CSC 351 (APPLICATION OF COMPUTER IN NURSING) 2 UNITS

Course Synopsis

Week 1: Course Overview – Definition of terms and terminologies

a. Computer Science as a multidisciplinary discipline.

b. Informatics (Information Science and Computer Science)

c. Nursing Informatics (Information Science, Computer Science, and Nursing

Science)

d. The goal and importance of Nursing Informatics

Week 2:
a. History of Nursing Informatics

b. Perspectives to Nursing Informatics

c. Relationship between data, information and knowledge

d. Expert Systems (Knowledge Base)

Week 3:

a. Nursing Informatics tools and methods

b. Nursing Information System (NIS)

Week 4:

a. Application of technology to patient care

b. Decision support systems

Course Grading:

Attendance: 10%

Test: 20%

Assignment: 10%

Examination: 60%

***N.B: Admittance to examination is subject to at least 80% class attendance***

 CSC 351 (APPLICATION OF COMPUTER IN NURSING) 2 UNITS

Introduction

Nursing informatics is a distinct specialty within the nursing profession. With a history dating
back 25 - 30 years, nursing informatics has defined its practice as "the specialty that integrates
nursing science with multiple information and analytical sciences to identify, define, manage,
and communicate data, information, knowledge, and wisdom in nursing practice”. Nursing
informatics supports nurses, consumers, patients, the inter-professional healthcare team, and
other stakeholders in their decision making in all roles and settings to achieve desired outcome.

Information science

Information science is the aggregation of knowledge and practice that deals with the effective
collection, storage, retrieval, and use of information. It is concerned with record-able information
and knowledge, and the technologies and related services that facilitate their management and
use. Information Science is a multidisciplinary science that involves aspect from computer
science, cognitive science, social science, communication science and library science that deals
with obtaining, gathering, organizing, manipulating, managing, storing, retrieving, recapturing,
disposing of, distributing, or disseminating information.

Nursing Informatics

The term nursing informatics was first seen in literature in the 1980s, including a definition of
combining nursing, information, and computer sciences for managing and processing data into
knowledge for use in nursing practice as illustrated in Fig 1. In 1994, The American Nurses
Association (ANA) defined Nursing Informatics as a specialty that integrates nursing science,
computer science, and information science to manage and communicate data, information,
knowledge, and wisdom in nursing practice. Another definition is that from the American
Medical Informatics Association (AMIA), which defines Nursing Informatics as a science and
practice that integrates nursing, its information and knowledge and their management with
information and communication technologies to promote the health of people, families and
communities worldwide. The most elaborate definition of NI is that provided by Saba and
McCormick. They defined NI as the use of technology and/or a computer system to collect,
store, process, display, retrieve, and communicate timely data and information in and across
health care facilities that administer nursing services and resources, manage the delivery of
patient and nursing care, link research resources and findings to nursing practice, and apply
educational resources to nursing education.

Fig 1: Nursing Informatics (Image source: slideshare.net)

NI is one example of a discipline-specific informatics practice within the broader category of

health informatics. Nursing informatics as a field emerged from the overarching discipline of
health informatics and alongside the expanding field of medical informatics. At present, it is a
field of study which is still developing and is based on the concept that health care data and
information can be effectively managed and communicated using computer systems, networks,
modems and telecommunications.

The goal of NI is to improve the way healthcare is dispensed to populations, communities,

families, and individuals by optimizing information management and communication. This is
achieved by designing and using informatics solutions and/or technology to support all areas of
nursing practice including, but not limited to:

 The direct provision of care

 Establishing effective administrative systems

 Designing useful decision support systems,

 Managing and delivering educational experiences,

  Enhancing and supporting life-long learning

 Supporting nursing research

The term individuals refer to patients, healthcare consumers and any other recipient of nursing
care or informatics solutions. The term patient refers to consumers in a certain wellness or illness
state.

NI supports consumers, patients, nurses, and other providers in their decision making in all roles
and settings. This support is accomplished using information structures, information processes,
and information technology.

Importance of nursing informatics

1. Provides a nursing perspective to ICT.
2. Illuminates nursing values and beliefs.
3. Denotes a practice base for nurses in health informatics.
4. Produces unique knowledge.
5. Distinguishes groups of practitioners.
6. Focuses on the phenomena of interest for nursing.
7. Provides needed nursing language and word context (Brennan, 2003) to health
informatics.
History of Nursing Informatics
In order to understand NI, one must understand its history. Health care began to use computers in
the 1950s. Computers in this era were typically used in the business office. In the 1970s, nursing
began to realize the importance of computers to the nursing profession and became involved in
the design and purchase of information systems. In the 1980s, medical and nursing informatics
specialties emerged. The personal computer was introduced, which allowed for flexibility in how
these clinical systems were used. It also brought to everyone‘s attention that not just NI
specialist, but all healthcare personnel would need to know about these systems. The post-2000
era saw an unprecedented explosion in the number and sophistication of both computer hardware
and software. Electronic patient record became an integral part of clinical information systems.
Telemedicine became possible and was recognized as a specialty in the late 1990s. NI has
experienced rapid growth in the last 40 years, and it does not appear to be slowing. It will be
interesting to see what will happen over the next 40 years. Informatics is modeled after the
French word informatique and was first used as medical informatics in the late 1970s, followed
by its use in nursing in the 1980s.

Nursing Informatics Perspectives

The healthcare delivery environment is dramatically changing and nursing has found itself in the
midst of these revolutionary changes. Health care providers are expected to be able to provide
safe, competent care in a highly technical and digital environment. Today‘s nursing practice
requires nurses to be constantly aware of new developments. Nursing is increasingly becoming
as high tech as it is a high touch profession. Today‘s nurses have more technology at their
disposal than any nurses ever before, and as one might expect, it‘s considerably improving
patient care and healthcare management as a whole.

One area where nurses are putting technology to use is in informatics which is officially known
as the study of information management. In the world of health care, health informatics is the
management of health information. Nursing information includes data collected by nurses; data
used by nurses; data about nursing activity; and data about the nursing resource and research.
Using electronic medical records, devices that collect health information electronically, and other
electronic information standards, health informatics nurses are responsible for managing,
interpreting, and communicating the data that comes in and out of health care facilities, all with
one primary purpose: Improving the quality of patient care.
Relationship between data, information and knowledge

Data, information and knowledge are key components of nursing informatics. They help in
understanding clinical information systems and their impact on health care. Patient safety is a
primary concern of any health care provider, and nurses are often on the front lines of ensuring
that their patients are kept safe by preventing medication errors, misdiagnoses, falls, and other
problems. Nursing informatics provides important data that can prevent these errors; for
example, an electronic record can provide information about a possible dangerous medication
interaction or allergy that might not otherwise be immediately apparent. Armed with data which
translate into information and knowledge, nurses can make quick decisions that would keep
patients safe.

Fig 2: Information cycle

Data can be vaguely defined as a collection of unprocessed facts and details about an entity.
They are discrete entities that are described objectively without interpretation. An example might
be a person‘s weight. Without additional data elements such as height, age, overall well-being, it
would be impossible to interpret the significance of an individual number. Information, on the
other hand, is the result of processing data i.e. data that are interpreted, organized, or structured.
For example, height, weight, age, and gender are data elements that can be used to calculate the
BMI. The BMI can be used to determine if the individual is underweight, overweight, normal
weight or obese. Knowledge is information that is synthesized so that relationships and trends
are identified and formalized. Knowledge is built on a formalization of the relationships and
interrelationships between data and information. A knowledge base (Expert Systems) makes it
possible to understand that an individual may have a calculated BMI that is over 30 and not be
obese. At this time, several automated decision support systems includes a knowledge base and a
set of rules for applying the knowledge base in a specific situation. For example, the knowledge
base may include the following information. “A fever or elevated temperature often begins with
a chill. At the beginning of the chill, the patient‘s temperature may be normal or even sub-normal
but in 30 minutes it is likely the patient will have a spiked temperature.” A rule might read: “if a
patient complains of chills, then take the patient‘s temperature and repeat in 30 minutes.”

Data is the raw material for information which in turn is the raw material for knowledge. As data
are transformed into information and information into knowledge, as depicted in fig 2, each level
increases in complexity and requires greater application of human intellect.

Data, which are processed to information and then knowledge, may be obtained from
individuals, families, communities, and populations. Data, information, and knowledge are of
concern to nurses in all areas of practice. For example, data derived from direct care of an
individual may then be compiled across persons and aggregated for decision-making by nurses,
nurse administrators, or other health professionals. Further aggregation may address
communities and populations. Nurse educators may create case studies using these data, and
nurse researchers may access aggregated data for systematic study.

As an example, an instance of vital signs for an individual; heart rate, respiration, temperature,
and blood pressure can be considered (a set of) data. A serial set of vital signs taken over time,
placed into a context, and used for longitudinal comparisons is considered information. That is, a
dropping blood pressure, increased heart rate, respiratory rate, and fever in an elderly,
catheterized person are recognized as being abnormal for this person. The recognition that the
person may be septic and, therefore may need certain nursing interventions reflects information
synthesis (knowledge) based on nursing knowledge and experience.
Nursing informatics tools

Good nursing practice requires detailed record keeping that is comprehensive, timely and
accurate. Without complete recording, there is no evidence to prove that care was provided to the
patient, and in nursing practice there is a saying that “what is not recorded has not been done”
(Marinic & Taiye, 2015). Furthermore, poor record keeping not only undermines patient care but
makes the nurses more vulnerable to legal claims which arise from breakdown in communication
that results from incomplete or inadequate records.

Informatics tools and methods from computer and information sciences are considered
fundamental elements of NI. Information technology includes computer hardware, software,
communication, and network technologies, derived primarily from computer science.
Information structures organize data, information, and knowledge for processing by computers.
Information management is an elemental process within informatics in which one is able to file,
store, and manipulate data for various uses.

Nurses may generate and record data from their own observations or with the assistance of
various devices. In this way, free text informational data such as drug dosages administered,
resources used, problems diagnoses, etc are recorded manually. Free text is then interpreted and
organized by some standardized principle, either manually or by the computer. In this way, data
(often qualitative data that cannot be traditionally measured) can be organized and processed.
Data actually becomes information when the separate components are interpreted, organized,
combined and structured within a specific context to convey particular meanings.

Certain applications are designed to collect, sort, organize, store, retrieve, select, and aggregate
data. For example, database management systems (DBMS) are primarily used to manage data in
a database. A DBMS can be used to maintain an almost unlimited number of databases.
Examples of DBMS include Microsoft Access, Oracle/MySQL etc. Nursing and health data may
be classified into four basic types:

1. Resource data (e.g. financial information)

2. Patient or client demographics

3. Activity data (clinical data) and

4. Health service provider data

These primary data are recorded manually or collected electronically. Manual collection allows
for a greater possibility for error. Data that has been electronically recorded follows a
programmed set of instructions built into the software, thus cutting down substantially on the
occurrence of collection error. One paramount importance in the collection process is the data
collection form and computer interface used for inputting the data; these will affect
completeness, consistency and accuracy.

Quantitative data collection tools include questionnaires, interviews, surveys, quizzes,

assessments, E-mail interviews, and web-based surveys.

A questionnaire is a data collection instrument consisting of a series of questions and other

prompts for the purpose of gathering information from respondents. The questionnaire was
invented by Sir Francis Galton. Questionnaires are one of the most popular form of data
collection and can be administered in hard copy on paper, or programmed into a web site where
individuals may answer the questions electronically. Other electronic data collection tools
include Personal Digital Assistants (PDAs) and on-site laptops. A benefit of using electronic data
collection is the ability to transmit data to another computer directly for compilation and
analysis, thereby cutting down on error.

Questionnaires allow collection of both subjective and objective data in a large sample of the
study population in order to obtain results that are statistically significant, especially when
resources are limited. It is a good tool for the protection of the privacy of the participants. The
validity of data and information depends on the honesty of the respondent. The questionnaires
can measure both qualitative and quantitative data, but it is more appropriate for quantitative data
collection.

Nursing Information System (NIS)

Nursing Information System (NIS) is a part of health care information system that deals with
nursing aspects, particularly the maintenance of the nursing record. In health care organizations
as in other fields, the first computer-based management information systems implemented were
typically limited to financial applications. Quantitative financial data are easily automated, and
the benefits are readily observable and measurable. However, the role of management
information systems in today's nursing departments continues to expand as nursing managers
recognize the value of information as an essential resource. The increasing complexity of patient
care problems, combined with the pressures for efficiency and effectiveness in patient care have
prompted nursing managers to require quick access to useful and reliable information. With these
kinds of demands, manual data processing has become increasingly ineffective in supporting
healthcare management and decision making.

The advantages of automation extend far beyond the ability of a computer to crunch numbers.
While it is true that more data can be processed at a greater speed, automated management
information systems provide for enhanced accuracy, increased detail, and flexibility in reporting,
as well as standardization of the information reported.

As the number of hospital information systems (HISs) have rapidly increased, systems for
nursing also have increased. Since nursing care is a major operating cost within a hospital
budget, nursing management is important for cost saving and it contributes to the financial
stability of hospitals. Moreover, nursing management also affects clinical practice; it is
responsible for managing nursing units, personnel (recruitment, selection of staff, development,
working environment), budgets (budgeting, cost control, and financial results), nursing practice
(introducing and maintaining standards), and the development of services. For these activities,
effective nursing management relies on the effective use of up-to-date information about patient
flow and acuity, staffing, and costs. Thus, evaluation of these systems should be conducted to
manage costs, activity planning, resource allocation, and quality assurance. With advances in
computer software, nursing management applications have been expanded to the extent that they
are now beginning to support decision making and strategic planning.

For information to influence management in an optimal way, it has to be used by decision

makers at each point of the management spiral. Examples of these decision points include
undertaking situational analysis, setting priorities, or implementing a programmed activity.
Information is crucial at all management levels of the health services, from the periphery to the
centre. It is crucial for patient/client management, for health unit management, as well as for
health system planning and management. This means that not only policymakers and managers
need to make use of information in decision making but also care providers, including doctors,
health technicians, and community health workers. Unless this occurs, the considerable
opportunity costs involved in the set-up and maintenance of health information systems can be
difficult to justify.

How can Technology help Nurses care for patients?

The use of computer and information technology to support an electronic health record (EHR) is
quickly becoming a standard practice in health care. For nurses and other healthcare personnel,
the use of computer technology provides quick access to important information about health or
illness. It means patients no longer have to provide health information multiple times as they
receive care and the assurance that members of the health-care team have ready access to current
health information.

Nurses use computers in their daily work to:

1. Record on the electronic health record patients’ personal health-care story, the treatments
they carry out for patients, and patients’ response and progress toward health care goal for
monitoring and for ready access by other team members.

2. Obtain information about patients’ past and ongoing treatments and medications and the
results to ensure the best care is provided.

3. Review data about patients’ current and past health situation and plan of care on the
electronic health record, which helps them monitor patients’ recovery process over time.

4. Access clinical knowledge such as drug information, nursing assessments, articles and
nursing best practice guidelines and resources to better understand patients’ health situation
and plan of care.

To provide information management assistance to nurses, the three of source data capture,
nursing data standards, and decision support system must be addressed. These three areas are
crucial to providing computer support for nurses in the delivery of patient care.

Source Data Capture

Source data capture refers to the process of gathering data and information about patients where
it originates, that is, with the patient. The concept of terminal by the bedside was introduced in
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 appears to favor the bedside
terminal as a means to reduce much of the clerical workload and improve access to clerical data.

Nursing Data Standards

Standards are critical in the development and implementation of electronic health records
(EHRs). The effectiveness of health delivery is dependent on how the nurses have access to
critical health information where and when it is needed. Nurses continually use mental processes,
often unconsciously, to organize information systematically by grouping data according to
common features. This is done in order to make sense of the massive amounts of information
with which they are daily bombarded. This problem arises because nurses do not have a common
system or language to communicate precisely, even with each other. If it cannot be named, it
cannot be controlled, financed, taught, searched for or put it into public policy, because nursing
does not have universally accepted methods for defining and collecting nursing data. 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 component 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. This information is essential for nurses to be able to develop evidence-based
practice. Data to support evidence-based practice is required not only for clinical practice, but
also to inform evidence-based decision making by nurse managers. Therefore, as the
development of nationwide health database increases, it is vital that the minimum number of
essential nursing elements be included in the database.

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 nomenclature. These words/labels
can then be combined within a defined structure and systematic management to form a language
system for nursing. From the 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 centre of spiral; and the continuous process of development, refinement
and modification in response to external change begins again.

Decision Support Systems

Decision Support Systems (DSS) are a computer-based form of decision enhancing tools,
integrating information (ideally from high quality research studies) with the characteristics of
individual patients, to provide advice to clinicians (Dowding D et al., 2007). Clinical Decision
Support Systems (CDSS) used interchangeably with DSS have been shown to lead to significant
quality and safety improvements in patient care and improve workflow among clinicians.

Nurses have a unique dual role regarding information; they are both generators and consumers of
an enormous amount of data in any given patient encounter. CDSS are computer software
applications that match patient characteristics with a knowledge base to generate specific
recommendations. Decision support can take many forms and is often integrated subtly into
many aspects of an EHR. It is not intended to replace the provider‘s knowledge or experience,
but rather to facilitate the best decision possible with the best information available. CDSS
represent the intersection of clinical decision-making, cognitive sciences, evidence-based
practice, and computer science all contextualized by the practice setting, patient population,
provider needs, and information technology infrastructure.

Decision support systems offer great potential to assist nurses to handle the volume of data and
information they encounter daily. Six major uses of decision support have been identified;

1. Alerting systems: These systems notify the clinicians of an immediate problem that calls for
a prompt action or decision. These alerts are commonly clinician alerts that appear on the
screen at time of entry of orders, assessments, or laboratory values. These systems may also
provide management alerts based on problem with an individual patient or an individual
clinician.

2. Interpreting Systems: This type of CDS system is one that works to interpret particular data
such as electrocardiogram or blood gases. 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. Assistive Systems: A system that is used to simplify clinician interaction 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 list, patient specific drug
dosing, or appropriate parameter for charting based on earlier identified patient problems.

4. Critiquing: Systems that do this 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
problem. For example, a clinician might enter orders for a change in respirator settings
which the system will then critique in light of the most recently entered blood gases. The
clinician would be presented with an alternate set of orders and the rationale for change
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 so as to rule out, rule
in, or otherwise refine the list of diagnostic possibilities. Other system that can be considered
in this category are those which provide predictive scoring of mortality, estimation of
treatment benefits based on effects of competing risks, or prediction of specific risks.

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. While those systems with fixed protocols are easy to program and to
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 that
clinicians give a rationale for changing the plan or the protocol and this is used to determine
further data needs and decision rules so that the protocols are further refined. The variation
in the 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, so the
refined protocols result in a progressively higher quality of care.
Course Project:

Attempt to build a knowledge base for an expert system that can satisfactorily advise respondents
based on the following:

1. Vital signs (Group 1)

2. BMI (Group 2)

3. Bloated Stomach (Group 3)

4. Recurring malaria (Group 4)

5. Fatigue (Group 5)

Review Questions:

1. Briefly discuss the nexus between Computer Science and Nursing as a Profession.

2. Discuss at least four (4) importance of Nursing Informatics.

3. Using an empirical example, fully show your understanding of the terms data, information
and knowledge.

4. Briefly discuss at least three (3) Nursing informatics tools.

5. Manual data collection and entry is very prone to error.

a. Why is this the case?

b. How can this be avoided?

6. Discuss five ways Nursing informatics help Nurses to dispense health-care to patients.

7. Write short notes on the following:

i) Source data capture ii) Nursing data standards iii) Decision Support Systems

8. Are decision support systems different from expert systems? Justify your response.

9. Discuss various ways computers have aided Nurses training and research.