
have done well under the old conditions and lukewarm defenders in those
who may do well under the new.
—Niccolò Machiavelli in The Prince

A large integrated healthcare system decides to embark on an aggressive “transfor-

mation” project to accomplish several major objectives.
r Improve patient safety and quality
r Become more patient-centric
r Improve continuity of care across the delivery system
r Make life easier for caregivers and patients
r Reduce care variation and unnecessary expenses
They decide that information technology (IT) is a key enabler, and they invest
$25 million in new software, hardware, and vendor-supplied consulting over a 4-year
period. The investment includes, among other things, a new central data repository
for electronic health records, patient registration and scheduling software, enterprise-
wide networking, clinical documentation for nursing, computer-based physician or-
der entry and results reporting software, implementation of new care guidelines, and
physician remote access to patient records.
After 4 years and $30 million, the project is behind schedule. The consultant esti-
mates that it will take an additional year and a half and $5 million to complete. The
applications that have been installed are working, but nothing has improved. Physi-
cian and nurse productivity has declined. Nurses complain that their workload has
increased. Users are disgruntled with the Information Systems Department and are
asking when the systems will be fully operational. The chief financial officer is asking
what the organization has gained by the substantial investment. The cheif executive
officer wants to know how it happened. The chief information officer has resigned.
Senior management wants to bring in a new consulting firm to help rescue them.

As the example illustrates, many IT implementations fail because atten-

tion is not paid to how workflow and processes are affected when new
technology is put in place. Sometimes people are not able to adjust to the new

267
268 Professional Nursing Informatics

processes, or the new processes are not appropriately designed to improve

workflow efficiency. As a result, the systems are just not used. Redesigning
processes before installing a new IT system is more cost-effective than doing
the reverse.
This chapter introduces the reader to the concepts of project management,
process redesign, and change management in the context of healthcare or-
ganizations undergoing IT implementations. Process redesign cannot suc-
cessfully occur without concurrent change management, and project man-
agement is also an integral component. Descriptions of the major stages and
phases of these three activities are provided.

Background
In 1991 the U.S. Institute of Medicine (IOM) published The Computer-
Based Patient Record, recommending that electronic health records (EHR)
be widely adopted for use within the next 10 years (Dick et al., 1991). Six
years later, a revised and updated edition was released, reiterating the need
and updating the progress. By 2003, best industry estimates of EHR use
in the United States were 20% in hospitals, 10% in physician offices, and
5% in ambulatory clinics (http://www.healthcare-informatics.com/reports/
industry20.pdf).
In 1999, the IOM released To Err is Human: Building a Safer Health System
(Kohn et al., 1999). This report summarized two major studies about patient
safety in the United States, showing that between 44,000 and 98,000 patients
die each year owing to medical errors. In 2001 the IOM published Crossing
the Quality Chasm: A New Health System for the 21st Century, again reiter-
ating the need for change. This report noted that “The American health-
care delivery system is in need of fundamental change . . . the frustration
levels of both patients and clinicians have probably never been higher. Yet
the problems remain.” (Committee on Quality of Healthcare in America,
2001).
Our current healthcare delivery system has a number of problems.
r Lack of information for clinicians when they need it
r Healthcare processes that allow avoidable errors to occur
r Inefficiencies and system waste

The solutions are available to correct these problems, so why have we not
adopted them? Implementing a new healthcare information system is a com-
plex endeavor that requires a significant shift in thinking and policy.
Process redesign (reengineering) makes quantum changes to core busi-
ness processes, allowing much greater performance improvements than can
be achieved by incremental change. Process redesign means evaluating the
desired outcome and changing the way that outcome is attained. This usually
 A Process Redesign Approach to Successful IT Implementation 269

involves much more than merely streamlining the existing processes and re-
moving unnecessary steps. It often means completely revising peoples’ job
descriptions, removing existing tasks, and adding new ones. Process redesign
is necessary for organizations to take full advantage of technological solu-
tions. Process redesign is usually perceived as threatening by the people
it affects. If process redesign is so difficult and painful, why do it at all?
In healthcare, we simply no longer can accept the status quo. Healthcare
requires a major shift in thinking, policy, and processes. The only way to
accomplish the needed changes is through process redesign.

Key Definitions
r Process—the method by which a task is accomplished. Processes can in-
volve several people from several departments. For instance, the process
by which a medication is ordered for an inpatient by their physician is as
follows.
1. Physician decides what order to place.
2. Physician finds the chart (or asks a nurse or resident to find the chart).
3. Physician finds the order sheet in the chart.
4. Physician writes the order on the sheet and signs it (or tells the nurse,
resident, or unit secretary to write the order).
5. Physician gives the chart to the unit secretary (or to the resident or
nurse to give to the unit secretary).
6. Unit secretary puts the chart in the stack to be processed.
7. Later. . . .
8. Unit secretary opens the chart to the orders section.
9. Unit secretary reads the order (and may ask the nurse or secretary to
decipher the handwriting).
10. Unit secretary transmits the order to pharmacy using a computer or-
der system, fax, telephone, or courier for example, depending on the
specific process at the hospital).
11. Pharmacist receives the order and processes it (which includes sending
the medication to the patient’s unit).
12. Nurse receives the medication.
13. Nurse administers the medication to the patient.
14. Nurse records the medication administration in the medication admin-
istration record (MAR).
15. Nurse charts the medication administration, the patient’s response,
and (we hope) the lack of reaction to the administration.
r Project management—Project management includes planning, schedul-
ing, organizing, monitoring, budgeting, and reporting for all aspects of
a project.
270 Professional Nursing Informatics

Approaches to Changing Healthcare Delivery

There are two major components involved in change related to the imple-
mentation of any information system in the healthcare delivery system:
r Process redesign (process reengineering, process transformation) means
changing the processes by which tasks are accomplished to achieve greater
accuracy and efficiency. Typical tasks include registering a patient, medi-
cating a patient, documenting clinical information, replenishing stock sup-
plies, and billing for services.
r Change management is helping people adjust to the changes they face as
a result of process redesign and IT implementation.

Information Technology Implementation

Information technology implementation refers to installing hardware and
software applications. However, many IT implementations do not provide
the anticipated value to an organization. People are unable to adjust to
the new processes, or the new processes are not appropriately designed to
improve workflow efficiency; hence the systems are not used.
There are two approaches a healthcare system can take when imple-
menting information technology to improve healthcare delivery. One ap-
proach is commonly known as a “plain vanilla” installation, which consists of:
(1) purchasing an IT system; (2) installing the technology into the health-
care system; (3) determining how the new IT system can be used to improve
healthcare delivery; and (4) trying to convince people to use the new IT sys-
tem. This approach is preferred by some EHR vendors because it requires
little customization of the applications and can be performed more quickly.
Unfortunately, this type of installation often results in disappointment on the
part of the purchasing healthcare system because the new IT system does
not meet the needs of the healthcare system. Many IT systems installed “off
the shelf” have some (many) of their functionalities ‘turned off’ shortly after
the system goes “live.”

Process Transformation
The second approach is commonly described as process transformation. It
requires more work but usually results in more effective outcomes and a
satisfied healthcare system. This approach involves the following.

1. Determining exactly what the healthcare system hopes to accomplish

2. Looking at the clinical and business processes that need to be changed to
accomplish those goals
3. Deciding how the healthcare system’s “future state” will look
4. Redesigning the processes to reflect the “future state”
 A Process Redesign Approach to Successful IT Implementation 271

5. Building (or modifying) the EHR applications to work with those re-
designed processes
6. Training the people whose “worlds will change” when the new EHR sys-
tem is installed
7. Installing the EHR system
8. Evaluating how well the new EHR system meets the organizational needs
Process transformation requires the integration of process redesign and
change management with the IT implementation. A key success factor for
process transformation is that it must be sponsored and managed from the
highest organizational levels.

Process Redesign Methodology

Most EHR vendors have teams of consultants who specialize in assisting
healthcare organizations to implement the vendor’s applications and sys-
tems. These teams are primarily focused on preparing the installation site
to receive the EHR application. If a healthcare organization wants the sys-
tem customized to their specific requirements, it must assemble a team to
manage the process redesign component. Healthcare systems rarely have
specific teams in place who are skilled in process transformation activities;
these activities are not a part of the regular activities of a healthcare organi-
zation. When healthcare systems do not have outside help during a “system
install,” they may end up frustrated, as illustrated in the opening example.
Healthcare consulting companies may be called in to fill this gap.
Healthcare consulting companies perform four types of activity for their
clients.
r Strategic planning: establish a vision of how the organization will deliver
and manage care in the future; understand how technology can help to
achieve this vision; and develop a roadmap of the initiatives required to
reach the vision
r Process redesign and system selection: determine how the processes of
the healthcare system will change to accomplish the organizational goals;
select a suitable EHR vendor to provide an IT system that can help reach
those goals
r Implementation: determine how the IT system “build” (the “look and feel”
of the applications) should be performed; use the healthcare system vision
to drive the IT system installation
r Optimization: after an IT system is installed, making the functions of the
IT system meet the needs of the healthcare organization
Project management is the art of bringing together ideas, people, and phys-
ical resources in a productive manner to achieve specific objectives. One of
the most important success factors for a healthcare system transformation
project involving millions of dollars and hundreds of employees is to know
272 Professional Nursing Informatics

exactly what the project will accomplish and all the steps needed to com-
plete the project before starting. All credible project managers use a project
management methodology to manage the projects, from the initial plan-
ning phase through to the project wrap-up. Using a standardized, consistent
methodology for project management allows the project to proceed in a
predictable, reliable manner. Choice of project management methodology
depends on the personal preference of the user; all commercially available
project management methodologies have similar components and can be
used successfully.
Success can be defined by certain factors.
r Clearly defined and agreed-upon project objectives
r Tools and methods to support project management
r Project completed on time and within budget
r Delivery of consistent level of quality
r Project outcomes accepted by the organization
Common stages in project management methodologies include the
following.
1. Project initiation. Project charters and documentation as well as methods
and tools are put in place for sharing knowledge about the project prior
to the project start-up to ensure that the project team has the information
needed to plan for project launch. The intent of this stage is to ensure
that everyone on the project shares the same expectations. Organization
structure for the project is created, and members of the project team
are recruited. The best methodologies include all key stakeholders in the
organization on the teams and committees.
2. Project launch. Kick-off meetings orient the team and organization to the
project, the tools, and the methodologies to be used to accomplish the
objectives.
3. Ongoing project management. Methods, tools, and templates facilitating
the management of project plans, risks and issues, meetings, and docu-
mentation are clarified.
4. Ongoing communication. Communication of project expectations, activ-
ities, and progress across the organization is used throughout the project.
5. Project completion. The objectives and expectations of the project are
achieved, including final documentation and project information.
6. Project review. A debriefing is held, and the lessons learned are identified.
There are a number of major phases in a process redesign project. The
exact sequence and the staff used to accomplish these phases may vary de-
pending on whether the project is being managed and staffed internally, or
if external consultants have been called in to assist with the project. Effec-
tive project management throughout these phases is essential to achieving
project goals. Detailed discussion of each of these phases is beyond the scope
of this book.
 A Process Redesign Approach to Successful IT Implementation 273

Change Management
Process redesign is about changing the way people do things. Change man-
agement is about helping people deal with these changes. Redesigning the
processes by which people do their work can improve efficiency and pro-
ductivity as well as reduce waste, but it may be perceived as frightening or
even threatening. The most common reaction to a process redesign project
is resistance. When processes change, the people who perform those pro-
cesses have to change as well. It is difficult for people to accept change until
they understand both the organizational and personal implications. It is im-
portant to reiterate that “change management” refers to managing peoples’
reactions to change, not to managing changes in software and technology.
Senior executive leaders of an organization who embark on a major pro-
cess redesign project have certain concerns.
r How long will it take to accomplish?
r How much will it cost?
r What will be the return on investment (ROI)?
r How will this affect our customers (patients and family members in the
case of healthcare organizations)?
When employees think about organizational change, or process redesign
projects, they have specific concerns.
r Will I still have a job, or will I be “downsized”?
r What will my new responsibilities be?
r Do I have the necessary skills and knowledge to be able to perform my
new tasks?
r Will I have time to eat during my lunch break?

Although employees want their organization to be successful and to make

the changes needed to maintain a competitive edge, they are also concerned
about how those changes will affect them personally. Change management
programs are needed to help the employees adjust to the changes that occur
in conjunction with process redesign projects. Process redesign projects that
do not include change management programs are difficult to complete and
may result in a significant loss of skilled employees. The best and brightest of
the employees are in demand and have no trouble finding another position
with an organization they believe is “safer” as an employer. Often such
projects are abandoned before they achieve success.
There are five major principles that must be followed for a successful
change management program.
1. Change management must come from the top. Just like a successful pro-
cess redesign project, a successful change management program must clearly
originate from the senior executive levels. The decision to change the orga-
nization must come from the top decision-makers of the organization. The
274 Professional Nursing Informatics

senior executives not only must kick off the change management program,
they must continue to be seen as fully involved in the program throughout
its duration.
2. Change management must be supported throughout the organizational
hierarchy; managers must become agents of change. Change management
begins at the top and continues down through each hierarchical layer until it
reaches the regular workers in an organization. Because the natural reaction
to change is resistance, the managers must be educated by their supervisors
about the change. They must understand the organizational implications
as well as the personal implications of the impending changes. When the
managers are comfortable with the new notions, they can act as change agents
to the people they manage. Each level of the organizational hierarchy must
understand and accept the upcoming changes; then they can act as change
agents to the level below them.
3. Change managers must communicate a vision throughout the organiza-
tion; they must show an existing problem that needs to be corrected. People
need to understand the organizational reasons for change. Although the
change may be difficult, it is easier to accept when the need for change is
understood. People are more willing to make personal sacrifices for the or-
ganization if they believe those sacrifices will make the organization more
stable and more likely to be a reliable employer. The vision communicated
by the change managers should clearly explain the current problem and
how the changes will rectify matters. This information should come from
the senior executive level (Hiatt and Creasy, 2003). Most individuals wish to
hear organization-specific information from people most familiar with the
organizational workings.
4. Change management programs must address the needs and concerns of
all the employees. Change managers must listen as well as talk. Often man-
agers have a specific message they are tasked with communicating to a list
of employees. They go to each of the individuals in turn and tell them the
message. Each of these individuals may then be tasked with giving the same
message to another list of employees. Unfortunately, after the first cycle of
“communications” the true meaning of the message has been lost. Com-
munication implies two-way interaction. A good change manager gives the
message and then asks employees what they heard. During this process, the
employee can ask questions and express their concerns. Often their ques-
tions have nothing at all to do with the proposed process changes; their
questions are personal: Will I still have a job? Will I have enough hours?
Am I going to have to get new training or learn new skills? For the project
to go smoothly, each employee needs to understand the process and to have
his or her questions answered.
5. The change must be reinforced and must become part of the corporate
culture: “That’s how we do things around here.” It is crucial to the orga-
nization’s long-term success that the change be reinforced. Managers and
employees must understand that the process changes are permanent—that
 A Process Redesign Approach to Successful IT Implementation 275

they cannot just go along for a couple weeks and then resume “business as
usual.” Process redesign projects usually cost millions or tens of millions of
dollars. A hospital cannot afford to invest these resources in a major project
and then fall back into the previous routines.
There are five specific phases of a change management program. A suc-
cessful change manager recognizes these phases and addresses the important
issues in each.
1. Awareness of impending change. During this phase, the affected peo-
ple become aware that change is imminent, and that the change is going to
affect them. It is preferable for the awareness to come from respected, au-
thoritative sources than from the rumor mill. People prefer to hear of major
organizational movements from the leaders of the organization, than from
their colleagues. Ideally, this event occurs during the early project phase
of the business process redesign. Too often change management activities
are added as an afterthought when implementation of the redesigned pro-
cesses encounters problems. Initiating change management early helps en-
sure smooth implementation.
2. Acceptance of need for change. Most people resist impending change.
“Why fix it if it isn’t broken?” Change management includes an educational
program that contains explanations of the reasons for change for every-
one in the organization. There must be communication (two-way dialogue)
between the employees and their immediate supervisors about the need
for change. Once people understand the reasons for the change, they are
able to accept the need for change. Acceptance of need for change must
occur on both emotional and intellectual levels. It is crucial that there
be communication between the supervisors and employees—that the su-
pervisors do not merely “give their spiel” and move along. This phase
is crucial for the employees to be able to express their anxieties and
concerns and to obtain answers to their questions. This must filter from
top to bottom. Initially, the senior leadership educates the top-level man-
agement about the change; then senior management educates the mid-
dle management; middle management educates the direct supervisors; and
so on.
3. Knowledge of the process of change. After the organization has made
the decision to move forward with the upcoming change, people begin to
learn how their world will change and what they must do to accommodate
the changes. In the best case, people from the organization help design the
new processes they will use. Even if they are not involved in the design phase,
there are new policies and procedures to learn. Employees must learn how
they will work in the new environment and become comfortable with the
new procedures.
4. Process of change. Managing change occurs on two levels: the orga-
nizational level and the individual level. The strategies for implementing
the business process redesign occur at the organizational level. The include
276 Professional Nursing Informatics

evaluating the scope of change, assessing the organization’s ability to adapt

to new processes, and determining the timing and content of messages to
be communicated. Enabling employees to accept and embrace the new pro-
cesses occurs at the individual level. This is where the role of the change agent
becomes heavily people focused. Creating and maintaining clear channels
of communication helps the change agents hear the employees’ fears and
concerns and address those concerns before resistance to the new processes
becomes hardened throughout the organization. In an ideal organization,
each employee ultimately learns the skills needed to manage change at the
individual level. The entire organization thus has recreated itself as change-
embracing and is able to adapt quickly to business course changes. This is the
ideal. Most organizations must settle for creating an active body of change
agents who can be called into action when process changes are planned.
5. Reinforcement of change. After the new processes have been success-
fully implemented and accepted, it is essential to continue to monitor the
environment to ensure that there is no slipping back into “the old ways.”
When difficulties are encountered while doing something new, it is human
nature to revert to prior behaviors. Those behaviors had become automatic,
requiring less thinking and attention; and even if they were awkward, slower,
or clumsy, the employee could get the job done. At this reinforcement stage,
the change agent must provide support to the individual, evaluate the fail-
ure points for the organization, and participate in ongoing process redesign
planning to further improve acceptance. It is important to note that rein-
forcement of change is of major significance for sponsors of change at the
leadership level of the organization. Too frequently these leaders assume
that their job is done and they turn their attention to something else. Em-
ployees may perceive this to mean that there is no longer support for the
“new ways.”

To achieve consistently the business objectives of the organization for im-

proved reaction time and time to market, for example, and to retain skilled
individuals and permit them to function effectively in an organization, it
is essential to be familiar with and employ change management principles
whenever process redesign occurs. Process redesign and change manage-
ment are the twins of effective organizations today.

Summary
Healthcare organizations today must adapt new technologies to improve
their ability to provide safe and efficient care to patients. Technology is
available that can make dramatic improvements in current healthcare pro-
cesses, but technology cannot be implemented successfully without adequate
organizational preparation. This preparation involves redesigning current
processes to make optimum use of the technology and helping people deal
 A Process Redesign Approach to Successful IT Implementation 277

with the changes brought by the redesigned processes. Process redesign is

a method of improvement that requires organizations to redesign the pro-
cesses by which their tasks are completed. When process redesign occurs,
the lives of people who perform those redesigned tasks are affected. Change
management is needed to help people adjust to these changes in their lives.
Together, process redesign, information technology implementation, and
change management can dramatically improve the delivery of healthcare.

References
Committee on Quality of Health Care in America. (2001). Crossing the Quality
Chasm: A New Health System for the 21st Century. Washington, D.C.: Institute of
Medicine, National Academy Press.
Dick, R.S., Steen, E.B., & Detmer, D.E. (eds.) (1991). The Computer-Based Patient
Record. Washington, D.C.: Institute of Medicine, National Academy Press.
Hiatt, J.M., & Creasey, T.J. (2003). Change Management: The People Side of Change.
Loveland, CO: ProSci Learning Center.
Kohn, L.T., Corrigan, J.M., & Donaldson, M.S. (eds.) (1999) To Err is Human: Build-
ing a Safer Health System. Washington, D.C.: Institute of Medicine, National
Academy Press.

Website of Interest
http://www.healthcare-informatics.com/reports/industry20.pdf (accessed
August 10, 2004).
Part V
Professional Nursing Informatics
20
Nursing Informatics Education:
Past, Present, and Future
With contributions by Susan K. Newbold, Jo Ann Klein,
and Judith V. Douglas

Today’s healthcare environment continually places increasing demands on

nurses to communicate, share data, and synthesize information through the
use of information systems, with or without the assistance of computers
(Chapman et al., 1994; Ngin and Simms, 1996). In addition to having knowl-
edge of information systems, nurses who are computer literate have the
opportunity to use the power and efficiency of computer systems to play
an important role in enhancing patient care delivery, offering safe care,
and shaping nursing practice. In July 2004, Dr. Charles Safran, President of
the American Medical Informatics Association, announced at the National
Health Information Infrastructure Conference in Washington, DC that 6000
informatics nurses would be needed to support patient care delivery in the
United States.
Computer-literate nurses are defined as licensed nurses who demonstrate
competence in understanding and using computer hardware, software, ter-
minology, and operating systems (Saba and McCormick, 2001). In today’s
information age, nurses are expected to keep pace with rapidly advancing
technology. Appropriate utilization of computers and information systems
can help nurses make well informed decisions regarding management and
patient care issues. It is therefore critical that education in the use of com-
puterized healthcare knowledge systems be included as an important com-
ponent of basic, as well as advanced, nursing curricula.
Nurse educators are expected to teach how to develop, retrieve, and imple-
ment electronically stored data to optimize information-dependent clinical
decisions. Also, the nurse educator is expected to provide guidelines con-
cerning newly emerging nursing knowledge and ways that this knowledge
can be accessed. This need requires the nurse educator to keep abreast of
the advancing technology on a theoretical as well as practical basis.
The intent of this chapter is to explore the development of graduate-
level nursing informatics education from its inception to the present, with
an emphasis on the importance of computer and information literacy as
an integral part of the educational program. After discussing the evolution

280
 Nursing Informatics Education: Past, Present, and Future 281

of nursing informatics education and incorporating an existing nursing

informatics model, goals and objectives for future nursing informatics edu-
cation are suggested.
A review of the literature provides a historical overview of nursing infor-
matics education, including a discussion of the recognition of nursing infor-
matics as a formal specialty by the American Nurses Association (ANA) with
certification through the American Nurses Credentialing Center. Through
this recognition, the specialty of nursing informatics has assumed standards
of practice that should be integrated into the graduate-level nursing infor-
matics educational curriculum. Studies that have been conducted to de-
termine the educational needs of nursing informatics students were also
examined.

Review of the Literature

Historical Overview of Nursing Informatics Education
During the 1980s, nurses who were involved in informatics were primarily
self-educated because of the small number of formal graduate programs
available to prepare nurses to work in this specialty. During that time, the
number of faculty involved in these graduate programs was small enough
that they could independently network in an effort to exchange course con-
tent. Education focused on teaching the use of computers as a tool for word
processing, spreadsheet analysis, graphics production, and statistical appli-
cations (Arnold, 1996). These early programs addressed only the nature of
information systems and their selections for nursing practice (Graves et al.,
1995; McGonigle, 1991).
In 1988, Dr. Barbara Heller was instrumental in establishing the first grad-
uate program in nursing informatics at the University of Maryland School
of Nursing in Baltimore. The focus of this formalized program included an
understanding of nursing informatics science and systems theory in a clinical
and management context, with particular emphasis on its impact on nursing
practice (Romano and Heller, 1990).
The Maryland program was developed in close collaboration with the
university’s information services division, headed by Dr. Marion J. Ball,
who worked with the School of Nursing to launch their technology-assisted
learning centers, develop an outside advisory board for the program, and
initiate innovations in the curriculum. Together with Dr. Kathryn Hannah,
she contributed the major initial texts for the program (Ball and Hannah,
1984, Ball et al., 1988, 1995; Hannah et al., 1999).
A second graduate school program followed in 1990 when the University
of Utah initiated a nursing informatics program that focused on the transfor-
mation of nursing data into information to support clinical decision making.
282 Professional Nursing Informatics

Students learned about nursing informatics theory, design and analysis of

clinical nursing systems, clinical nursing database design, decision support,
and administration of clinical nursing information systems (Arnold, 1996).
This program followed on the heels of a discontinued grant-funded summer
postdoctoral seminar for nursing informatics that began at Utah during the
summer of 1988 and ended before the opening of that university’s graduate
program in nursing informatics.
Since the inception of Utah’s graduate-level nursing informatics program,
a lack of federal funding has limited the development of other, similar
programs. Funding resources are critical for providing adequate computer
hardware, software, support services, faculty, and individual implementation
strategies for these programs.
In September 1998, the New York University School of Nursing, under
the direction of Dr. Barbara Carty, began a program with a nursing infor-
matics graduate track. This program includes theory and clinical applications
with multiple preceptorship experiences encompassing all aspects of nursing
informatics.
The University of Colorado Health Sciences Center School of Nursing
offers a Master of Science program in nursing designed to prepare nurses
for advanced practice roles. In addition, they offer a post-master’s certificate
with specialization in healthcare informatics, and a post-bachelor’s health-
care informatics certificate program.
Despite a lack of funding for new programs, the need for nursing in-
formatics courses has been recognized by other nursing schools. These ed-
ucational institutions have integrated nursing informatics courses in their
undergraduate and graduate curricula in the form of required courses, elec-
tives, conferences and continuing education workshops. Furthermore, the
traditional classroom has expanded beyond its walls to include distance ed-
ucation, telemedicine, and continuing education offerings. Excelsior College
is the first program to offer a nursing masters program focused on nursing
informatics that is totally online. The program, which began in 1999, offers
a Master of Science degree in nursing administration with an emphasis on
clinical informatics that is accredited by the National League for Nursing.
A 17-credit post-bachelor’s certificate can also be obtained in clinical infor-
matics.
In 2003 The University of Arizona College of Nursing began to offer a
doctorate in nursing with one option for study being healthcare informatics.
Students can study online except for an intensive 2-week presession each
year.

Continuing Education in Nursing Informatics

The University of Maryland School of Nursing hosts an annual Summer
Institute in Nursing Informatics. In addition to invited speakers, attendees
 Nursing Informatics Education: Past, Present, and Future 283

can make presentations and posters. Exhibitors and networking events are
included in this 3-day event. Preconference and postconference workshops
are offered, including the Weekend Immersion in Nursing Informatics. Other
organizations that offer yearly continuing education for nursing and health-
care informatics include the American Medical Informatics Association
(www.amia.org) and the Healthcare Information and Management Systems
Society (www.himss.org). The Canadian Nursing Informatics Association
(www.cnia.ca) also offers nursing informatics education and links to other
educational offerings.

Recognition as a Nursing Specialty

In 1992, nursing informatics was formally recognized as a nursing specialty
by the American Nurses Association. This recognition of nursing informatics
as its own specialty was followed by the development of nursing informatics
standards of practice, which were published by the American Nurses Asso-
ciation in 1995 and revised in 2001. These standards require that informat-
ics nurses acquire and maintain current knowledge in nursing informatics
practice (American Nurses Association, 2001). To achieve this, the infor-
matics nurse is required to seek additional knowledge and skills appropriate
to the practice setting by participating in educational programs and activ-
ities, conferences, workshops, interdisciplinary professional meetings, and
self-directed learning. Thus, nursing informatics educators are needed to
provide appropriate learning opportunities. The standards also suggest that
each informatics nurse keep a record of his or her own learning activities
and seek certification and recertification when eligible.
Nursing informatics certification became available in 1995 through the
American Nurses Credentialing Center (ANCC). Major topics on the cer-
tification examination include (1) system analysis and design; (2) system
implementation and support; (3) system testing and evaluation; (4) human
factors; (5) computer technology; (6) information/database management;
(7) professional practice/trends and issues; and (8) theories (ANCC, 2004).
To be eligible to take the nursing informatics certification examination,
applicants are required to have a baccalaureate or higher degree in nursing
or related areas, maintain licensure, and have 2 years of active experience
as a registered nurse. In addition, each candidate must have a minimum of
2000 hours of experience in the field of nursing informatics during the 5 years
before taking the examination. In lieu of this experience, 12 semester hours of
academic credit in informatics in a nursing graduate program and a minimum
of 1000 hours in informatics nursing may be substituted (ANCC, 2004). Since
1997, the certification examination has been available by computer at 55
testing facilities throughout the United States. It was the first computerized
ANCC certification examination, and to date more than 1000 nurses have
been certified.
284 Professional Nursing Informatics

Nursing Informatics Graduate-Level Education Today

Many educational and practice institutions have initiated programs to pre-
pare nurse clinicians simply as users of automated systems, and others are
preparing healthcare information systems specialists. Despite the increased
use of computer systems in nursing informatics, the management component
of informatics presented by Graves and Corcoran (1989) remains essential.
The nursing informatics student is still taught to have the “functional abil-
ity to collect, aggregate, organize, move, and represent information in an
economical, efficient way that is useful to users of the system” (Graves and
Corcoran, 1989).
Today, nurses can take advantage of the virtual classroom where the ed-
ucational process occurs outside the formal classroom setting. In this envi-
ronment, use of telecommunication technologies through computer-based
intranets, extranets, and the Internet make innovative multimedia teaching
possible. This teaching methodology is ideal for students who require flexible
class schedules secondary to work and family obligations. The virtual class-
room, as an interactive process, enables nursing students and their teachers
to utilize telecommunication software applications such as interactive video
instruction, electronic mail, bulletin boards or newsgroups, and chat con-
ferencing as a learning milieu. To supplement virtual classroom activities,
students are guided to utilize the Internet, where databases of nursing and
healthcare information and other applicable learning resources can be ac-
cessed from school and home computers. It is therefore the responsibility
of nurse educators to train students to access, retrieve, and implement this
growing base of virtual learning tools and to provide feedback to students
regarding their success in implementing these tools. O’Neil et al. (2004) have
offered a practical step-by-step process to take nurse educators through the
necessary steps to transform a traditional course into an on-line or partially
online course.

Studies Examining Nursing Informatics

Educational Needs
As early as 1990, when no formal nursing informatics program existed at
their school, the Computing Advisory Council (CAC) at The University of
Texas Health Science Center School of Nursing at San Antonio made rec-
ommendations for integration of nursing informatics into graduate research
coursework (Noll and Murphy, 1993). At that time, it was recommended that
students achieve the following areas of competence upon completion of the
graduate program, regardless of their major: (1) analyze and select relevant
information sources; (2) access existing Internet resources for nursing and
related disciplines; (3) extract, manage, and organize data; (4) analyze the
nurse’s role in data security and integrity; (5) analyze the impact of nursing
 Nursing Informatics Education: Past, Present, and Future 285

information systems; (6) evaluate and use appropriate software for advanced
practice; and (7) demonstrate information transfer between computer sys-
tems (Noll and Murphy, 1993).
These programs, which incorporate nursing informatics coursework in
their graduate level curricula, confirm that achieving computer competence
is not easy for all the participants. Magnus et al. (1994) participated in a grad-
uate course titled “Nursing Informatics” at the Hunter–Bellevue School of
Nursing that emphasized the integration and use of computer and infor-
mation technology as it related to the management and processing of data,
information, and knowledge to support nursing practice and the delivery of
care. At that time, there was noted resistance to using computers because
of fear of the unknown. Magnus and her classmates suggested that partici-
pating in the course helped diffuse the “mystery” surrounding the material
(Magnus et al., 1994). Noll and Murphy (1993) reported that integration of
nursing informatics material with hands-on application facilitated learning.
In addition, students noted that information about software packages, par-
ticularly bibliographic databases, was extremely helpful and would be useful
in the development of their graduating theses.
A study conducted by Saranto and Leino-Kilpi (1997) identified and de-
scribed computer skills required in nursing and what should be taught about
information technology in nursing education. A three-round Delphi survey
was conducted with a panel of experts representing nursing practice, nursing
education, nursing students, and consumers. The experts agreed that nurses
must know how to use the computer for word-processing purposes as well
as for accessing and using hospital information systems and electronic mail
(e-mail). Nurses must also be aware of system security and show a positive
attitude toward computers. Conclusively, the study determined that hospi-
tal information systems and nursing informatics should be integrated into
laboratory and hospital training (Saranto and Leino-Kilpi, 1997).
In 1996, Dr. Jean Arnold, then associated with the College of Nursing,
Rutgers, the State University of New Jersey, conducted a survey among
497 respondents in a northeastern metropolitan area to determine the in-
formatics needs of professional nurses. The subjects primarily represented
informatics specialists, nurse educators, and nurse managers, many with mas-
ters or doctoral degrees. Respondents were asked to indicate their current
knowledge and desired knowledge of nursing informatics in 23 content areas
that are included in the ANCC nursing informatics certification examination.
The survey revealed that 73% of the respondents were interested in re-
turning to school to earn certification in nursing informatics, and 59% were
interested in a graduate degree (Arnold, 1996). Decision support, integra-
tion of nursing informatics, advanced nursing informatics, decision analysis,
and graphics presentations were the content areas most highly ranked by
informatics nurses. In addition, informatics trends and issues information
were the foremost educational needs identified by informatics nurses in the
survey. The results reported by informatics nurses in both areas differed
286 Professional Nursing Informatics

from the responses by nurse educators and nurse managers, suggesting that
position titles and responsibilities have an impact on a subject’s interest in
advanced education in addition to the subject’s use of computer applications
(Arnold, 1996).
As a result of her survey, Arnold recommended that informatics nursing
curricula content include “graphic presentation of data, decision support,
electronic communications, integration of nursing informatics within ba-
sic and other specialty programs, critique of computer-assisted clinical data
analysis, and expert knowledge acquisition” (Arnold, 1996). She also recom-
mended including review courses for the informatics certification examina-
tion and emphasized the need for more graduate and continuing education
programs to meet the increased demand for informatics knowledge.
Staggers et al. (2002) also conducted a Delphi study to determine the areas
of competence needed for nurses in the field of information technology. Their
research revealed 305 such competencies proposed for nurses at four levels of
practice: the beginning nurse, the experienced nurse, the informatics nurse,
and the nurse innovator.

Future of Nursing Informatics Education

Clearly, there is a need to standardize graduate nursing informatics curricula
based on the standards of nursing informatics practice defined by the ANA,
nursing informatics certification requirements defined by the ANCC, and
utilization of a nursing informatics model such as that developed by Saba
and McCormick (2001) incorporating the suggested adaptations.
For the nurse educator to teach and reinforce this newly acquired nurs-
ing informatics knowledge effectively, computer systems should be readily
available at all sites where nursing education occurs or clinical decisions are
made, and in any place where nursing is practiced. Students must be allowed
to experience situations where computer applications related to nursing in-
formatics can be used, which includes utilization of the virtual classroom.
One of the primary barriers to utilization of the virtual classroom in nurs-
ing informatics education has been the speed with which telecommunica-
tion and computer technology has been developing, resulting in frequently
changing software and hardware requirements and a financial investment
that many schools are not able to sustain. It is hoped that as the cost of
computer hardware and accompanying software systems continues to de-
cline, computerized educational modalities and clinical information banks
will become more readily accessible.
The development of nursing informatics curricula for graduate-level nurs-
ing students demands that the minimum standards be based on an un-
derstanding of the ANA’s nursing informatics standards of practice. Op-
timally, the curricula is based on the understanding and application of
the ANA’s nursing informatics standards of practice in addition to the
 Nursing Informatics Education: Past, Present, and Future 287

requirements for achieving certification in nursing informatics through the

ANCC.
To achieve these goals, there must be practical application of the pre-
sented information systems theory. This should include not only additional
educational experiences but also substantial hands-on experience through
preceptorship arrangements. First-hand experience ensures that all mas-
ter’s level nursing informatics graduates have a high level of competence
in both theory and practice. Because this is such a crucial goal, course-
work should continue to focus on computer applications and related issues
in nursing practice, nursing administration, nursing education, and nursing
research.

Defining an Educational Model for Graduate-Level

Nursing Informatics
Not only is there a need for more nursing informatics programs, a need
also exists for an educational framework to promote standardization and
structure in the nursing informatics curricula. Because the specialty is so
new, there has been limited research regarding the development of models
specifically designed for nursing informatics education. Utilization of educa-
tional models would provide the needed framework not only for theoretical
education but also for practical applications.
Riley and Saba’s nursing informatics education model (NIEM) is an ed-
ucational application aimed at undergraduate students that can be adapted
for graduate students. The model can fulfill the need for a theoretical and
practical framework in addition to meeting the desired requirements of in-
formatics nurses cited in Arnold’s survey (Saba and McCormick, 2001).
The NIEM emerged and evolved with the development of computer
technology in the healthcare industry. As illustrated in Figure 20.1 NIEM
identifies three dimensions of content that comprise nursing informatics
computer science, information science, and nursing science. NIEM further
identifies the educational outcomes that must be addressed in the three
domains of learning: cognitive, affective, and psychomotor. Once the ob-
jectives are achieved in each domain of learning, students can integrate
nursing informatics into their nursing roles. This integration of knowledge
and competence in nursing education requires that a program include con-
tent, hands-on application, and attitude. The model supports the integration
of computer and information technology into nursing education to enhance
critical thinking skills and provide an active learning experience. Confidence,
psychomotor skill level, and knowledge attainment are enhanced in the pro-
cess. An advantage of using this model is the ability for the student nurse to
make decisions in simulated case studies without risk to the patient (Saba
and McCormick, 2001).
288 Professional Nursing Informatics

FIGURE 20.1. Riley and Saba’s nursing informatics education model (NIEM). (From
Saba V, McCormick K. Essentials of Computers for Nurses. New York: McGraw-Hill,
2001, p. 558, with permission.)

As summarized here, NIEM’s objectives occur in four steps. Because ba-

sic computer skills are germane to fundamental nursing education, the first
step gives students the knowledge and technical skills to function effectively
(Lawless, 1993; Saba and McCormick, 2001). Computer application con-
tent at this level includes concepts of computer hardware and software as
well as computer system components. Students are required to use a word
processing program for assignments and to format documents in American
Psychological Association (APA) format. System content includes the use
of computerized databases and search engines for reference material (Saba
and McCormick, 2001). Although it is hoped that all students entering a
graduate-level program are proficient in basic computer skills and appli-
cations, this step provides the needed content and practical experience for
those students entering graduate-level programs with little or no computer
knowledge.
Saba and McCormick (2001) recommended that the nursing informatics
student have knowledge of word processing, database, presentation, and
spreadsheet software programs in addition to bibliographic retrieval using
CD-ROM software as well as Internet searches. This hands-on computer
experience is augmented by the assignment of e-mail addresses and required
subscription to a class e-mail discussion group, which can be utilized for
discussion and assignments. Nursing literature supports the use of e-mail as
an informal exchange of communication to help new computer users cope
with the stress of using new technology and to enhance critical thinking skills
(Magnus et al., 1994; Todd, 1998).
 Nursing Informatics Education: Past, Present, and Future 289

The second step of Riley and Saba’s model involves application of com-
puter technology to document and access health information for the pur-
poses of patient assessment. On an undergraduate level, Riley and Saba
introduce the Saba Home Healthcare Classification of Nursing Diagno-
sis and Intervention in the classroom to develop patient care plans and
in the hospital patient information system for recording care (Saba and
McCormick, 2001).
At the graduate level, step 2 can be adapted to include organizational the-
ory and associated computer applications, such as utilization of Microsoft
Project software for project management simulation. In addition, students
can apply computer applications to healthcare financial management course-
work to determine staffing needs, cost–benefit ratios, and budgets. It is during
step 2 that this author suggests the electronic health record (EHR) be in-
troduced, particularly in regard to classification systems and taxonomies,
managed care, and the social, legal, and ethical issues associated with the
EHR.
The third step of the Riley and Saba model introduces undergraduate
students to advanced concepts utilizing existing information systems in clin-
ical agencies to plan and implement patient care (Saba and McCormick,
2001). On a graduate level, this step can be adapted to include telecommu-
nications in healthcare with an emphasis on understanding the policy devel-
opment that led to the current trend toward telemedicine and telenursing
applications in addition to its utilization. Also, knowledge about system re-
quirements and design and development applications should be imparted
through actual student experience working in venues such as outpatient
agencies, vendors, hospital information system departments, and consulting
firms.
Riley and Saba’s fourth and final step requires students to integrate com-
puter technology into nursing care. It includes evaluation, quality improve-
ment, multidisciplinary collaboration, and utilization of available resources
with the technology. In addition, students are required to examine the so-
cial, legal, and ethical issues they encounter through the use of computer
technology (Saba and McCormick, 2001).
This final step has been integrated into earlier steps of the graduate-level
adapted model. Therefore it is suggested that the fourth step be revised to
include implementation of a full systems analysis. To achieve this, the stu-
dent must work on a systems development life cycle in a preceptor-based
practicum real-life experience during the course of a 1-year internship. This
plan would allow the student to benefit from long-term hands-on experience
under the guidance of an experienced practitioner. In turn, this experience,
coupled with earlier short-term practical experience, would enable students
to claim credible nursing informatics experience when searching for employ-
ment after graduation.
Clearly, Riley and Saba’s model is adaptable and can be applied to all
levels of nursing informatics education. Because the practice of nursing
290 Nursing Informatics Education: Past, Present, and Future

informatics can occur in any area where nurses practice, this model is appli-
cable in all practice settings (Lange, 1997). It is therefore a realistic model
for standardizing nursing informatics education methodology.

Summary
Informatics knowledge, in this age of information, is necessary for growth
of the nursing profession. The number of available nursing informatics
graduate-level programs is increasing, but the informatics expertise of fac-
ulty members to teach in those programs is critical if the nursing profession
is to meet the challenges presented by integration of this rapidly advancing
technology into healthcare. Therefore the graduate-level nursing informatics
educational environment must continue to strive to become a forum where
educator and student meet in an expanded capacity made possible by an in-
crease in the integration of computer competence in the nursing informatics
curricula.
This practice does not undermine the importance of noncomputerized
systems in the field of nursing informatics but responds to the challenge
of keeping pace with the changing regimen. By creating a pilot nursing in-
formatics program utilizing the suggested adaptations of Riley and Saba’s
NIEM, increased computer and information literacy and competence can
be achieved in a graduate-level nursing informatics program. Therefore it
is suggested that research be conducted to determine the effectiveness of
such a program to (1) measure the effectiveness of the proposed program
in relation to improving computer literacy and therefore increasing compe-
tence; (2) determine the feasibility of developing an actual program; and
(3) add to the current knowledge base about nursing education curriculum
requirements for nursing informatics graduate-level programs.
Once validated through research, this proposed model can serve as a
guideline for schools of nursing that are in the process of considering,
planning, developing, or implementing graduate-level nursing informatics
curricula.

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21
The Future for Nurses in Health
Informatics
With contributions by Joyce Sensmeier, Susan K. Newbold,
and James Cato

Since we have entered the new millennium, the emphasis on health infor-
matics has been increasingly growing. The focus of development, which was
initially on hardware, has moved to an emphasis on application software.
As the understanding of health informatics continues to evolve, however,
hardware and software are increasingly recognized as merely a means to
capture, transport, and transform data into information that enables care-
givers to provide people with the best possible health services. This new
information-rich environment also contains new and powerful tools that en-
able caregivers and care recipients alike to seek and use information to make
health-affecting decisions and to generate new health knowledge. To gain
maximum benefits from this new environment, expanded understanding of
how people seek and use information by drawing on cognitive science and
organizational development is essential (Ball and Nelson, 2004; Ball et al.,
2004).

Visions of the Future

Haux (1998) defined a vision for medical informatics that rests on 10 aims.
Ball et al. (1997) explored the implications of these aims for the nursing
profession.
r Aim 1: diagnostics—the visible human body. Remote access to high-quality
digital images supports new modes of care delivery (Dayhoff and Siegel,
1998; Zimmerman, 1995). These images can be minimized, ensure access
to specialists, and create new requirements for coordinating and man-
aging care. Other influential developments include the incorporation of
images of various types into electronic patient records. Many of these
advances have already taken place and continue to enhance the informa-
tion available to caregivers, including nurses; and they affect the ways in
which caregivers deliver care. The National Library of Medicine’s Vis-
ible Man and Visible Woman are now accessible via the Internet or

292
 The Future for Nurses in Health Informatics 293

CD-ROM; the availability of such images can increase knowledge of

the human body and ultimately contribute to nursing assessment and
intervention.
r Aim 2: therapy: medical intervention with as little strain on the patient as pos-
sible. Noninvasive diagnostics and minimally invasive surgery are growing
significantly, thanks to laparoscopic procedures and computer-aided vi-
sualization as well as laser surgery. Clearly, these advances affect nurses
involved in the procedure. When combined with other forces, they also af-
fect nurse’s involvement throughout the care process, influencing factors
such as limiting the number of hospital days and changing the role of the
hospital-based nurses.
r Aim 3: therapy simulation. Nurse educators have been leaders in using
simulation-based training for their students, offering simulation laborato-
ries to teach basic skills. Further development of simulation technologies
will allow nurses to refine advanced skills. Multimedia computer–based
training will supplement hands-on laboratory experiences even more in
the years to come.
r Aim 4: early recognition and prevention. Today, increasing numbers of
nurse practitioners are providing primary care, and nurse-managed clinics
are becoming the mechanism for delivering affordable primary care. Both
trends suggest that nursing will become responsible for patient education,
working with patients to develop health behaviors that prevent illness
and promote wellness. Use of the Internet and new functions, such as
information prescriptions, are putting more and more tools into the hands
of healthcare providers.
r Aim 5: compensating for physical handicaps. Devices used on an ongoing
basis by patients tend ultimately to involve nursing in their support as
a daily living skill. Teaching these skills has long been the concern of
nursing. New informatics applications in this area will require a new level
of knowledge and sophistication among nursing staff. To accomplish these
goals, a revolution needs to occur in the nursing curriculum. Each nurse
must have a comfort level with enabling technologies, which is not present
today.
r Aim 6: health consulting: the informed patient. Patient education is re-
ceiving new attention. Multimedia programs guide patients when they
are deciding on interventions for their condition. Moreover, videotapes,
CDs, and DVDs are available for purchase in pharmacies with titles ad-
dressing conditions ranging from alcoholism to gastrointestinal ulcers. As
more health-related information becomes available to consumers via the
Internet, patients definitely need guidance for evaluating and using this
information. Nursing has often provided this guidance in the past and will
increasingly continue to do so as counselors and teachers of patients and
clients. Tools provided by responsible organizations such as Health on the
Net (HON) are there to help the consumers and patients make informed
decisions.
294 Professional Nursing Informatics

r Aim 7: health reporting. To date, public health has relied on retrospec-

tive reports to control disease. Today the information infrastructure offers
the capability to intervene in a timelier manner through ongoing surveil-
lance of certain conditions and through programs such as clinical alerts of
national the Library of Medicine (NLM) clinical alerts. The National In-
stitutes of Health is extending the boundaries through its Human Genome
Project and Gene Bank. We have yet to realize the benefits that can re-
sult from large-scale data repositories providing population-based health
statistics. Nursing will play a role in using and understanding outcomes
information to improve the management and quality of care. The next
initiative, called the National Health Information Infrastructure (NHII),
will be a transformational initiative (discussed later).
r Aim 8: enterprise information systems. Nurses have long been the front-
line users of information systems in healthcare. Indeed the nurse is the
foot soldier of our healthcare system. Clinical informatics must focus
on making information tools an integral component of the care process,
noticeable only by their absence. Technology should free up the caregiver,
eliminating cumbersome and repetitive data entry. Increasingly, technol-
ogy will need to support health professionals including nurses in a wide
variety of settings in large-scale integrated health service networks. As
members of the healthcare team, nurses will continue to be at the hub
of patient care—even when are functioning in a telehealth/telemedicine
setting.
r Aim 9: medical documentation. Movement toward the electronic health
record (EHR) continues in the United States (NHII), Canada (Canada
Health Infoway), and the United Kingdom and Australia (GEHR). In the
United States, President Bush has challenged the profession to develop
an EHR for every citizen within the next 10 years. The major obstacles
are nontechnical: Questions remain regarding medical knowledge repre-
sentation and the structure of the record. The Unified Nursing Language
System (UNLS) has been integrated into the NLM’s Unified Medical Lan-
guage System (UMLS); SNOMED is free for use in the United States and
the United Kingdom. The Telenurse project in the European Commu-
nity, the International Classification of Nursing Practice initiative of the
International Council of Nurses, the International Standard Known as
Reference Terminology Model for Nursing (ISO 18104), and other ini-
tiatives, both national and international, are all having a major impact
on electronic nursing documentation. All these activities are improving
nursing documentation and thereby enhancing the visibility of the nursing
contribution to patient care. Of course, data protection and patient confi-
dentiality remain key critical issues. The Health Insurance Portability and
Accountability Act of 1996 (HIPAA) has also had a major impact.
r Aim 10: comprehensive documentation of medical knowledge and
knowledge-based decisions for case management. These efforts are closely
linked to outcomes and quality assurance. Patient safety has moved to
 The Future for Nurses in Health Informatics 295

the top of the list as an initiative that is key to the future of nursing.
New ethical considerations will arise as we move to the future. How will
knowledge-based systems affect issues of clinical judgment and responsi-
bility? Clearly the nursing profession must address these issues, in both
concept and practice.
Since the release of the above aims, other initiatives have taken place
moving forward the agenda of healthcare information technology. In July
2004, at the National Health Information Infrastructure (NHII) Summit, Dr.
David Brailer, the National Coordinator of Health Information Technology,
unveiled the four goals of his office to mobilize U.S. Health Information
Technology (HIT) initiatives during the current decade. Although nursing
is not emphasized in these efforts, nursing must play a major role in taking
these concepts from theory to practice.
r Goal 1: inform clinical practice. This goal focuses largely on efforts to bring
electronic health records directly into clinical practice.
r Goal 2: interconnect clinicians. This allows information to be portable and
to move with consumers from one point of care to another.
r Goal 3: personalize care. Consumer-centric information helps individu-
als manage their own wellness and assists with their personal healthcare
decisions.
r Goal 4: improve population health. Population health improvement en-
visions improved capacity for public health monitoring, quality of care
measurement, and bringing research advances more quickly into medical
practice.
Making these efforts meaningful to the nursing profession will require
extensive lobbying by nurses to increase the awareness of policy makers of
the importance of nursing content in the HIT initiatives to achieve the goals
of the NHII. Moreover, a major change will be required in nursing education.
This means diffusing nursing informatics training throughout the nursing
curriculum rather than in isolated fashion, as we have done to date. We are
still training nurses the way we did 50 years ago, and we need to change our
approach if these efforts are to transform the delivery of healthcare.

New Roles for Nurses in Nursing and

Healthcare Informatics
As the discipline known as nursing informatics (see Chapter 1) continues
to evolve within the context of health informatics, nurses can and should
contribute in the areas of research, education, administration, and practice.
In the area of research, nurses with appropriate preparation are already par-
ticipating in developmental projects. All the major developers and vendors
of computerized health information systems employ nurses as consultants,
296 Professional Nursing Informatics

advisors, systems engineers, systems analysts, or programmers. Major re-

search initiatives, led by nurse researchers, are underway to study the use of
the Internet and the World Wide Web for delivery of patient care or edu-
cation. Nurses have also participated in government-funded investigations
studying the effects of the implementation of such systems on healthcare
delivery and nursing practice. In addition, nurses have been extensively in-
volved in research related to the development of international data and in-
formation standards for health data and information as well as nursing data
and information. Major research effort is well underway in the uniquely
nursing area related to the development of reference terminology models
for nursing as a basis for information standards related to nursing clinical
language and vocabulary.
Most recently, nurses are developing information management methods
and tools for use in transforming health and nursing data into information.
Similarly, nurses have been in the forefront of projects exploring the educa-
tional and instructional uses of large mainframe computers, personal com-
puters, laptops, blackberries, tablets, multimedia, and the Internet. These
nurses are actively involved in developing and evaluating computer hard-
ware, software, peopleware, and multimedia materials in educational insti-
tutions and at organizations that provide patient care. In the future, nurse
researchers should be initiating studies of the ergonomic and change man-
agement issues associated with the use of information technologies in nursing
practice and nursing education.
Nurse administrators require computer skills, informatics skills, and in-
formatics knowledge to fulfill their roles. In addition, these nurses should
be able to select systems that help in the management of patients and staff,
such as nursing documentation systems and staffing and scheduling prod-
ucts. Nurse administrators should also be prepared to promote and support
their organizations’ implementation of systems that foster patient safety and
quality nursing practice.
In the area of practice, nurses have traditionally been the interface be-
tween the consumer and the healthcare system. In the application of nurs-
ing informatics, nurses with baccalaureate or master’s degree preparation
can and should participate in the selection and implementation of systems.
Parker and Gassert (1996) long ago concluded that informatics nurse spe-
cialists (INSs) are eminently qualified to assist the healthcare industry in
implementing Joint Commission on the Accreditation of Healthcare Orga-
nizations (JCAHO) standards in the clinical environment (JCAHO, 1994).
In fact, Parker and Gassert (1996) asserted that INSs can function more ef-
fectively and appropriately as systems analysts in patient care settings than
the nonclinical systems analyst, who may have a background in computer
science, engineering, or another discipline. Nurses must articulate for the
computer program designers and systems engineers the automated systems
needs of healthcare professionals and consumers. A related role is that of
 The Future for Nurses in Health Informatics 297

change agent, someone who facilitates the business process design (or re-
design) related to the delivery of patient care. This role enables organizations
and the people in them (including nurses) to use information and informa-
tion systems with the maximum degree of effectiveness and efficiency. The
development and wide dissemination of Telehealth applications ultimately
may provide an expanded scope of practice for nurses as the delivery of
health services is transformed.
In the area of education, INSs should be teaching and interpreting the jar-
gon and basic tenets of modern nursing for the information specialists. They
should also be preparing their professional colleagues for the inevitable
widespread implementation of automated information systems. This prepa-
ration can be accomplished through basic and ongoing education programs.
In facilities where information systems are being installed or upgraded,
nurses are and should continue to be the trainers for nurses using new or
upgraded applications software. The American Nurses Association (ANA)
officially recognized and defined the INS as far back as 1992 and has put in
place a process for certifying INSs (Newbold, 1996).
The goal of these new roles for nurses is to create patient-centered, enter-
prise health information systems that meet the needs of the consumer for
use in healthcare agencies and institutions. Healthcare professionals should
not be required to change their patterns of practice to conform to a com-
puter system. Thus, for information systems to best assist in the process of
patient care decision making by nurses, nursing informatics must receive and
respond to input from nursing. Nurses and information specialists must co-
operate in the development of information systems that produce the types of
information needed by nurses in their practice. Information specialists and
nurses must establish a dialogue that results in each group understanding
the needs and constraints under which the other functions.
As early as 1971, Singer warned that the more complex the system, the
higher the cost of change and therefore the more rigid and inflexible the
system becomes (Singer, 1971). Thus, caution when designing and imple-
menting any information system is essential. Future nursing needs must be
anticipated and provision made for flexibility in the design of programs in
the information system selected for use. Again, a general understanding is
needed between nurses and information specialists regarding the functions
and limitations of computers and the dynamic nature of nursing to select
flexible hardware and design-satisfactory computer programs. Only nurses
can provide the input necessary to ensure that nursing needs are met by
healthcare information systems.
Because of the widespread integration of nursing informatics into health-
care agencies and institutions, the role of the nurse will become more in-
tensified and diversified. Redefinition, refinement, and modification of the
practice of nursing will intensify the nurse’s role in the delivery of patient
care. At the same time, the nurse’s role will acquire greater diversity by virtue
298 Professional Nursing Informatics

of employment opportunities in the nursing informatics field. Nursing’s con-

tributions can and will influence the evolution of healthcare computing. The
contributions of nurses are essential to the expansion and development of
healthcare computing. By providing leadership and direction, nurses can
ensure that healthcare computing and nursing informatics evolve to benefit
the patient. That expected benefit is to expand and improve the quality of
healthcare received by patients.

Role of Professional Associations

Nurses interested in having a positive impact on the development of the infor-
mation management aspects of their profession are faced with the formidable
task of keeping up with a body of knowledge that becomes quickly outdated.
“State-of-the-art” technology changes with meteoric haste. The slightest
lapse in one’s monitoring of new technological developments can result in

one s knowledge becoming historical.
How does an individual stay current in this field? Obviously, the profes-
sional journals and trade magazines provide an important service. Unfortu-
nately, people on the frontiers of developing new technology and its applica-
tions are often too busy developing, with no time left for writing about their
activities. Thus, a curious dichotomy is occurring. People are reverting to
more informal means of communication to disseminate information about
the newest developments in high-technology information processing.
Professional associations fulfill the vital function of facilitating the ex-
change of current information on informatics developments. Individuals in-
volved in the health informatics field are more than willing to welcome “new
blood” with fresh ideas. They are also more than eager to expound on their
ideas to new listeners. Often, contact initiated on a face-to-face basis at pro-
fessional association annual meetings results in establishment of an informal
network of colleagues. These informal networks serve to maintain contact
between conferences for the purpose of sharing information and ideas. In
addition, professional associations provide a forum for the communication
and exchange of ideas. Formal addresses by leaders in the field and informal
discussions in the corridors and at social events during conferences facilitate
this exchange of ideas. Professional associations also publish newsletters,
journals, and conference proceedings. These media are aimed at accelerat-
ing wide dissemination of information about new information management
methods, technology, and software and their use and applications.
Nurses with interest and expertise in health informatics should seek mem-
bership in three types of organization.
r The first is affiliation with multidisciplinary associations whose focus is
health informatics. The purpose of membership in this type of organization
is to maintain and expand expertise in health informatics.
 The Future for Nurses in Health Informatics 299

r The second type of organizational membership is maintenance of affilia-

tions with nursing professional organizations. This membership should be
maintained for the dual purpose of providing leadership and sharing ideas
and information about health informatics in the nursing community.
r The third type of affiliation is membership in vendor-sponsored user
groups.

Multidisciplinary Professional Associations

When addressing the multidisciplinary professional affiliation, it is readily
apparent that although few nurses have achieved a high level of preparation
in nursing informatics and health informatics there is a growing cadre of
nursing colleagues with a shared interest in this field. The value of affiliating
with a multidisciplinary association lies in the scope and depth of expertise,
information, and perspective available from contact with experts in health
informatics. In the United States, the American Medical Informatics Asso-
ciation (AMIA) offers a variety of activities.
r Conducting scientific, technical, and educational meetings, one of which is
the annual AMIA fall symposium
r Publishing and disseminating digests, reports, proceedings, and other per-
tinent documents independently and in the professional literature
r Advising and coordinating functions and matters of interest to the mem-
bership
r Stimulating, sponsoring, and conducting research into the application and
evaluation of technologic systems as they apply to healthcare and medical
science
r Representing the United States in the international arena of medical sys-
tems and informatics
In 1982, the nurse members of this association formed a Nursing Profes-
sional Specialty Group (PSG) within SCAMC, the organization that later
became AMIA. This subgroup meets at the same time as the AMIA annual
meeting and the spring congress. It is also active in promoting and facilitat-
ing communication among its members between meetings. The PSG is now
known as the Nursing Informatics Working Group (NI-WG). The Mission
of NI-WG is to promote the advancement of nursing informatics within the
larger multidisciplinary context of health informatics. The organization and
its members pursue this goal in many arenas: professional practice, educa-
tion, research, governmental and other service, professional organizations,
and industry. The Working Group represents the interests of nursing in-
formatics for members in the Working Group and in AMIA and provides
member services and outreach functions.
Another valuable multidisciplinary organization is the Healthcare Infor-
mation and Management Systems Society (HIMSS). HIMSS is one of the
healthcare industry’s leading membership organizations and is exclusively
300 Professional Nursing Informatics

focused on promoting the optimal use of healthcare information technol-

ogy and management systems for the betterment of healthcare. HIMSS was
founded in 1961 and currently has offices in Chicago, Washington, DC, and
other locations across the United States. HIMSS represents more than 15,000
individual members and 220 member corporations that employ more than
1 million people. HIMSS frames and leads healthcare national public policy
and industry practices through its advocacy and educational and professional
development initiatives, which are designed to promote the contribution that
information and management systems make to ensure quality patient care.
After separating from the American Hospital Association in 1994, HIMSS
convened its first conference and exhibition as an independent organization
in Phoenix, Arizona, with 248 exhibitors and 6300 attendees. During the
past decade, this annual event has grown into a prime venue that focuses
on healthcare information and management systems. In 2004, this event at-
tracted more than 700 exhibitors and 20,000 attendees.
As the role of nursing in the design and implementation of information
systems continues to expand, HIMSS has increased its number of educational
offerings and related activities to support the needs of clinicians. During
the 1990s, seminars focusing on nursing informatics topics, such as clinical
documentation and medication management, and networking activities with
local chapters increasingly drew nurses to HIMSS membership. In 2004,
HIMSS convened its first nursing informatics symposium immediately prior
to the HIMSS annual conference and exhibition, with more than 300 nurses
attending. The 2004 HIMSS nursing informatics survey confirmed that nurses
play a critical role in clinical documentation systems, indicating that nearly
75% of the 537 respondents were currently involved in implementing these
systems. Half of the respondents were implementing computerized provider
order entry (CPOE) systems or EMR systems.
Canada’s Health Informatics Association (COACH) is a multidisciplinary
group of healthcare and information processing professionals who are active
in the area of medical informatics and healthcare computing. The purpose of
COACH is to create a forum for the exchange of ideas, concepts, and devel-
opments in the information processing field within the Canadian health-
care environment. Within this framework, COACH’s objectives are the
following.
1. To continuing dialogue among healthcare institutions, associations, and
governments relative to all health information processing applications
2. To disseminate information on applications or approaches through me-
dia such as seminars, workshops, conferences, or newsletters, thereby
providing various sectors of the healthcare system with a source of in-
formation and expertise
There is a growing cadre of nurses active in COACH.
The preceding national organizations provide membership opportuni-
ties for individuals. These organizations also have counterparts in 38 other
 The Future for Nurses in Health Informatics 301

countries. On an international level, these various national health (medical)

informatics societies constitute the membership of the International Medi-
cal Informatics Association (IMIA). IMIA is a nonpolitical, international,
scientific organization whose mandate is the open exchange of scientific in-
formation and assistance in health informatics between member countries.
IMIA defines itself as an international and world representative federation
of national societies of health informatics and affiliated organizations. IMIA
does not have individual members, although there may be several delegates
from each country as observers; each country has only one designated rep-
resentative with one vote.
The IMIA has long held the position that “the term ‘medical informatics’
is a compromise between several relevant adjectives and is considered syn-
onymous with ‘health informatics.’ ” IMIA’s prime function is educational
relative to the dissemination of knowledge of health information processing.
IMIA accomplishes its educational objectives through the following groups.
1. Triennial Medinfo conferences, which have been held in Stockholm
(1974); Toronto (1977); Tokyo (1980); Amsterdam (1983); Washington,
DC (1986); China and Singapore (1989); Geneva (1992); Canada (1995);
Seoul (1998); London (2001); and San Francisco (2004). These large con-
ferences provide an excellent review of the state of the art of medical
informatics. Information on forthcoming Medinfo conferences can be
found at their Web site, http://www.hon.ch/medinfo.
2. Working groups on special topics such as nursing, education, electrocar-
diographic processing, and confidentiality, security, and privacy.
3. Working conferences, of which more than 30 have been held in the past
15 years.
4. By far, the largest special interest group is the nursing informatics group,
which also meets every 3 years and will meet next in Seoul in 2006; in
Helsinki in 2009; and in North America in 2012.
The IMIA also represents the International Federation of Information
Processing (IFIP) in the health informatics field to such organizations as the
World Health Organization (WHO), the World Medical Association, and
at world conferences such as the Alma Ata WHO/UNICEF conferences on
primary healthcare. Finally, IMIA disseminates knowledge by means of pub-
lications, particularly the IMIA Year Book, now on a CD, and distribution
of Medinfo and working conference proceedings. Additional information is
available from the IMIA web site (http://www.imia.org).
In the fall of 1982, following an IMIA-sponsored working conference on
the impact of computers on nursing, the IMIA general assembly accepted
the proposal that an international working group on nursing be formed (see
Chapter 3). Working Group 8 provides an international focus for activity in
nursing informatics and an international core of interested and committed
people who work toward implementing IMIA objectives regarding nursing.
In 1985, the first meeting of this group was held in Calgary, Canada. The
302 Professional Nursing Informatics

working group organizes an international symposium at 3-year intervals.

Each symposium produces a volume of proceedings to provide the widest
possible distribution of the information presented at the meeting. Informa-
tion on the special interest group and its nursing informatics symposia can be
found on their Web site at http://www.gl.umbc.edu/∼abbott/nurseinfo.html.

Nursing Professional Organizations

The second type of membership that nurses interested in healthcare com-
puting should maintain is their affiliation with the nursing professional as-
sociations. The importance of this type of membership is in the obligation
of professionals to share their expertise and knowledge with colleagues.
The banding together of nurses with expertise in nursing informatics in na-
tional nursing organizations raises other members’ awareness of this aspect
of nursing. It also provides a contact point for nurses desiring to expand their
knowledge in this area.
The Canadian Nursing Informatics Association (CNIA, 2005) (http://
www.cnia.ca) is the culmination of efforts to catalyze the emergence of a
new national association of nurse informaticians. Its mission is to be the
voice for nursing informatics in Canada. The goals of CNIA are as follows.
r To provide nursing leadership for the development of nursing/health in-
formatics in Canada
r To establish national networking opportunities for nurse informaticians
r To facilitate informatics educational opportunities for all nurses in Canada
r To engage in international nursing informatics initiatives
r To act as a nursing advisory group in matters of nursing and health infor-
matics
r To expand awareness of nursing informatics to all nurses and the health-
care community
CNIA is associated with COACH through a strategic alliance that enables
CNIA to represent Canadian nurses in the IMIA Nursing Informatics Work-
ing Group (see below). CNIA also holds affiliate group status with the
Canadian Nurses Association.
Another example of this second type of organization is CARING—also
known as the Capital Area Roundtable on Informatics in Nursing. CARING
has been based in the Washington, DC area for more than 22 years. It is
the most geographically dispersed national nursing informatics group, with
nearly 1000 members in 50 states and 16 countries, and is active in promoting
education, networking, and job opportunities (Newbold, 2004).
Recently CARING and 17 other organizations formed the Alliance in
Nursing Informatics. This group is now developing its mission and objectives
and will unite the various nursing informatics groups in the United States. It
is planned that the focus is to be on political and research activities, which
are underserved by the other individual groups.
 The Future for Nurses in Health Informatics 303

The Nursing Informatics Collaboration Task Force (NICTF) was recently

convened to provide a forum for regional and national nursing informatics
groups that are working together to guide the design and lead the implemen-
tation of clinical systems. The task force was formed through the efforts of the
Nursing Informatics Working Group of the AMIA, the professional nurses
represented by the HIMSS, and the ANA. The NICTF, in one of its first joint
efforts, provided testimony to the President’s Information Technology Advi-
sory Committee (PITAC) during an open meeting on April 13, 2004. Nurses
represent the largest group of organized professionals in healthcare in the
United States. Nurse informaticists are fulfilling a critical role in creating an
effective healthcare information infrastructure, developing clinical nursing
documentation and information systems, developing research agendas, and
educating others in nursing informatics. The NICTF continues to expand
its scope of activities following successful initiatives such as the nursing in-
formatics symposium at Medinfo 2004 and participation in the 2005 annual
HIMSS conference and exhibition.

Vendor-Sponsored User Groups

Practically all major vendors of software applications for healthcare encour-
age and support the establishment of formal organizations for users of their
products. This type of affiliation facilitates the exchange of ideas and ap-
proaches among users of similar software applications. This practice also
prevents duplication of effort related to experience with use of a particular
software application. It also provides a forum for users to communicate with
the vendor about changes or upgrades to the software. All of the major ven-
dors vendor have such a group, such as Eclipsys Users Group with emphasis
on Nursing (EUN), Cerner, and Siemens.

Summary
Nurses find professional organizations valuable for the positive impact they
provide on the information processing aspects of their profession. Partici-
pation in three types of organizations—multidisciplinary, nursing, vendor-
sponsored—is highly recommended.
This chapter considered the trend toward new roles for nurses as a result
of the widespread use of computer-based enterprise health information sys-
tems. Without question, new roles for nurses will continue to develop. At
the same time, the current role of the nurse is changing. The survival and ad-
vancement of the profession, however, depend on nurses abandoning their
previous professional stance of passive reaction and adopting a new antici-
patory, proactive position. Nursing must be prepared to exploit information
technology fully and to participate actively in information management to
advance the practice of nursing.
304 Professional Nursing Informatics

References
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pp. 320–330.
Appendices
Appendix A
Generic Request for Proposal
We are pleased to offer the Request for Proposal in electronic format on the publisher’s
Web site, which can be found at http: //springeronline.com/0-387-26096-X.

XYZ Health Services

REQUEST FOR PROPOSAL

For an

Advanced Clinical Information System

Date

NOTE: Proposal Submittal Deadline: XYZ P.M., mm/dd/yyyy

307
308 Appendix A: Generic Request for Proposal

Table of Contents

I. EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . 5

II. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
A. OBJECTIVE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
B. GENERAL INFORMATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
C. RFP INSTRUCTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
III. RESPONDENT BACKGROUND INFORMATION . . . . 12
A. Company Profile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
B. Design/Development Philosophy . . . . . . . . . . . . . . . . . . . . . . . . 13
C. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
D. General Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
IV. XYZ’S ESSENTIAL REQUIREMENTS AND
EXPECTATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
A. Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
B. Specific Solution Descriptions . . . . . . . . . . . . . . . . . . . . . . . . . . 18
V. PROPOSED SOLUTION . . . . . . . . . . . . . . . . . . . . . . 38
A. Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
B. Infrastructure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
C. Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
VI. TECHNICAL REQUIREMENTS . . . . . . . . . . . . . . . . 40
A. Compliance with Regulations and Industry Standards . . 40
B. Applications and Integration . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
C. Support and Problem Escalation . . . . . . . . . . . . . . . . . . . . . . . . 41
D. Business Continuity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
VII. ACIS IMPLEMENTATION . . . . . . . . . . . . . . . . . . . . . 43
A. Program Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
VIII. XYZ CONCEPT CENTER . . . . . . . . . . . . . . . . . . . . . 45

IX. COSTS/PRICE QUOTATION . . . . . . . . . . . . . . . . . . . 46

XI. APPENDIX A: OVERVIEW OF XYZ . . . . . . . . . . . . . 49

A. Core Business . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
B. Mission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
C. Vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
D. Values. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
 Appendix A: Generic Request for Proposal 309

E. Volumes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
F. Overview of XYZ ACISs Environment . . . . . . . . . . . . . . . . . . 50
G. Overview of Associated Information Systems
Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
H. Overview of Information Services . . . . . . . . . . . . . . . . . . . . . . . 51
XII. APPENDIX B: XYZ SYSTEM SELECTION CRITERIA . 52

XIII. APPENDIX C: APPLICATIONS AND INTEGRATION

TABLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

XIV. APPENDIX D: XYZ CONCEPT CENTER

REQUIREMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . 67
A. Goals and Objectives for the XYZ Concept Center . . . . 67
B. Assumptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
C. Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
D. Timeframe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
E. Vendor Deliverables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
F. Evaluation Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
XV. APPENDIX E: XYZ CONCEPT CENTER
INTERFACES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

XVI. APPENDIX F: CONTRACTUAL REQUIREMENTS . . . 75

A. Principles to be addressed in the Contract . . . . . . . . . . . . . 75
B. Specific Terms to be Included in the Contract . . . . . . . . . . 77
XVII. APPENDIX G: DEMONSTRATION SCRIPTS . . . . . . . 90

XVIII. APPENDIX H: GLOSSARY OF TERMS . . . . . . . . . . . 91

Appendix B
Nursing Informatics Special
Interest Groups
Susan K. Newbold

Alliance for Nursing Informatics Brasilian Nursing

Area: United States Association Nursing Informatics
Contact: Connie J Delaney Group at Brazilian Nursing
([email protected]) or Association (GEINE)
Joyce Sensmeier Contact: Heimar F. Marin
([email protected]) ([email protected]) or
Christine Cunha
American Medical Informatics ([email protected])
Association (AMIA)
4915 St Elmo Avenue, Suite 401 British Computer Society Nursing
Bethesda, MD 20814 USA Specialist Group
1-301-657-1291 (See also NPIG)
[email protected] (www.bcsnsg.org.uk)
Editor ITIN
American Medical Informatics ([email protected]). Also
Association (AMIA) Nursing [email protected]
Informatics Working Group
(www.amia.org/working/ni/
Canadian Nursing Informatics
main.html)
Association (CNIA)
www.cnia.ca
American Nursing Informatics
Association (ANIA)
(www.ania.org) Capital Area Roundtable on
Informatics in Nursing
Australian Nursing Informatics (CARING)
Special Interest Group www.caringonline.org
Health Informatics Society
Australia, Inc. European Federation for Medical
413 Lygon Street Informatics–WG 5 Nursing
East Brunswick, VIC Australia 3057 Informatics in Europe
61-3-9388-0555, 61-3-9388-2086 (fax) www.nicecomputing.ch/nieurope/
[email protected] index.htm

310
 Appendix B: Nursing Informatics Special Interest Groups 311

Patrick Weber, Chair, IMIA IMIA NI Education Working

representative (patrick.weber@ Group (http://welcome.to/imia-ni-
nicecomputing.ch) education)
Paula M Procter, Vice Chair
([email protected]) IMIA-SIG-NI WG on Open
Denise Barnett, Secretary Source Nursing Informatics
(101630.2751@compuserve (www.osni.info/html/index.php)
.com)

National League for Nursing

Health Informatics New Zealand 61 Broadway, New York, NY 10006,
(HINZ) USA
www.hinz.org.nz 1-800-669-1656, 1-212-363-5555
PO Box 32 515 [email protected]
Devonport, Auckland, NZ
[email protected]
Chairperson National League for Nursing (NLN)
([email protected]) Nursing Educational Technology
Administration manager Information Management
([email protected]) Advisory Council
(ETIMAC)
http://www.nln.org/aboutnln/
Healthcare Informatics Society of AdvisoryCouncils TaskGroups/
Ireland Nursing Special Interest etimac.htm
Group
www.hisi.ie/html/nursing.htm
NURSINFO Hong Kong
Helen Sit Wing-Fun
Health Information and ([email protected])
Management Systems Society
(HIMSS)
Nursing Informatics Special Interest
HIMSS
Group of the GMDS
230 East Ohio, Suite 600
The German Association of
Chicago, IL 60611, USA
Medical Informatics, Biometry,
1-312-664-4467 (tel); 1-312-664-6143
and Epidemiology [Deutsche
(fax)
Gesellschaft fuer Medizinische
[email protected]
Informatik, Biometrie und
See www.himss.org for the
Epidemiologie
41 chapters (www.himss.org/asp/
(GMDS)]
chapters.asp)
Matthias Hinz, Vice Chairman of
the NI SIG
International Medical Informatics Institute for Medical Informatics
Association (IMIA) Special Fetscherstrasse 74
Interest Group on Nursing D-01307 Dresden,
Informatics (SIGNI) Germany [email protected].
(www.imia.org/ni/index.html) tu-dresden.de
312 Appendix B: Nursing Informatics Special Interest Groups

Nursing Professions Informatics Spanish Society of Nursing

Group (NPIG) Informatics and Internet (SEEI)
United Kingdom
www.nhsia.nhs.uk/npig/ http://www.seei.es
[email protected]
Perinatal Information Systems
User Group (PISUG) Swiss Special Interest Group
International Nursing Informatics (SIG-NI)
Debbie Aiton, PISUG President Patrick Van Gele
([email protected]) ([email protected])
Appendix C
Sources of Additional Healthcare
Informatics Information

Books and Internet

American Nurses Association. (2001). Scope and Standards of Nursing
Informatics Practice. Washington, DC: ANA.

Androwich, I.M., Bickford, C.J., & Button, P.S. et al. (2003). Clinical Infor-
mation Systems: A Framework for Reaching the Vision. Washington, DC:
American Nurses Association.

American Nurses Association. (2005) Informatics Certification Exam-

ination Information (www.nursingworld.org/ancc/certification/cert/exams/
TCOs/BSN27 Infor TCO.html).

Ball, M.J., Hannah, K.J., Newbold, S.K., & Douglas, J.V. (eds) (2000). Nurs-
ing Informatics: Where caring and technology meet, 3rd ed. New York:
Springer. See the entire series of Healthcare Informatics books by Springer.
(www.springeronline.com).

Womack, D., Newbold, S.K., Staugaitis, H., & Cunningham, B. (2004). Tech-
nology’s role in addressing the nursing shortage: innovations and examples.
(http://maryland.nursetech.com/F/NT/MD/NursingInnovations2004.pdf).

Journals and Magazines

Advance for Health Informatics Tel. 800-355-5627
Executives [email protected]
ADVANCE Newsmagazines/
Merion Publications, Inc. Advance for Health Information
2900 Horizon Drive Professionals
King of Prussia, ADVANCE Newsmagazines/
PA 19406 Merion Publications, Inc.

313
314 Appendix C: Sources of Additional Healthcare Informatics Information

2900 Horizon Drive JHIM: Journal of Healthcare

King of Prussia, PA 19406 Information Management
Tel. 800-355-5627 230 East Ohio Street, Suite 500
[email protected] Chicago, IL 60611-3269
Tel. 312-664-4467; Fax 312-664-6143
The British Journal of Healthcare www.himss.org
Computing & Information
Management
Tel. +44 1932 821723; Healthcare Informatics
Fax +44 1932 820305 4530 West 77th Street, Suite 300
[email protected]. Minneapolis, MN 55435
co.uk Tel. 612-835-3222

CIN: Computers Informatics in Health Data Management

Nursing 118 South Clinton Street, Suite 700
Lippincott Williams & Wilkins Chicago, IL 60661-3628
PO Box 1620 Tel. 312-648-0261
Hagerstown MD 21741
Tel. 1-800-638-3030 or
1-301-223-2300 Health Management Technology
Nelson Publishing/Health
Health Informatics Journal Management Technology
Sage Publications 2500 Tamiami Trail North
2455 Teller Road Nokomis, FL 34275
Thousand Oaks, CA 91320 Tel. 941-966-9521
Tel. 805-499-9774 or 800-818-7243;
Fax 805-499-0871 or 800-583-2665
Hospitals & Health Networks
Journal of AHIMA 737 North Michigan Avenue
233 N. Michigan Avenue, Suite 2150 Chicago, IL 60611-2615
Chicago, IL 60601-5800 Tel. 312-440-6800
Tel. (312) 233-1100 http://www.hhnmag.com/hhnmag/
[email protected] index.jsp

Journal of the American Medical Modern Healthcare

Informatics Association (JAMIA) 360 N. Michigan Avenue, 5th Floor
Hanley & Belfus, Inc. Chicago, IL 60601-3806
Customer Services Department Tel. 312-649-5350 or
6277 Sea Harbor Drive 312-649-5297
Orlando, FL 32887-4800
Tel. 800 654-2452 Toll-free (U.S.
and Canada); 407-345-4000 Nursing Education Perspectives
(outside the U.S. and Canada); 61 Broadway
407-363-9661 New York, NY 10006
[email protected] Tel. 800-669-1656 or 212-363-5555
 Appendix C: Sources of Additional Healthcare Informatics Information 315

Nursing Economic$ Nursing Management

Anthony J. Jannetti, Inc. Lippincott Williams & Wilkins
East Holly Avenue, Box 56 PO Box 1620
Pitman, NJ 08071-0056 Hagerstown, MD 21741
Tel. 856-256-2300; Tel. 1-800-638-3030 or
Fax 856-589-7463 1-301-223-2300
Appendix D
Professional Societies

American Academy of Nursing Canadian Organization for the

555 East Wells Street, 11th Floor Advancement of Computers in
Milwaukee, WI 53202-3823 Health (COACH)
Tel. 414-287-0289; Fax 414-276-3349 2 Carlton Street, Suite 1304
[email protected] Toronto, Ontario M5B 1J3, Canada
Tel. 416-979-5551
American Association of Colleges http://www.coachorg.com
of Nursing
One Dupont Circle NW, Suite 530 Healthcare Information and
Washington, DC 20036 Management Systems Society
Tel. 202-463-6930 (HIMSS)
http://www.aacn.nche.edu 230 East Ohio Street, Suite 600
Chicago, IL 60611-3201
American Medical Informatics Tel. 312-664-44677
Association (AMIA) http://www.himss.org
Nursing Informatics Working
Group
4915 St. Elmo Avenue, Suite 401 IEEE Computer Society
Bethesda, MD 20814 1730 Massachusetts Avenue NW
Tel. 301-657-1291 Washington, DC 20036
http://www.amia.org Tel. 202-371-0101
http://www.iccad.com/ieee.html or
http://www.computer.org/
American Nurses Association
Council on Nursing Services and
Informatics International Medical Informatics
America Nurses Association Association (IMIA)
600 Maryland Avenue, Nursing Informatics Special Interest
Suite 100 West, SW Group
Washington, DC 20024-2571 Ulla Gerdin, RN, Chair
Tel. 202-651-7000 Swedish Institute for Health
http://www.ana.org Services Development (SPRI)

316
 Appendix D: Professional Societies 317

Box 70487 Bethesda, MD 20892-2178

Stockholm, Sweden http://www.nih.gov/ninr/
Tel. 011-46-8-702-4600
[email protected] National League for Nursing
http://www.imia.org Council on Nursing Informatics
National League for Nursing
Medical Group Management 61 Broadway
Association New York, NY 10006
104 Inverness Terrace East Tel. 800-669-1656 or 212-363-5555
Englewood, CO 80112 http://www.nln.org
Tel. 303-799-1111 nlninform@n/n.org
http://www.mgma.com
Sigma Theta Tau International
Honor Society of Nursing
Midwest Nursing Research 550 West North Street
Society (MNRS) Indianapolis, IN 46202
10200 W. 44th Avenue, Suite 304 Tel. 317-634-8171
Wheat Ridge, CO 80033 http://www.nursingsociety.org/
Tel. 720-898-4831
http://www.mnrs.org/ Society for Medical Decision
Making
National Institute of Nursing 1211 Locust Street
Research Philadelphia, PA 19107
31 Center Drive, Room 5B09, Tel. 215-545-7697; Fax 215-545-8107
MSC 2178 http://www.smdm.org
Appendix E
Academic Informatics
Programs Worldwide

Programs in the United States

Arizona School of Health Sciences (Mesa, Arizona)

Centers for Disease Control (Atlanta, GA)

Public Health Informatics Fellowship Program (Epidemiology Program
Office)

Cleveland Clinic (Cleveland, OH)

Medical Informatics Fellowship (Division of Medicine/ Department of
General Internal Medicine)

College of St. Scholastica (Duluth, MN)

Health Informatics

Columbia University (New York, NY)

Dental Informatics, School of Dental and Oral Surgery

Columbia University (New York, NY)

Medical Informatics (Graduate School of Arts and Sciences)

Dalhousie University (Halifax, Nova Scotia, Canada)

Drexel University (Philadelphia, PA)

Institute for Healthcare Informatics (College of Information Science and
Technology)

Duke University (Durham, NC)

Clinical Informatics (Department of Community and Family Medicine,
Division of Medical Informatics)

318
 Appendix E: Academic Informatics Programs Worldwide 319

Duke University (Durham, NC)

Nursing Informatics (School of Nursing)

East Carolina University (Greenville, NC)

The Brody School of Medicine, Telemedicine Center, Advanced
Telemedicine Training

Eastern University (St. Davids, PA)

School of Professional Studies, Nursing Informatics Certificate Program

Emory University (Atlanta, GA)

Department of Biostatistics, MSPH Program in Public Health Informatics

Excelsior College (Albany, NY)

Clinical Systems Management/Healthcare Informatics (Graduate and
Certificate Programs in Nursing and Allied Health)

George Mason University (Fairfax, VA)

School of Computational Sciences (Bioinformatics Programs)

George Washington University Medical Center (Washington, DC)

School of Public Health and Health Services

∗
Harvard Medical School (Boston, MA)
Center for Clinical Computing, Beth Israel Deaconess Medical Center;
Brigham & Women’s Hospital/Harvard Medical School, Decision
Systems Group, Brigham and Women’s Hospital; Massachusetts
General Hospital/ Harvard Medical School, Laboratory of Computer
Science, Massachusetts General Hospital

Indiana University
Indianapolis, IN
School of Informatics-Bioinformatics/Chemical Informatics/
Human-Computer Interaction

∗ Harvard-MIT-NEMC Research Training Program,

Joint Division of Health Sciences & Technology:

Decision Systems Group, Brigham and Women’s Hospital
Children’s Hospital Informatics Program, Childrens Hospital Medical Center
Center for Clinical Computing, Beth Israel Deaconess Medical Center
Laboratory of Computer Science, Massachusetts General Hospital
Division of Clinical Decision Making, Informatics and Telemedicine, New England
Medical Center
Medical Computer Science, Massachusetts Institute of Technology
320 Appendix E: Academic Informatics Programs Worldwide

Massachusetts Institute of Technology (Cambridge, MA)

Clinical Decision Making Group
Laboratory for Computer Science/Harvard-MIT Division of Health
Sciences and Technology

Medical College of Wisconsin and the Milwaukee School of Engineering

(Milwaukee, WI)
Medical Informatics

Montana Tech/University of Montana (Butte, Montana)

Medical Informatics
College of Math and Sciences

Mount Sinai-NYU Health System (New York, NY)

Medical Informatics
Division of Clinical Informatics Mount Sinai-NYU Health System IT and
Center for Medical Informatics, Department of Medicine, Mount Sinai

National Library of Medicine (Bethesda, MD)

Medical Informatics Training Program
Lister Hill National Center for Biomedical Communications

New England Medical Center/Tufts University (Boston, MA)

Division of Clinical Decision Making, Informatics, and Telemedicine,
Department of Medicine

New York University (New York, NY)

Nursing Informatics
Division of Nursing

Oregon Health and Science University (Portland, OR)

Department of Medical Informatics & Clinical Epidemiology, School of
Medicine and Biomedical Information Communications Center

Philadelphia VA Center for Health Equity Research and Promotion

(CHERP) (Philadelphia, PA)
Medical Informatics Fellowship

Regenstrief Institute for Healthcare (Indianapolis, IN)

Medical Informatics Fellowship
Indiana University School of Medicine

Saint Louis University (St. Louis, MO)

Nursing Informatics
School of Nursing
 Appendix E: Academic Informatics Programs Worldwide 321

Stanford University (Stanford, CA)

Stanford Medical Informatics
School of Medicine

State University of New York (Brooklyn, NY)

Medical Informatics

University of Alabama at Birmingham (Birmingham, AL)

Health Informatics Program
Department of Health Services Administration

University of Arizona (Tucson, AZ)

Systems Management/Informatics
College of Nursing

University of California–Davis (Davis, CA)

Medical Informatics
School of Medicine

University of California–Irvine (Irvine, CA)

Informatics in Biology and Medicine
Department of Information & Computer Science

University of California–San Francisco (San Francisco, CA)

Biological and Medical Informatics

University of Colorado Health Sciences Center (Denver, CO)

Healthcare Informatics
School of Nursing

University of Illinois at Chicago (Chicago, IL)

Biomedical and Health Information Sciences
College of Applied Health Sciences

University of Illinois at Chicago (Chicago, IL)

School of Public Health

University of Iowa (Iowa City, IA)

Nursing Informatics
College of Nursing

University of Maryland (Baltimore, MD)

Nursing Informatics
School of Nursing
322 Appendix E: Academic Informatics Programs Worldwide

University of Medicine and Dentistry in New Jersey (Newark, NJ)

Biomedical Informatics
School of Health Related Professions

University of Miami (Miami, FL)

Medical Informatics

University of Michigan (Ann Arbor, MI)

School of Dentistry

University of Michigan Health Center (Ann Arbor, MI)

Department of Pharmacy Services

University of Minnesota (Minneapolis, MN)

Health Informatics
Division of Health Computer Sciences

University of Missouri (Columbia, MO)

Health Management and Informatics
School of Medicine

University of Nebraska Medical Center (Omaha, NE)

College of Nursing

University of New Mexico (Albuquerque, NM)

Health Sciences Library and Informatics Center

University of North Carolina (Chapel Hill, NC)

Division of Medical Computing and Informatics
School of Medicine, Biomedical Engineering

University of Pittsburgh (Pittsburgh, PA)

Pittsburgh Biomedical Informatics Training Program
Nursing Informatics
Dental Informatics

University of South Florida (Tampa, FL)

College of Nursing

University of Texas Houston Health Science Center (Houston, TX)

Health Informatics
School of Health Information Sciences

University of Utah (Salt Lake City, UT)

Department of Medical Informatics, School of Medicine
 Appendix E: Academic Informatics Programs Worldwide 323

University of Utah (Salt Lake City, UT)

Clinical Informatics
College of Nursing

University of Victoria (Victoria, BC, Canada)

Health Information Science
School of Health Information Science

University of Virginia (Charlottesville, VA)

Health Evaluation Sciences

University of Washington (Seattle, WA)

Department of Medical Education and Biomedical Informatics, Division of
Biomedical & Health Informatics

University of Wisconsin (Madison, WI)

Department of Biostatistics & Medical Informatics
Medical School

Vanderbilt University (Nashville, TN)

Bioinformatics Programming
Vanderbilt University Medical Center

Yale University (New Haven, CT)

Center for Medical Informatics, School of Medicine

Programs Outside the United States

Australia
University of New South Wales
Sydney, Australia
Master of Health Informatics
Degrees available: Masters (available from 2004), PhD in Health
Informatics

University of Tasmania
Launceston, Australia
Department of Rural Health
Graduate program in E-Health (Health Informatics)
Degrees available: graduate certificate, graduate diploma

University of Wollongong
Wollongong NSW, Australia
Master of Health Informatics
324 Appendix E: Academic Informatics Programs Worldwide

Austria
University for Health Informatics and Technology Tyrol (UMIT)
Innsbruck, Austria
Medical Informatics
Degrees available: BSc in Medical Informatics, MSc in Medical
Informatics, PhD in Medical Informatics

Brazil
Marilia Medical School
Marilla, Estate of Sao Paulo, Brazil Medical course:
undergraduate

Universidade Federal de Pernambuco (UFPE)

Grupo de Tecnologias da Informação em Saúde (TIS)
Health Information Technology Group
Recife-PE, Brazil
Undergraduate course: lessons for the medical course and others
health courses
Postgraduate courses: internal medicine master’s program, informatics
master’s program

Canada
Dalhousie University
Halifax, Nova Scotia, Canada
Degree available: Master of Science (MSc)

University of Victoria
Victoria, British Columbia, Canada
Health Information Science
Degrees available: Bachelor of Science (BSc), Master of Science (MSc),
PhD (by special arrangement)

University of Waterloo
Waterloo, Ontario, Canada
Education Program for Health Informatics Professionals (EPHIP)
Certificate program: online/distance education programs

Cuba
Instituto Superior de Ciencias Médicas de La Habana (ISCM-H)
La Habana, Cuba
Degree available: Master’s in Health Informatics
 Appendix E: Academic Informatics Programs Worldwide 325

Germany
Georg-August-University Goettingen
Applied Informatics/Health Information Officer
Goettingen, Germany
Degrees available: BSc, MSc in Medical Informatics
University of Essen
Essen, Germany
Medizin-Management with Informatics specialization
Degrees Available: Bachelor of Arts (BA), Master’s (soon)
University at Leipzig/Germany
Leipzig, Germany
Institute for Formal Ontology and Medical Informationscience (IFOMIS)

Greece
National and Kapodistrian University of Athens
Athens, Greece
Health Informatics
Degrees available: Master of Science (MSc), Doctorate (PhD)

Ireland
Trinity College Dublin
Dublin, Ireland
Degree available: MSc in Health Informatics

The Netherlands
University of Amsterdam
Amsterdam, The Netherlands
Medical Information Sciences
Degrees available: Bachelor’s and Master’s

Peru
Instituto de Medicine Tropical Alexander Von Humbold
Universidad Peruana Cayetano Heredai
Lima, Peru
Specialized programs: Health Informatics, Telemedicine, Artificial
Intelligence
326 Appendix E: Academic Informatics Programs Worldwide

United Kingdom
Centre for Health Informatics and Multiprofessional Education (CHIME)
London, UK
Degrees available: MPhil, PhD available by research in this area

Imperial College
London, United Kingdom
Degrees available: MSc in Health Informatics and Management

King Alfred’s Winchester

Winchester, UK
Degrees available: Master of Science (MSc)

University College London

London, UK
Degrees available: Master of Science (MSc); diploma and certificate
programs in health informatics; Graduate program (3 exit points); PG
certificate; PG diploma; MSc

University of Edinburgh
Edinburgh, UK
School of Informatics, Specialism in Bioinformatics
Degrees available: Master of Science (MSc), Master’s (Mres),
Doctorate (PhD)

University of Sheffield
Sheffield, UK
Degrees available: certificate diploma, Master of Science (MSc), MPhil and
PhD available by research in this area

University of Wales Swansea

Swansea, Wales, UK
School of Health Science, Centre for eHealth and Learning
Appendix F
Transforming Clinical
Documentation:
Preparing Nursing for Change
Linda Dietrich

Preplanning for Nurse Executives

r Changing an existing documentation system requires careful and deliber-
ate planning.
r The following points must be considered when an organization changes its
system. It is important to ask: What are the reasons we are changing the
documentation system?
1. The need to improve the quality of nursing documentation requires
not only new or revised tools but also new ways of thinking. What
is written contains the judgment of the writer, including analysis and
evaluation.
2. The need to reduce the amount of time in charting is critical. A chart-
ing approach that reduces the amount of time spent on charting is
essential.
3. The need to contain costs requires nurses to reexamine their doc-
umentation practices and be more efficient as well as improve any
reimbursement issues related to documentation.
4. The need to reduce duplication is essential.
5. The emphasis on multidisciplinary care is vital, as is and the need to
ensure that patients are not asked the same questions by different
providers.
6. Increasing emphasis on patient outcomes has necessitated a change
in the content of nursing documentation. Care planning has taken
on many forms, focusing on critical paths, care maps, and clinical
pathways.
r Before making any changes in a documentation system you must first
determine the desired outcome. Deciding on the desired outcome of
the change directs the planning and implementation process. In addi-
tion to the above reasons to consider, the following are outcomes to

327
328 Appendix F: Transforming Clinical Documentation

consider in conjunction with the reasons to change a documentation

system.

Outcomes
1. The chart is legally sound.
2. The chart reflects the nursing process.
3. The chart describes the patient’s ongoing status from shift to shift.
4. The plan of care and chart complement each other.
5. The documentation system is designed to facilitate retrieval of informa-
tion for qualitively improving activities and research.
6. The documentation system supports the staffing mix and acuity levels in
the current healthcare setting.
r The purpose of nursing documentation is to provide evidence that all es-
tablished standards have been met. It is incumbent upon those preparing
and establishing documentation systems to see that it meets statutory,
regulatory, and common law as well as voluntary standards.
r Certain sources that should be consulted when designing any nursing
documentation system.

1. Legal requirements
Code of Federal Regulations
State nurse practice acts
State administrative codes
Municipal codes
Case law
Agency legal counsel
2. Accreditation standards
Joint Commission on Accreditation of Healthcare Organizations
Federal health insurance program (Medicare)
State health insurance program (Medicaid)
Third party payers (HMOs, private insurance)
Peer review organizations
Federal grant agencies
3. Professional standards
Nursing—A Social Policy Statement
American Nurses Association—Standards of Clinical Nursing Practice
(latest edition)
National Specialty nursing associations standards of practice
ANA Code for Nurses
Professional literature
National practice guidelines (AHCPR)
4. Institutional requirements
Policies and procedures
 Appendix F: Transforming Clinical Documentation 329

Issues Surrounding Standardized Languages:

Definition of Terms
Classification: a systematic arrangement of classes; a structural framework
arranged according to similar groups
Database: A collection of interrelated files with records organized and stored
together in a computer system
Data set: A collection of related data items; a directory
Data element: the smallest unit of data that has meaning without interpre-
tation; a raw fact, material, or observation.
Language: in computing and communications, a set of characters (symbols,
alphabets, codes, syntax), conventions, and rules used to convey ideas and
information
Nomenclature and vocabulary: a consistent method for assigning names to
elements of a system
Nursing minimum data set: an essential set of information items that have
uniform definitions and categories concerned with nursing. Its purpose
is to meet the informational needs of nurses in any care delivery set-
ting through the healthcare system as well as other professionals and re-
searchers.
Taxonomy: a method for classifying a vocabulary of terms for a specific topic
according to specific laws or principles
Regarding standardized languages of NIC (interventions), NOC (out-
comes), NANDA (diagnoses), and SNOMED. Remember that all of these
are nomenclatures. They are not evidence-based standards that drive care.
They are not documentation systems. They are not plans of care. They con-
tribute to how you decide to orchestrate these elements in your plan of care
for patients. They are not acuity systems or staff assignment systems.
There are other nomenclature initiatives (both nursing-related and non-
nursing-related) that are not listed here. One example is the electronic health
records (EHR) functional standards initiative, currently being led by the
EHR Technical Committee (EHRTC). The goal of this initiative is to fur-
ther the HL7 mission of designing standards that support the exchange of
information for clinical decisions and treatments and to help lay the ground-
work for nationwide interoperability by providing common language pa-
rameters that can be used to develop systems that support electronic records
(http://www.hl7.org/EHR/).

General Questions for a “Preparing for Planning” Session

1. Scope—How many people and what areas/organizations do they repre-
sent?
2. What are your objectives in convening this group?
330 Appendix F: Transforming Clinical Documentation

3. What are the outcomes you want to achieve at the end of this meeting?
4. Can a meeting be set up with the participants ahead of time to discuss
briefly their expectations about the outcomes of the planning meeting
and where they are currently with their thinking?
5. How many types of information systems (estimate) are in place already?
6. How many are undergoing a selection process?
7. Is your organization’s clinical documentation system a necessary evil or
a strategic asset?
8. Philosophy of management—Do any of these organizations have shared
decision-making models in place?
9. What types of documentation systems are currently in place in these
organizations? Narrative, charting by exception, critical paths, standard-
ized care plans, collaborative protocols?
10. Reasons and outcomes—Are any of these more compelling than oth-
ers? For example, many states want reports on nurse–patient ratios.
Is this something you would expect from a nursing documentation
system?
11. What are the learning needs of the group? Do you want them to do some
prereading ahead of time? Can we do a quick learning needs assessment
regarding their understanding of information technology and how it re-
lates to patient care processes? Do you want them to develop a shared
understanding of, for example:
Information technology in healthcare—past and present high level
Electronic health record—what is it, future considerations
Clinical information systems

Thoughts on Clinical Documentation Automation for

Leaders and Executives
Many executives talk about the potential benefits of automating clinical doc-
umentation. Frequently, the discussion is focused on calculating savings from
reducing paper usage or reducing overtime. This approach does not take into
account the breadth of benefits that automation can bring to healthcare or-
ganizations. Examples include the following.

r Prevention of complications
r Interdisciplinary integration at point of care
r Evidence-based practice patterns
r No duplications and repetitions
r Better patient outcomes
r Increased clinician job satisfaction
r Improved clinician recruitment and retention rates
r Decreased nursing overtime
r Fewer coding errors and omissions
 Appendix F: Transforming Clinical Documentation 331

Guidelines for Success

Lead the Charge and Stay Involved
If you believe in the quality, satisfaction, and financial benefits of automating
clinical documentation, you must lead the implementation effort and stay
involved in the process to the end. Staying involved is important because it
takes a lot of time and effort to automate an clinical documentation system
in the right way. Do not let the process slow down or stray from the stated
goals.

State Your Goals Clearly

Your goals for automation should be aligned with your organization’s strate-
gic goals to ensure that everyone in your organization is pulling in the same
direction. State your organization’s goals for automation clearly, so you can
recognize success when the goals are achieved.

r Would you like to prevent complications and reduce variability?

r Stop duplication and redundancy?
r Increase clinician retention?
r Improve patient outcomes?
r Reduce nursing overtime?
r All of the above?

Make Sure Your Clinicians Own the System

The clinicians must drive automation of clinical documentation because they
are the ones who will use it. The new system must improve their lives and
reflect their needs and priorities, not those of the IT department. The clini-
cians are the customers. Challenge them to develop a system that improves
documentation and thereby improves patient care outcomes, professional
growth, and the caregivers’ work lives. Do not let them automate the way
they have “always done it” simply to stay within their comfort zone.

Choose the Right Vendor

Select a vendor whose systems support your organization’s goals for au-
tomation. If your focus is acute care, choose a vendor that has developed
systems for acute care units. Make sure the vendor’s software functionality
aligns with your goals. Your clinicians should be the focus—and have a major
say—in selecting a vendor. Find a vendor who will be your partner.
332 Appendix F: Transforming Clinical Documentation

An Enterprise-Wide or Departmental Solution

r Have you considered an enterprise-wide clinical information system that
can be customized to meet departmental needs?
r Will departments be allowed to purchase department-specific systems?
r Most enterprise clinical information systems have an integrated “core”
component consisting of physician order entry, clinical documentation,
and a medication administration record. These elements may cover most
of the clinical information system requirements, but some departments
(e.g., obstetrics) have distinctive needs related to their particular devices
and to the integration of data from these devices into a patient’s record.

References
American Nurses Association. (2004). Nursing: Scope and Standards of Practice.
Washington, D.C.: Nursebooks.org.
Burke, L.J., & Murphy, J. (1995). Charting by Exception Applications: Making It
Work in Clinical Settings. Albany, N.Y.: Delmar, pp. 12203–5015.
Belmont, C., Wesorick, B., Jesse, H., Troseth, M., & Brown, D. (2003). Clinical Doc-
umentation. www.HCTProject.com.
Appendix G
Research Databases of
Interest to Nurses
With the assistance of Helen Lee Robertson
and Lorraine Toews

ACP Journal Club (1991–present)

r More than 1100 structured abstracts of individual published articles from
core clinical journals with expert commentary on clinical relevance of study
r Covers internal medicine, psychiatry, obstetrics/gynecology, pediatrics,
surgery, family medicine, public health
r Electronic equivalent to print journals ACP Journal Club and Evidence-
Based Medicine
AgeLINE (1978–present)
r Bibliographic references and abstracts related to aging and middle age
from interdisciplinary perspectives of psychology, economics, sociology,
gerontology, public policy, business, health and healthcare services, con-
sumer issues
r Journal articles, books, book chapters, reports, government documents
r Journal coverage includes research, professional and general interest titles
r Available at no charge from http://research.aarp.org/ageline/home.html

Alt-Health Watch (1990–present)

r Focuses on the many perspectives of complementary, holistic, and inte-
grated approaches to healthcare and wellness
r Provides full text for articles from more than 140 international and often
peer-reviewed journals, reports, and proceedings, as well as association
and consumer newsletters
r Also includes pamphlets, booklets, special reports, original research, and
book excerpts
AMED (Allied and Complementary Medicine Database) (1985–present)
r Bibliographic citations and abstracts covering journals in complementary
medicine, physiotherapy, occupational therapy, rehabilitation, podiatry,
palliative care
r Produced by the Healthcare Information Service of the British Library

333
334 Appendix G: Research Databases of Interest to Nurses

r Each record includes controlled indexing terms using the AMED The-
saurus based on MeSH (MEDLINE indexing terms)
BioMed Central (2001–present)
r An independent publishing house committed to providing immediate free
access to peer-reviewed biomedical research with all research articles
in journals published by BioMed Central immediately and permanently
available on-line without charge
r More than 100 searchable peer reviewed research journals covering gen-
eral to specialist biomedical sciences, including nursing
r Available at no charge from http://www.biomedcentral.com/
CINAHL (Cumulative Index to Nursing & Allied Health) (1982–present)
r Covers the literature related to nursing and allied health
r Indexes most English-language nursing publications, primary journals in
allied health fields and selected consumer health, and biomedicine journals
r Journal articles, book chapters, dissertations, proceedings, standards of
practice
r Most of CINAHL’s 11,000 subject headings adapted from MEDLINE’s
MeSH but are supplemented with more than 2000 nursing/allied health-
specific headings
r More than 800,000 citations
Cochrane Database of Systematic Reviews (1991–present)
r More than 1500 regularly updated systematic reviews of primary clinical
research studies prepared by the Cochrane Collaboration
r Two types: completed reviews and protocols for reviews currently being
prepared
r Abstracts available at no charge from http://www.update-software.com/
publications/Cochrane/
Database of Abstracts of Reviews of Effectiveness (DARE)
r Prepared by the National Health Services’ Centre for Reviews and Dis-
semination (NHS CRD) at the University of York (UK)
r Full text structured abstracts (summaries) of systematic reviews from a va-
riety of medical journals about the effects of interventions, each summary
providing a critical commentary on the quality of the review
r Covers diagnosis, prevention, rehabilitation, screening, and treatment
r Available at no charge from http://www.york.ac.uk/inst/crd/darehp.htm
Dissertation Abstracts (1861–present)
r Searchable database listing doctoral dissertations and selected Masters
theses from accredited North American degree-granting institutions
r Abstracts included for Doctoral records since 1980 and Master’s since 1988
r Contains more than 1.8 million records
 Appendix G: Research Databases of Interest to Nurses 335

EMBASE (Excerpta Medica) (1980–present)

r Major biomedical and pharmaceutical database indexing more than 3500
international journals—European emphasis
r Covers drug research, pharmacology, toxicology, clinical and experimental
human medicine, health policy and management, public health, occupa-
tional health, environmental health, drug dependence and abuse, psychi-
atry, forensic medicine
r Selective coverage for nursing, dentistry, veterinary medicine, psychology,
and alternative medicine
r Uses the EMTREE controlled thesaurus
r More than 8 million citations and abstracts
ERIC (Education Resources Information Center) (1966–2003)
r The world’s premier database of journal and nonjournal education litera-
ture
r Sponsored by the Institute of Education Sciences (IES) of the U.S. De-
partment of Education
r Contains more than 1.1 million citations, including more than 107,000 full
text nonjournal documents
r Available at no charge from http://www.eric.ed.gov/
Health and Psychosocial Instruments (HaPI) (1985–present)
r Indexes information on measurement instruments (i.e., questionnaires,
interview schedules, checklists, index measures, coding schemes, manuals,
rating scales, tests) in the fields of healthcare, psychosocial sciences, and
organizational behavior
r More than two-thirds of tools cover medical and nursing areas such as pain
measurement, quality of life assessment, and drug efficacy evaluation
r Records from the Behavioral Measurement Database Services (BMDS)
r Contains more than 105,000 records
IngentaConnect
r Comprehensive, interdisciplinary keyword-searchable collection of aca-
demic and professional research articles
r More than 17 million citations from 28,000 publications, including 6100
on-line
r Online and offline access to the full text of electronic articles available
through online purchase or through subscriptions via Ingenta
r Free searching available from http://www.ingentaconnect.com/
International Bibliographic Information on Dietary Supplements (IBIDS)
(1986–present)
r Collaboration between the U.S. National Institutes of Health (NIH) and
the U.S. Department of Agriculture (USDA) providing citations and
336 Appendix G: Research Databases of Interest to Nurses

abstracts from the published international and scientific literature on di-

etary supplements
r More than 730,000 citations from four major database sources: biomedical-
related articles from MEDLINE; botanical and agricultural science from
AGRICOLA; worldwide agricultural literature through AGRIS; and se-
lected nutrition journals from CAB Abstracts and CAB Health
r Covers the use of supplements in human nutrition, fortification of foods,
nutrient composition of herbal and botanical products, population sur-
veys on dietary supplement use, the growth and production of herbal and
botanical products
r Available at no charge from http://dietary-supplements.info.nih.gov/
Health Information/IBIDS.aspx
International Pharmaceutical Abstracts (IPA) (1970–present)
r International coverage to the world pharmacy literature; related health,
medical, cosmetic journals, and state pharmacy journals; abstracts of pre-
sentations at major pharmacy meetings
r Topics covered: drug therapy, toxicity, and pharmacy practice as well as
legislation, regulation, technology, utilization, biopharmaceutics, informa-
tion processing, education, economics, and ethics
r Contains more than 350,000 records, including 10,000 references to alter-
native and herbal medicine
r Produced in cooperation with the American Society of Health-System
Pharmacists International
MEDLINE (1966–present)
r Major English-language biomedical database produced by the U.S. Na-
tional Library of Medicine (NLM) covering medicine, nursing, dentistry,
veterinary medicine, allied health and preclinical sciences
r More than 12 million bibliographic citations and author abstracts from
more than 4800 biomedical journals
r Uses MeSH (Medical Subject Headings), a hierarchical, controlled vocab-
ulary thesaurus of biomedical terms for indexing
r Electronic counterpart to Index Medicus, Index to Dental Literature, and
the International Nursing Index
NIOSHTIC-2
r Bibliographic database of occupational safety and health publications, doc-
uments, grant reports, and other communication products
r Supported by the National Institute for Occupational Safety and Health
(NIOSH)
r Available at no charge from http://www.cdc.gov/niosh/srchpage.html
NLM Gateway
r Allows users to search in multiple retrieval systems at the NLM
 Appendix G: Research Databases of Interest to Nurses 337

r Searches MEDLINE/PubMed, TOXLINE Special (toxicology refer-

ences), NLM Catalog, MedlinePlus (consumer health), ClinicalTrials.gov
(clinical research studies), DIRLINE (Directory of Health Orgs), Genet-
ics Home Reference (genetic conditions and genes), Meeting Abstracts,
HSRProj (Health Services Research Projects in Progress), OMIM (Online
Mendelian Inheritance in Man), and HSDB (Hazardous Substances Data
Bank)
r Available at no charge from http://gateway.nlm.nih.gov/gw/Cmd

POPLINE (POPulation information onLINE) (1970–present)

r World’s largest database on reproductive health, population, family plan-
ning, and related health issues
r More than 300,000 citations with abstracts to scientific articles, reports,
books, and unpublished reports
r Includes links to free, full-text documents; the ability to limit searches to
peer-reviewed journal articles, and many abstracts in French and Spanish
r Maintained by the Johns Hopkins Bloomberg School of Public
Health/Center for Communication Programs
r Available at no charge from http://db.jhuccp.org/popinform/basic.html

PsycINFO (1967–present)
r Bibliographic database that provides abstracts and citations to the schol-
arly, predominantly English-language literature in the behavioral sciences
and mental health
r Indexes nearly 2000 peer-reviewed journals; also books, dissertations, and
other secondary publications
r More than 2 million records, including historical records back to the 1800s
r Controlled vocabulary indexing using the Thesaurus of Psychological In-
dex Terms

PubMed (1950s–present)
r Developed by the U.S. National Center for Biotechnology Information
(NCBI) at the NLM
r More than 15 million citations, including MEDLINE, OLDMEDLINE,
“in process,” and “as supplied by publisher” citations
r Includes links to sites providing full-text content, some of which is available
at no charge
r Available at no charge from http://pubmed.gov

REHABDATA (1956–present)
r Produced by the U.S. National Rehabilitation Information Center
r Contains approximately 69,000 abstracts of books, reports, articles, and
audiovisual materials relating to disability and rehabilitation research
338 Appendix G: Research Databases of Interest to Nurses

r Each abstract includes bibliographic information, a 250-word abstract, and

(when appropriate) information regarding the project that produced the
document
r Available at no charge from http://www.naric.com/search/rhab/
Social Services Abstracts (1980–present)
r Provides bibliographic coverage of current research focused on social
work, human services, and related areas, including social welfare, social
policy, and community development
r Abstracts and indexes more than 1400 serial publications and includes
abstracts of journal articles and dissertations and citations to book reviews
r Major areas of coverage include community and mental health services,
crisis intervention, family and social welfare, gerontology, poverty and
homelessness, social and health policy, support groups/networks, violence,
abuse, neglect, and welfare services
r Contains almost 100,000 records
Sociological Abstracts (1963–present)
r Abstracts and indexes the international literature in sociology and related
disciplines in the social and behavioral sciences
r It provides abstracts of journal articles and citations to book reviews drawn
from more than 1800 serial publications and provides abstracts of books,
book chapters, dissertations, and conference papers.
r Major areas of coverage include culture and social structure, evaluation
research, family and social welfare, rural and urban sociology, social psy-
chology and group interaction, studies in violence and power, substance
abuse and addiction, and women’s studies.
r It contains approximately 620,000 records.
Web of Science
r Web interface to the ISI citation databases, Science Citation Index (1945–
present), Social Sciences Citation Index (1956–present), Arts & Humanities
Citation Index (1975–present)
r Covers 8700 of the most prestigious, high-impact research journals in the
world
r Includes searchable references to citations in the articles
r Can navigate backward using “cited references” to follow an author’s prior
influences and forward using “times cited” to track the work’s impact on
current research
Websites of Interest for Nursing Research
r Canadian Health Services Research Foundation (CHSRF)
http://www.chsrf.ca/home e.php
r The CHSRF is an independent, not-for-profit corporation, established
with endowed funds from the Canadian federal government. It promotes
 Appendix G: Research Databases of Interest to Nurses 339

and funds management and policy research in health services and nurs-
ing.
r The site has information on research funding, research in progress, re-
search reports, and knowledge transfer.

r Canadian Institutes of Health Research (CIHR)

http://www.cihr-irsc.gc.ca/e/193.html
r Canada’s premier health research funding agency website, it has infor-
mation on health research funding, knowledge translation, institute pub-
lications, and partnerships.

r National Institute of Nursing Research (USA)

http://ninr.nih.gov/ninr/
r The U.S. National Institute of Nursing Research, one of the 25 institutes
and centers within the National Institutes of Health, has information on
research funding and programs and news and links to related nursing
organizations.

r National Institutes of Health: Scientific Resources (USA)

http://www.nih.gov/science/
r This subsection of the NIH website provides information on intramu-
ral research, special interest groups, library catalogs, journals, training,
laboratories, scientific computing, and more.
Glossary

Acoustic coupler: A specific type of modem which uses the standard tele-
phone set.

A/D: Analog-to-digital converter.

Analog: A computer that compares and measures one quantity with another.

ANSI: American National Standards Institute

Application program: A computer program written to solve a specific prob-

lem or perform a specific task.

Architecture: The art and science of designing and erecting buildings. Build-
ings and other large structures: the low brick and adobe architecture of the
Southwest. A style and method of design and construction: Byzantine ar-
chitecture. Orderly arrangement of parts; structure: the architecture of the
federal bureaucracy; the broad architecture of a massive novel; computer
architecture.

Arithmetic logic unit (ALU): Internal part of computer (found in CPU) that
performs the arithmetic computations.

ASCII: American Standard Code of Information Interchange.

Assembly language: A hardware dependent symbolic language, usually char-

acterized by a one-to-one correspondence of its statements with machine
language instructions.

Auxiliary storage: Data storage other than main memory, such as that on a
disk storage unit.

Backup: A duplicate copy of a file or program. Backups of material are made

on disk or cassette in case something happens to the original.

340
 Glossary 341

Backup position listing: A list of personnel who can fill a given position, as
well as alternate personnel who can fill the same position.

BASIC: Beginner’s All-Purpose Symbolic Instruction Code. A popular com-

puter language invented at Dartmouth for educational purposes. An easy-
to-learn, easy-to-use language.

Batch processing: A mode of processing in which any program submitted to

the computer is either run to completion or aborted. No interactive commu-
nication between program and user is possible.

Baud: Unit of measurement of transmission speed, equivalent to bits per

second in serial transmission. Used by microcomputer.

Binary number system: Number system made up of the digits 0 and 1—“the
language of the computer.”

Bit: Binary digit (0 or 1).

Browser: A computer program which allows the user to search for data across
the networks of computers which make up the Internet.

Bubble memory (data): Thin film of synthetic garnet. The bubbles are mi-
crons in size and move in a plane of the film when a magnetic gradient is
present. Viewed under a microscope with a linear polarized light, the bub-
bles appear to be fluid circular areas that step from space to space following
fixed loops and tracks.

Bug: An error in a program or an equipment fault.

Business Continuity Planning (BCP): An all encompassing, “umbrella” term

covering both disaster recovery planning and business resumption planning.

Business interruption: Any event, whether anticipated (e.g., public service

strike) or unanticipated (e.g., blackout) which disrupts the normal course of
business operation at a corporate location.

Byte: Eight bits make up a byte (a letter, symbol, or number).

CAD: Computer-aided design.

CAD/CAM: Acronym for Computer-Assisted Design/Computer-Assisted

Manufacturing, terms used by designers, engineers, and managers.
342 Glossary

CAI: Computer-aided instruction. CAL Computer-aided learning. CAM

Computer-aided manufacture.

Care map: A sequential or branching plan of the anticipated key treatments

and diagnostic tests for a specific condition or medical diagnosis. IT may be
used as a template for comparing the actual experience of a patient with that
anticipated for the majority of patients with the same condition.

CASE: Computer Assisted Systems Engineering.

CD-ROM: Compact Disk Read Only Memory. A compact disk is round, flat
and silver in colour and can contain massive amounts of information (600
megabytes or more of data, text, graphics, video, or sound).

Central processing unit (CPU): Internal part of the computer that contains
the circuits which control and perform the execution of instructions. It is
made up of Memory, Arithmetic/logic unit, and Control unit.

Certified Disaster Recovery Planner (CDRP): CDRPs are certified by the

Disaster Recovery Institute, a not-for-profit corporation, which promotes
the credibility and professionalism in the DR industry.

Chip: An integrated circuit made by etching myriads of transistors and other

electronic components onto a wafer of silicon a fraction of an inch on a side.

CIPS: Canadian Information Processing Society.

Client/server: An architecture that has computers in a network assume dif-

ferent roles and tasks based on their particular strengths. Thus, a computer
might be identified as a file server or a database server.

CNA: Canadian Nurses Association.

COACH: Canadian Organization for Advancement of Computers in Health.

COBOL: Common Business-Oriented Language.

Cold-site: An alternate facility that is void of any resources or equipment

except air conditioning and raised flooring. Equipment and resources must
be installed in such a facility to duplicate the critical business functions of
an organization. Cold-sites have many variations depending on their com-
munication facilities, UPS systems, or mobility (Relocatable-Shell).

COM: Computer Output to Microfilm.

 Glossary 343

Compiler: A translation program which coverts high-level instructions into

a set of binary instructions (object code) for direct processor execution. Any
high-level program requires a compiler or an interpreter.

Computer: An electronic device capable of taking in, putting out, storing

internally, and processing data under the control of changeable processing
instructions within the device.

Computer literacy: A term used to indicate knowledge of what a computer

can do, how it works, how it is used to solve problems, and the limitations of
a computer.

Contingency plan: See Disaster Recovery Plan.

Control key: Key that executes commands, in conjunction with other keys
pressed simultaneously.

Control unit: Internal part of computer (found in CPU) that monitors the
sequence of operations for all parts of the computer.

CP/M: Control Program/Microprocessors.

CPU: Central processing unit.

CR: Change Request.

Critical needs: The minimal procedures and equipment required to continue

operations should a department, main facility, computer center, or a combi-
nation of these be destroyed or become inaccessible.

CRT: The Cathode-Ray Tube in a television set or video display monitor.

CRUD: Created, Read, Updated, or Deleted.

CSF: Critical Success Factor.

Cursor: A patch of light or other visual indicator on a screen that shows you
where you are in the text.

DA: Data Administrator.

Data: Recorded facts performing arithmetic and logical process on data.

Database: An organized collection of data or information.

344 Glossary

DB: Database.

DBA: Database Administrator.

DBMS: Database Management System.

DCE: Distributed Computing Environment.

Decision support system: A computer program devised to help a healthcare

professional select the most likely clinical diagnosis or treatment.

DFD: Data Flow Diagrams.

DI: Diagnostic Imaging.

Digital: A computer that uses numbers to solve problems by performing

arithmetic and logical processes on data.

Disaster: Any event creates an inability on an organization’s part to provide

critical business functions for some predetermined period of time.

Disaster prevention: Measures employed to prevent, detect, or contain inci-

dents which, if unchecked, could result in disaster.

Disaster prevention checklist: A questionnaire used to assess preventative

measures in areas of operations such as overall security, software, data files,
data entry reports, microcomputers, and personnel.

Disaster recovery: The ability to respond to an interruption in services by

implementing a disaster recovery plan to restore an organization’s critical
business functions.

Disaster Recovery Coordinator: The Disaster Recovery Coordinator may

be responsible for overall recovery of an organization or unit(s).

Disaster Recovery Plan: The document that defines the resources, actions,
tasks, and data required to manage the business recovery process in the
event of a business interruption. The plan is designed to assist in restoring
the business process within the stated disaster recovery goals.

Disaster Recovery Planning: The technological aspect of business continuity

planning. The advance planning and preparations which are necessary to
minimize loss and ensure continuity of the critical business functions of an
organization in the event of a disaster.
 Glossary 345

Disaster Recovery Software: An application program developed to assist an

organization in writing a comprehensive disaster recovery plan.

Disk: An external storage medium that is a flat, circular magnetic surface

used to store data. The data is represented by the presence or absence of
magnetized spots.

Disk drive: The device used to access or store information via a disk.

Distributed processing: Use of computers at various locations, typically in-

terconnected via communication links for the purpose of data access and/or
transfer.

Documentation: Refers to the orderly presentation, organization, and com-

munication of recorded specialized knowledge in order to maintain a com-
plete record of reasons for changes in variables. Documentation is necessary,
not so much to give maximum utility, as to give an unquestionable historical
reference record.

DOS: Disk-operating system.

DRGs: Diagnosis Related Groups. A method of costing care and treatment

by grouping together cases by diagnosis or treatment method.

DSS: Decision Support System.

EDI: Electronic Data Interchange.

EDP: Electronic Data Processing.

EIS: Executive Information System.

E-mail: Electronic mail. The messages created, sent, and read between net-
works of computer users without having to be printed on paper.

EPROM: Erasable Programmable Read-Only Memory. A type of ROM

that can be changed by means of electrical erasing.

Expert system: A computer program that stores knowledge in a special

database by expressing it in the form of logical rules. The program can then
logically reason, given that set of rules.

FDDI: Fibre Distributed Data Interface.

346 Glossary

File backup: The practice of dumping (copying) a file stored on disk or tape
to another disk or tape. This is done for protection case the active file gets
damaged.

FIPS: Federal Information Processing Standard.

Firmware: Computer instructions that are located in Read-Only Memory

(ROM). These instructions can be accessed but not altered.

Floppy disk: A flexible plastic disk enclosed in a protective envelope used

to store information.

Formal Decision Table: A logical presentation of all decision paths available

in the development of a computer system.

FORTRAN: Formula Translator.

Friendly: How easy a program or computer is to work with. A “user friendly”

program is one that takes little time to learn, or that offers on screen prompts,
or that protects the user from making disastrous mistakes.

FTAM: File Transfer, Access, and Management.

FTP: File Transfer Protocol.

FTS: File Transfer Systems.

GUI: Graphical User Interface.

Hard copy: Computer output printed on paper.

HDLC: High-level Data Link Control.

Head: Part of magnetic storage unit (Disk drive) which reads and writes
information on the magnetic media.

High-level languages: Programming languages that are as close to writing

English statements as possible.

HIS: Hospital Information Systems—a term used to describe overall hospital

use of computers. Examples would be nurse staffing, medical records, patient
admittance and discharge, patient bed control, and so on.

HMRI: Hospital Medical Records Institute.

 Glossary 347

Hot-site: An alternate facility that has the equipment and resources to re-
cover the business functions affected by the occurrence of a disaster. Hot-
sites may vary in type of facilities offered (such as data processing, communi-
cation, or any other critical business function needing duplication). Location
and size of the hot-site will be proportional to the equipment and resources
needed.

IC: Integrated circuit.

ICD-9-CM: International Classification of Diseases—9th rev—Clinical

Modification.

IEW: Information Engineering Workbench—Proprietary product.

I/O (input/output): An Input device such as a keyboard feeds informa-

tion into the computer. An Output device such as a printer or moni-
tor takes information from the computer and turns it into usable form.
Modems, cassettes, and disks work in both directions, so they are I/O de-
vices. Input and output are also used as verbs: You input data from the
keyboard.

Input: The data to be processed by the computer.

Input device: Device used to enter data to be processed by a computer (e.g.,

keyboard, light pen, touch screen).

Interactive video disk: A computer program uses a compact disk storing

large amounts of data to provide video sequences on screen for the user to
select the next sequence, or based on the answer given to a question.

Interface: A device or program that permits one part of a computer system

to work with another, as when making a connection between a cassette tape
recorder and the computer.

Internal memory: The internal storage of the computer. Made up of ROM

and RAM.

Internal hot-sites: A fully equipped alternate processing site owned and

operated by the organization.

Internet: A world-wide computer network, available via a modem and the

telephone line that connects universities, government departments, and in-
dividuals. Users can send and receive e-mail, join in electronic conferences,
and copy files.
348 Glossary

IMIA: International Medical Informatics Association. It organizes a

congress every three years and has a number of special interest groups
composed of representatives drawn from member countries. The British
Computer Society (BCS) is the member organization for the UK. The BCS
Nursing Specialist Group nominates one member to the IMIA Nursing Spe-
cialist Group (SIGN).

Interpreter language: Language that converts the higher-level languages and

assembler language to a language the computer machine can understand.

IPSE: Integrated Product Support Environment.

IRM: Information Resource Management.

ISDN: Integrated Services Digital Network.

ISO: International Standards Organization.

ISP: Information Systems Professional.

IT: Information Technology.

ITCH: Information Technology for Community Health (Annual Confer-

ence).

JADD: Joint Application Design and Development.

JCL: Job control language.

JIT: Just-in-Time.

K: Symbol used to express 1000. Ir a computer context it is 1024. Example

16K = 16,000 bytes; in reality it is 16,384 bytes.

LAN: abbreviation for Local Area Network. Computing equipment, in close

proximity to each other, connected to a server which houses software that
can be accessed by the users. This method does not utilize a public carrier.

Load: To enter a program into the computer from cartridge, cassette, or disk.

Loop: A group of instructions that may be executed more than once.

Low-level languages: Programming languages that are less sophisticated

than our normal English language.
 Glossary 349

LPM: Lines per minute.

Machine language: Language the computer actually understands. Nothing

more than everything converted into the binary system. i.e., 0’s and 1’s, the
presence or absence of electricity.

Magnetic tape: Flexible plastic tape, on one side of which is a uniform coating
of dispersed magnetic material, in which signals are registered for subsequent
reproduction. Used for registering television images, sound, or computer
data.

Mailbox: An e-mail account or address, to which messages can be sent and

stored, on a computer network such as Internet.

Mainframe Computer: A high-end processor, with related peripheral de-

vices, capable of supporting large volumes of batch processing, high perfor-
mance on-line transaction processing systems, and extensive data storage
and retrieval.

Mark sense card: An input device that allows the operator to use a special
pencil and computer readable card to input data.

Medical informatics: The discipline of applying computer science to medical

processes.

Megabyte: 1 million bytes or 8 million bits.

Memory: Internal part of computer (found in the CPU) where programs and
data are stored.

Metathesaurus: The combinations of several systematically arranged lists of

words, their synonyms, and antonyms. A word finder to help in the identifi-
cation of a language such as that used by nurses.

Microcomputer: A small inexpensive desk-top computer which uses floppy

disks or small hard disk drives.

Microprocessor: Another name for the CPU chip.

Minicomputer: A larger and more powerful computer than a microcom-

puter, which uses large capacity hard disks, works at a greater speed, and
has several hundred K of memory.

MIPS: Millions of instructions per second.

350 Glossary

MIS: Medical (or Management) Information System (Chapter 5). A term

used interchangeably with HIS; however, it specifically applies to a comput-
erized system related to patient care as opposed to a system used by the
finance department for billing financial statements, and so on.

Modem: Modulator/Demodulator. A device used to change computer codes

into pulses or signals that can travel over telephone lines.

Monitor: Video device; quality of display is better than that of a television

set.

MOS: Metal-oxide semiconductor.

Mouse: An input device that can be moved around over a flat surface causing
the cursor to move on the screen.

MVS: Multiple virtual storage.

NANDA: North American Nursing Diagnosis Association. Its conference

proceedings are published and list the currently approved diagnoses and
their definitions. NANDA encourages research to identify and clarify diag-
noses.

Network architecture: The basic layout of a computer and its attached sys-
tems, such as terminals and the paths between them.

Neural network model: A model on a computer system to mimic the way

the human brain processes information using large numbers of neurons all
working on one problem at the same time (parallel processing). Based on
repeated patterns, connections are made across the computer’s network of
“neurons” to produce the same result each time.

NFS: Network File System.

NIC: Nursing Interventions Classification.

NIS (Nursing Information System): A term used to describe overall nursing

use of computers. Examples would include source data capture, patient care
plans, and use of expert systems.

NIST: National Institute of Standards and Technology.

Node: The name used to designate a part of a network. This may be used
to describe one of the links in the network, or a type of link in the network
(e.g., host node or intercept node)
 Glossary 351

Nursing diagnosis: A clinical judgment about individual, family, or commu-

nity responses to actual or potential health problems or life processes. A
nursing diagnosis provides the basis for the selection of nursing interven-
tions.

Nursing informatics: The discipline of applying computer science to nursing

processes.

Nursing Minimum Data Set (NMDS): The agreed minimum number of items
of data, such as patient and nursing care elements, to be collected for man-
agerial and government purposes. In the United States, the term may be
used for the data elements identified by Werley et al. in 1985.

OA: Office Automation.

OCR: Optical Character Recognition.

OEM: Original equipment manufacturer.

Off-site storage: The process of storing records at a location removed from

the normal place of use.

Omaha System: Developed by the Visiting Nurses Association of Omaha

for use in community health nursing, there are three components a problem
classification scheme, a problem-rating scale for outcomes, and an interven-
tion scheme.

On-line: Being electronically connected, for example, a computer linked to

a printer so that it is ready to print, or one computer linked to another
computer such as over the Internet.

On-line terminal: The operation of terminals, disks, and other equipment

under direct and absolute control of the central processor to eliminate the
need for human intervention at any stage between initial input and computer
output.

Operating Software: A type of system software supervising and directing all

of the other software components plus the computer hardware.

OS: Operating system.

OSI: Open Systems Interchange. A particular technical standard that allows

computers of different origins to be linked together.

OSE: Open Systems Environment.

352 Glossary

OSF: Open Standards Foundation.

OSI: Open Systems Interconnection.

Output: Information transferred from internal storage to output device.

Output device: Devices or machines that deliver information from the com-
puter to the operator (e.g., CRT, tape, disk, keypunched card).

Paper tape: Refers to strips of paper capable of storing or recording informa-

tion. Storage may be in the form of punched holes, partially punched holes,
carbonization or chemical change of impregnated material, or by imprinting.

Parallel interface: A port that sends or receives the eight bits in each byte all
at one time. Many printers likely to be used in homes use a parallel interface
to connect to the computer.

Parsing: The computer science term for checking the correctness of each line
and the action of putting the line into proper form for next phase of program
execution.

Patient classification system: There are a variety of systems, some manual,

that assign either a patient’s nursing problems or the nursing activities re-
quired, to a defined level of dependency on nurses for care. Some systems
use nursing care plans to calculate the number of minutes of nurse time
needed in 24 hours.

PC: Personal Computer.

PC-DOS: IBM’s name for the Disk Operating System used in the IBM
Personal Computer.

(PDQ) Cancer system: Protocol Data Query. A data retrieval system for
cancer material.

Peripherals: Accessory parts of a computer system not considered essential

to its operation. Printers and modems are peripherals.

Personal Health Number (PHN): A unique identifier given to individuals

eligible for health services.

Physical Prevention: Special requirements for building construction as well

as fire prevention for equipment components.

PIR: Post Implementation Review.

 Glossary 353

POSIX: Portable Operating System Interface for Computer Environments.

Printer: Transforms computer output into hard copy.

Program: Shortened form of “computer program.” A set of stored instruc-

tions in a computer which directs the actions within the computer. See Ap-
plication program.

Programmable key: Another term for user-defined key.

Programming languages: Much like French, English, and German—the

grammar and punctuation accepted by the computer’s input device that
enables a user to communicate with the computer.

PROM: Programmable Read-Only Memory. A type of ROM that can be

changed, but only with a high degree of expertise.

Proprietary software: A computer program belongs to its developer. Pro-

grams (generally) cannot be copied and freely given away, just as you cannot
copy a book and give copies away.

RAM: Random-Access Memory or Read-Write Memory. This part of inter-

nal memory is known as temporary memory.

RDBMS: Relational Database Management System.

Read: To extract data from a computer’s memory or from a tape or disk.

Real-time: An action or system capable of action at a speed commensurate

with the time of occurrence of an actual process.

Reset: To reset the computer and its peripherals to a starting state before
beginning a task. Done automatically by the disk operating system.

RFD: Request for Development.

RFI: Request for Information.

RFP: Request for Proposal.

RISE: Relationally Integrated Systems Engineering.

Risk Analysis: The process of identifying the risks to an organization, assess

the critical functions necessary for an organization to continue operations,
define controls to reduce exposure, and evaluate the cost of such controls.
354 Glossary

The risk analysis often involves an evaluation of the probabilities of a partic-

ular event. Associated terms risk assessment, impact assessment, corporate
loss analysis, risk identification, exposure analysis, exposure assessment.

Risk management: The discipline that ensures that an organization does not
assume an unacceptable level of risk.

Robotics: General term for industrial robots used to increase production. An

example is the use of computer-controlled robots in automobile assembly
lines.

ROM: Read-only memory.

RPG: Report Program Generator.

SAA: Strategic Application Architecture.

SCAMC: Symposium on Computer Applications in Medical Care.

Scroll: To move a video display up or down, line by line, or side to side,

character by character.

SDE: Systems Development Environment.

SDLC: Systems Development Life Cycle.

Server: A master computer into which other computers hook, so it controls

a network of computers.

Soft-function key: See User-defined key.

Software: The general term for sets of computer instructions (programs)

which manage the general facilities of the computer and control the opera-
tion of application programs.

SNOMED: Systematized Nomenclature of Medicine.

Source code instructions: In many microprogrammed processors, source

code instructions are interpreted in the instruction register as pointers to the
microprocessor programs that emulate the particular instruction set being
executed. In the conventional approach, on the other hand, each instruction
is decoded and executed with specific control logic wired into the machine.

SSA: Strategic Systems Architecture.

 Glossary 355

Stakeholder: Any individual or organization with vested interest in the

health system.

Standards: Documented agreements containing technical specifications or

the precise criteria to be used consistently as rules, guidelines, or definitions
of characteristics to ensure that materials, products, processes, and services
are fit for their purposes.

Storage: Usually refers to long term storage, such as storage on tape or

disk.

Support: Help available from computer and software merchants. Also used
as a verb to describe what products are compatible with each other.

System: A group of actions or procedures which together are logically con-

nected by their operation and products and which accomplish a connected
set of organizational objectives.

TCP/IP: Transmission Control Protocol/Internet Protocol.

Telematics: The combination of telecommunications and computing. Data

communications between systems and devices.

Technical Threats: A disaster causing event that may occur regardless of any
human elements.

Terminal: Device used to transmit and receive data over communications

lines to and from the computer.

Top-down structure: A logical method of presenting the structure of a com-

puter application. The initial system is the head of the structure and is subdi-
vided into each of its component parts ultimately ending in a detailed level
that allows you to go directly to programming.

TQM: Total Quality Management.

Turnkey: A term used to describe a hardware-software combination that

comes in a “package.” There are no changes or options; the package must
be run as it is. An example is a microcomputer with a generalized software
package for nurse scheduling. A “turnkey” is the opposite of a “tailored”
system developed specifically for a nursing department.

Unique Lifetime Identifier (ULI): A unique identifier given to persons who

receive or provide health services in Alberta.
356 Glossary

User-defined key: A key whose function can be changed by which a command

or sequence of commands can be executed with a single keystroke. Same as
Programmable key and Soft-function key. Unlike a special-function key, a
user-defined key may have a predefined purpose.

VDU: Visual display unit.

VDT: Video display terminal.

Video terminal: Computer terminal which shows data on a cathode ray tube
(CRT), like a television tube, in letters, numbers, and so on.

Warm-site: An alternate processing site which is only partially equipped (as

compared to a hot-site, which is fully equipped).

Winchester disk: A powerful form of backup storage for a computer. It is a

rigid magnetic disk in a sealed container scanned by a head which does not
quite touch the disk, therefore not wearing it out.

Winchester drive: A form of hard disk permanently sealed into a case.

WLMS: Work Load Measurement System.

WMS: Workload Measurement System.

Write: To enter information into memory or onto a tape or disk.

WWW: World Wide Web. A database made of linked hypertext documents

originated by CERN, it exploded onto the computing scene during 1994.
You call it up from a starter screen. An early browser was a program called
Mosaic. WWW can provide graphics and sound but downloading these take
time.
Index

A Auditing, 223
Activity diagram, 195–196 Augusta, Lady Lovelace, 28
Administration applications, 129–141 Authentication, 222–223
Administrative modules of HIS, 61 Authorization, 223
Admission/discharge/transfer modules Automated care planning, 114
of HIS, 61–62 Automated scheduling of personnel,
AHA (American Hospital Association), 134
33 Automation, nursing office, 137–138
ALU (arithmetic logic unit), 16
American Hospital Association (AHA), B
33 Bar code reader, 111
American Medical Informatics Biomedical Data Processing (BMDP),
Association (AMIA), 38, 299 163
American Nurses Association (ANA), Bit, 13
7, 281 BlackBoard, 149–150
American Nurses Credentialing Center, BMDP (Biomedical Data Processing),
281 163
American Psychological Association Browsers, web, 47–48
(APA), 288 Business-oriented management
AMIA (American Medical Informatics information systems, 136–137
Association), 38, 299 Byte, 13
ANA (American Nurses Association),
7, 281 C
Antivirus programs, 26 Cable connection, 44
APA (American Psychological CAC (Computing Advisory Council),
Association), 288 284
Apple I, 30 CAI (computer-assisted instruction),
Application programs, 12, 19 145
Arithmetic logic unit (ALU), 16 Call centers, 125–126
Assessment data, 105 Canadian Institute for Health
nursing-generated, 107–111 Information (CIHI), 178–179
other than nursing-generated, Canadian Nurses Association, 177–179
106–107 Canadian Nursing Informatics
Assessment screen, example of, 112 Association (CNIA), 302

357
358 Index

Canadian Organization for the Clinical practice applications

Advancement of Computers in community based, 118–127
Health (COACH), 229, 300 facility based, 105–116
CAPI (computer-assisted personal CNIA (Canadian Nursing Informatics
interviewing), 160 Association), 302
Capital Area Roundtable on COACH (Canadian Organization for
Informatics in Nursing the Advancement of Computers
(CARING), 302 in Health), 229, 300
Cardiac risk assessment, 111 Color of display, 237
Care planning, automated, 114 Community-based care, 118
CARING (Capital Area Roundtable on Community health information
Informatics in Nursing), 302 networks (CHINs), 123
CASI (computer-assisted Computer-assisted instruction (CAI),
self-interviewing), 159 145
CATI (computer-assisted telephone Computer-assisted interviewing,
interviewing), 160 159–161
CD-ROM technology, 143 Computer-assisted personal
CDS (computerized decision support interviewing (CAPI), 160
systems), 97–98 Computer-assisted self-interviewing
Central processing unit (CPU), 12, (CASI), 159
15–16 Computer-assisted telephone
Change interviewing (CATI), 160
management of, 260–264, 270, Computer-based multimedia, 142–148
273–276 Computer graphics, 164
reinforcement of, 276 Computer input, 14–15
CHINs (community health information Computer-literate nurses, 280
networks), 123 Computer memory, 15
Chip, 13 Computer output, 17
CIHI (Canadian Institute for Health Computer storage, 16–17
Information), 178–179 Computer systems, unrealistic
CINAHL, 156 expectations for, 255–256
Class diagram, 197 Computer terminals, 20–21
Client outcome, 178 Computer terms, common, 13–14
Client/server computing, 24–25 Computer viruses, 46
Client status, 177 Computer workstations, 21
Clinical care, documentation in, nursing, 235–241
87–95 Computerized databases of literature,
Clinical databases, 161 156–157
Clinical documentation Computerized decision support systems
characteristics of, 89–90 (CDS), 97–98
electronic, 92–93 ComputerLink projects, 125
Clinical documentation issues, Computers, 12–26
informatics approaches to, in health care, 31–34
91–92 historical development of, 27–31
Clinical functions, software support for, impact of, on education, 142–144
64–67 nursing care and, 35–37
Clinical nursing documentation, 86–87 nursing education using, 149–150
Clinical nursing practice, current state of nursing use of, 34–37
nursing information in, 179–185 resistance to, 254–260
 Index 359

Computing, health care, 27–39 Decision support systems (DSS), 97–98,

Computing Advisory Council (CAC), 115–116
284 Dial-up connection, 43
Confidentiality, 219–220 Disaster recovery planning (DRP),
Consultants, 210–212 243–253
finding, 211–212 documenting written plan, 249–252
qualified, 211 plan testing and maintenance, 252
when needed, 210–211 planning process, 244
Continuous quality improvement planning team, 244
(CQI), 131 risk analysis, 246–248
Contract negotiations risk exposure, 248
for hospital information systems, risk identification, 245–246
207–209 risk prioritization, 248
purpose of, 209 risk reduction, 248–249
Contrast, 238 Disease surveillance networks, 123
CPU (central processing unit), 12, 15–16 Disk drive, removable, 17
CQI (continuous quality improvement), Documentation
131 clinical, see Clinical documentation
Cracking, 45 entries
CTD (cumulative trauma disorder), in clinical care, 87–95
239 clinical nursing, 86–87
Cumulative trauma disorder (CTD), 239 knowledge-based, 88
Cursor, 14 by nurses, 111–113
nursing orders as, 89–90
D Documentation approaches, 89
Data analysis, 163–164 DRP, see Disaster recovery planning
Data analysis packages, qualitative, DSL connection, 43–44
163–164 DSS (decision support systems), 97–98,
Data gathering, 159–160 115–116
Data integrity, 224–225 Dynamic balance of forces, Lewin’s,
Data issues, 113 262
Data mining, 161–162
Data protection, 218–232 E
Data Protection Act, United Kingdom, E-mail, 26, 49–50
230 message anatomy, 50
Data security, 218–219 Education, 142
Data security breaches, 221–222 impact of computers on, 142–144
Data standards, nursing, 95–96, nursing informatics, see Nursing
171–185 informatics education
Data usage integrity, protecting, Education applications, 142–153
222–224 EHR (electronic health record), 71, 74,
Database management system (DBMS), 75, 91, 268, 289
20 Electronic clinical documentation,
Databases, 19–20 92–93
clinical, 161 Electronic health record (EHR), 71, 74,
linking, 220 75, 91, 268, 289
multimedia, 147 Electronic mail, see E-mail
DBMS (database management system), EMISs, see Enterprise health
20 information systems
360 Index

Enterprise health information systems uses of source data capture in,

(EMISs), 57–82 94–95
evolution of, 69–71 Health care computing, 27–39
impact of, 79–81 Health care data, possible uses of,
integrated, 73–77 221
prerequisites for, 77–78 Health care information systems,
producing value-added information, linking nursing and, 212–215
79 Health care telematics, 119
responsibilities of, 71–73 Health informatics, 5
Epidemiological Information Health information, nursing values
(EPINFO), 163 related to, 171–172
EPINFO (Epidemiological Health Information Technology (HIT),
Information), 163 295
Ergonomics, 234–241 Health Insurance Portability and
European Standardization Committee, Accountability Act (HIPAA),
177 227–229
European Union Directive 95/46/EC, Health Level 7 (HL7), 198
230 Health networks, population, 123
Evidence-based nursing, 96–97 Health on the Net (HON), 293
Extranets, 54 Healthcare Information and
Eye strain, 236–238 Management Systems Society
(HIMSS), 299–300
F HHCC (Home Health Care
Financial modules of HIS, 61 Classification), 174
Firewall, 45 HIMSS (Healthcare Information and
Flash drive, 17 Management Systems Society),
Flicker, 237 299–300
Floppy disk, 16 HIPAA (Health Insurance Portability
and Accountability Act),
G 227–229
GHz (gigahertz), 14 HISs, see Hospital information systems
Gigahertz (GHz), 14 HIT (Health Information Technology),
Glare, 237–238 295
Graphical user interface (GUI), 19, 20 HL7 (Health Level 7), 198
Graphics, computer, 164 Home care services, 125
GUI (graphical user interface), 19, 20 Home Health Care Classification
Guidelines on the Protection of Privacy (HHCC), 174
and Transborder Flows of HON (Health on the Net), 293
Personal Data, 226–227 Hospital information systems (HISs),
31, 58–61
H components of, 61–67
Hacking, 45 contract negotiations for, 207–209
Hard disk drive, 16 functions of, 59
Hardware, 12, 14–17 insufficient involvement of nurses in
selection of, 199–216 installation of, 257–258
Hardware security, 222 issues related to, 67–69
Health care nursing aspects of, 84–100
computers in, 31–34 nursing responsibilities in, 230–232
resistance to, 254–260 Human-machine interface, 240
 Index 361

Human resource management, 136 International Federation of Information

Hypermedia/hypertext programs, 146 Processing (IFIP), 301
Hypertext, 47 International Medical Informatics
Association (IMIA), 37–38, 301
I International Standard 18104, 182–183
ICN (International Council of Nurses), International Standards Organization
175–176, 179–181 (ISO), 75, 182–183, 234
ICNP (International Classification for Internet, 30, 41–54
Nursing Practice), 149, 175, connecting to, 42–45
179–182 searching, 48
IFIP (International Federation of websites of, 166–167
Information Processing), 301 Internet addresses, 49
IMIA (International Medical Internet applications, 49–54
Informatics Association), 37–38, Internet chat, 53–54
301 Internet security, 224–225
Implementation concerns, 254–264 Internet security issues, 45–46
Informatics Interpreter for EHIS, 77–78
health, 5 Interviewing, computer-assisted,
medical, see Medical informatics 159–161
nurses and, 3–10 Intranets, 54
nursing, see Nursing informatics IOM (Institute of Medicine), 268
Informatics approaches to clinical ISO (International Standards
documentation issues, 91–92 Organization), 75, 182–183,
Informatics nurse specialists (INSs), 234
296, 297 IT (information technology), 212
Information, nurses managing, 138–141
Information age, 3 J
Information management, 3 JCAHO (Joint Commission on
Information management requirements, Accreditation of Hospital
defining, 189–198 Organizations), 256, 296
Information model diagram, 196–198 Joint Commission on Accreditation of
Information needs, nursing, 130–136 Hospital Organizations
Information systems, 58 (JCAHO), 256, 296
manual, 138–139
resistance to, 254–260 K
stages in development of, 190–191 Keyboard, 14, 18
Information technology (IT), 212 Knowledge-based documentation, 88
Information technology Knowledge-based systems, 99–100
implementation, 272
successful, process redesign approach L
to, 267–277 LANs (local area networks), 22–23
INSs (informatics nurse specialists), 296, Learning and Using ICNP, 149
297 Legislation, standards and, 226–230
Institute of Medicine (IOM), 268 Lewin’s dynamic balance of forces, 262
International Classification for Nursing Libel, 51
Practice (ICNP), 149, 175, Light pen, 14
179–182 Literature, computerized databases of,
International Council of Nurses (ICN), 156–157
175–176, 179–181 Local area networks (LANs), 22–23
362 Index

Logical Observations, Identifiers, N

Names, and Codes (LOINC), 183 NANDA (North American Nursing
LOINC (Logical Observations, Diagnosis Association), 174
Identifiers, Names, and Codes), National Health Information
183 Infrastructure (NHII), 78
National Institute for Safety and Health
M (NIOSH), 236
Mailing lists, 51–52 NCHI (nursing components of health
Management information systems information), 184–185
(MISs), 129 Newsgroups, 52
business-oriented, 136–137 Newsreader, 53
definition of, 129–130 NHII (National Health Information
nursing, 85–86 Infrastructure), 78
reporting via, 135–136 NI-WG (Nursing Informatics Working
Management of change, 260–264, 270, Group), 299
273–276 NIC (Nursing Interventions
Manual information system, 138–139 Classification), 174–175
Medical emergency aid through NICTF (Nursing Informatics
telematics (MERMAID), 123 Collaboration Task Force), 303
Medical informatics, 4–5 NIEM (nursing informatics education
nurses and, 5–6 model), 287–288
MEDLINE, 156 Nightingale, Florence, 171
Megahertz (MHz), 14 NIOSH (National Institute for Safety
MERLOT (Multimedia Educational and Health), 236
Resource for Learning and NMDS (Nursing Minimum Data Set),
On-line Teaching), 151 173–174
MERMAID (medical emergency aid NOC (Nursing Outcomes Classification
through telematics), 123 System), 174–175
MHz (megahertz), 14 North American Nursing Diagnosis
Millions of instructions per second Association (NANDA), 174
(MIPS), 16 Nurse administrators, 296
MIPS (millions of instructions per Nurse researchers, 7
second), 16 Nurses, 9
MISs, see Management information computer-literate, 280
systems documentation by, 112–113
Monitor, 17, 18 future for, in nursing informatics,
Mouse, 14, 18 292–303
Multidisciplinary professional informatics and, 3–10
associations, 299–302 insufficient involvement of, in
Multimedia, 145 installation of hospital
computer-based, 142–148 information systems, 257–258
Multimedia books, 147 managing information, 138–141
Multimedia databases, 147 medical informatics and, 5–6
Multimedia Educational Resource for in nursing, new roles for, 295–298
Learning and On-line Teaching Nursing, 4, 10, 263
(MERLOT), 151 evidence-based, 96–97
Multimedia technology linking, and health care information
effectiveness of, 150 systems, 212–215
limitations of, 151–152 nurses in, new roles for, 295–298
 Index 363

Nursing administration, 35 Nursing information needs, 130–136

Nursing care, computers and, 35–37 Nursing intensity, 178
Nursing components of health Nursing interventions, 177–178
information (NCHI), 184–185 Nursing Interventions Classification
Nursing computer workstations, (NIC), 174–175
235–241 Nursing management information
Nursing data, issues in development systems, 85–86
and use of, 96 Nursing Minimum Data Set (NMDS),
Nursing data standards, 95–96, 173–174
171–185 Nursing office automation, 137–138
Nursing documentation, clinical, Nursing orders as documentation,
86–87 89–90
Nursing education, 34–35 Nursing Outcomes Classification
using computers, 149–150 System (NOC), 174–175
Nursing functions, 4 Nursing professional organizations,
Nursing-generated assessment data, 302–303
107–111 Nursing research, 155
Nursing informatics Nursing responsibilities in hospital
applications of, 105–165 information systems,
at the bedside, 8 230–232
defined, 6–7 Nursing specialty, nursing informatics
development of, 6–7 recognition as a, 283
education, see Nursing informatics Nursing telepractice, 120
education Nursing use of computers, 34–37
future for nurses in, 292–303 Nursing values related to health
goal of, 7 information, 171–172
impact of, 7 Nursing workload measurement
at the nursing station, 8 systems (NWMSs), 135
professional, 267–303 NWMSs (nursing workload
recognition as a nursing specialty, 283 measurement systems), 135
vision of future of, 292–295
Nursing Informatics Collaboration Task O
Force (NICTF), 303 OECD (Organization for Economic
Nursing informatics education, 280–290 Cooperation and Development),
continuing, 282–283 226
defining a model for graduate-level, Open systems, 24
287–290 Operating systems, 12, 17–18
future of, 286–287 Operations security, 223–224
graduate-level at present, 284 Optical storage, 17
historical overview of, 281–282 Order alert, 65
studies examining needs for, 284–286 Order entry module of HIS, 62–64
Nursing informatics education model Organization for Economic
(NIEM), 287–288 Cooperation and Development
Nursing Informatics Working Group (OECD), 226
(NI-WG), 299 Ovid Technologies Inc., 157
Nursing information
current state of, in clinical nursing P
practice, 179–185 Patient classification systems (PCSs),
evolution of, 172–179 135
364 Index

Patient discharge abstract, 141 PROMIS (Problem Oriented Medical

Patient monitoring, 105–106 Information System), 36
Patient registry, 118 Protocols, 22
PCSs (patient classification systems),
135 Q
PDAs (personal digital assistants), Qualitative data analysis packages,
95 163–164
Pen-based technology, 15 Quality management, 131–133
Personal computers, 33
Personal digital assistants (PDAs), R
95 RAM (random-access memory), 13,
Personnel, automated scheduling of, 15
134 Random-access memory (RAM), 13,
PITAC (President’s Information 15
Technology Advisory Read-only memory (ROM), 13, 15
Committee), 303 Reference terminology model for
PLATO system, 144 nursing (RTMN), 182
Plotters, 17 Refresh rate, 237
“Point of care” devices, 94 Reinforcement of change, 276
Population health networks, 123 Remote access computing, 25
Portable terminal, 108, 109 Removable disk drive, 17
Posture, 238–239 Repetitive stress injury (RSI), 239
Practice programs, 148 Request for information (RFI), 202
President’s Information Technology Request for proposal (RFP), 199, 200,
Advisory Committee (PITAC), 202–204
303 Requirements definition, 191–193
Printers, 17 Research applications, 155–165
Privacy, 218, 219 Research documents, preparation of,
Privacy Rule, 227 158
Problem Oriented Medical Information Resistance to information systems and
System (PROMIS), 36 computers in health care,
Problem-solving programs, 148 254–260
Process, 269 Result reporting module of HIS, 64
Process redesign, 268–269 Return on investment (ROI), 275
approach to successful information RFI (request for information), 202
technology implementation, RFP (request for proposal), 199, 200,
267–277 202–204
Process redesign methodology, Robotics, 9
271–272 ROI (return on investment), 273
Process transformation, 270–271 ROM (read-only memory), 13,
Professional associations 15
multidisciplinary, 299–302 RSI (repetitive stress injury), 239
role of, 298–303 RTMN (reference terminology model
Professional nursing informatics, for nursing), 182
267–303
Professional organizations, nursing, S
302–303 Sacred cow, 261
Program integrity, 224–225 SAS (Statistical Analysis Software),
Project management, 269 163
 Index 365

Scheduling Total quality management (TQM),

with HIS, 64 131–133
of personnel. automated, 134 Touchscreen, 14
Security issues, Internet, 45–46 TQM (total quality management),
Self-evaluation, 201 131–133
Simulations, 148 Traditional procedures, changes in,
Site visits, vendor demos and, 204–205 256–257
SNOMED-CT, 183 Transistors, 29
Software, 12–13, 17–20 Tutorials, 147–148
selection of, 199–216
virus protection, 162 U
Software security, 222–223 UHDDS (Uniform Hospital Discharge
Software support for clinical functions, Data Set), 173–174
64–67 UML (unified modeling language),
Source data capture, 93, 107 192–193
criteria for, 93–94 UMLS (Unified Medical Language
uses of, in health care, 94–95 System), 175
Spam, 26 Unified Medical Language System
SPSS (Statistical Packages for the Social (UMLS), 175
Sciences), 163 Unified modeling language (UML),
Stand-alone components, 22 192–193
Standards, legislation and, 226–230 Uniform Hospital Discharge Data Set
Statistical Analysis Software (SAS), (UHDDS), 173–174
163 Uniform resource locator (URL),
Statistical Packages for the Social 47–48
Sciences (SPSS), 163 United Kingdom Data Protection Act,
Strategic planning, 273 230
Swim lane diagram, 196, 197 Unrealistic expectations for computer
System availability, 225–226 systems, 255–256
System implementation project, 199 URL (uniform resource locator),
47–48
T Usage integrity, 219–220
Tape, 17 Use case diagram, 194, 195
TC215 (Technical Committee on Health Usenet, 52
Informatics), 75, 182 User groups, vendor-sponsored, 303
Technical Committee on Health
Informatics (TC215), 75, 182 V
Telecounseling, 124–125 VDTs (visual display terminals),
Teleeducation, 123–124 234–235
Telehealth, 119–126 Vendor demos, site visits and, 204–205
challenges related to, 126–127 Vendor-sponsored user groups, 303
Telehealth applications, 121 Vendors
Telehealth users, 122 developing a short list of, 206–207
Telematics, health care, 119 oversell by, 254–255
Telemedicine Exchange Database, 122 Virus protection software, 162
Telemonitoring, 124 Viruses, computer, 46
TELENURSE, 176 Visible human body, 292–293
Telepractice, nursing, 120 Visiting Nurses Association (VNA),
Text editing facilities, 158 174
366 Index

Visual display terminals (VDTs), Websites of Internet, 166–167

234–235 Wide area networks (WANs),
VNA (Visiting Nurses Association), 174 23–25
Voice technology, 14 Wireless connection, 44
Workstations, nursing computer,
W 235–241
WANS (wide area networks), 23–25 World Wide Web (WWW), 30, 46
Web browsers, 47–48 Worldware, 148
WebCT, 149–150 WWW (World Wide Web), 30, 46
 Health Informatics Series
(formerly Computers in Health Care)

(continued from page ii)

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Successful Design and Implementation
E.L. Drazen, J.B. Metzger, J.L. Ritter, and M.K. Schneider

Introduction to Nursing Informatics, Second Edition

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Introduction to Nursing Informatics, Third Edition

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Information Retrieval
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Information Technology for the Practicing Physician

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Transforming Health Care Through Information

Case Studies
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Trauma Informatics
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Consumer Informatics
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Computer Applications in Health Care and Biomedicine, Second Edition
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Filmless Radiology
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Essential Technologies for Clinical Trials
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Clinical Information Systems

A Component-Based Approach
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Knowledge Coupling
New Premises and New Tools for Medical Care and Education
L.L. Weed