Nursing Informatics

Sanil Varghese

HEALTH CARE INFORMATICS- HISTORY

MEANING

• Informatics comes from the French word “informatique” which means “computer science”.

• Informatics is defined as computer science+information science.

DEFINITION

• Hebda (1998), defines nursing informatics as the use of computers technology to support nursing, including clinical practice, administration, education and research.

• ANA (American Nurses Association) 1994, has defined nursing informatics as the development and evaluation of applications, tools, processes and structures which assist nurses with the management of data in taking care of patients or supporting the practice of nursing.

APPLICATION OF NURSING INFORMATICS / GENERAL PURPOSE

Nursing Clinical Practice:• Work lists to remind staff of planned nursing interventions.• Computer generated client documentation.• Electronic medical record (EMR) and Computer based Patient

Record (CPR).• Monitoring devices that record vital signs and other

measurements directly into the client record (EMR).• Computer generated nursing care plans and critical pathways.• Automatic billing for supplies or procedures with nursing

documentation.• Reminders and prompts that appear during documentation to

ensure comprehensive charting.

Nursing Administration (Health care information system)

• Automated staff scheduling.• E-mail for improved communication.• Cost analysis and finding trends for budget

purposes.• Quality assurance and outcomes analysis.

Nursing Education:• Computerized record keeping.• Computerized assisted instruction.• Interactive video technology.• Distance learning- web based courses and degree

programmes.• Internet resources- formal nursing courses and degree

programmes.• Presentation software for preparing slides and

handouts- power points and MS words.

Nursing Research:• Computerized literature searching- CINHAL,

Medline and web sources.• The adoption of standardized language related

to nursing terms-NANDA etc.• The ability to find trends in aggregate data,

that is data derived from large population groups- SPSS.

Patient Education:

• Nursing informatics can be used for symptom management and patient education. The nurse can access the information for the patient or teach the patient where to find appropriate and helpful information. For example, on an oncology unit, nursing informatics can be used to teach patients effective symptom management of the treatment modalities which often cause pain, fatigue and poor nutritional status. Nursing informatics can also aid in other nursing interventions of the oncology nurse, such as analgesic administration and stress-reduction techniques.

Clinical Alert System:

• The computerized clinical alert system can be used in conjunction with the hospital pharmacy. A system design is created to alert both pharmacy and health staff when two or more drug prescriptions are incompatible.

Patient Data:

• Nursing informatics can also be useful in a physician’s clinic. In a managed care environment, information systems make administrative management more efficient. The private practitioner, program or facility to manage every aspect of patient care can use one data management system. In each of these health care settings data management systems can be applied to treatments, diagnostics, documentation, practice management, insurance claims and referrals and protocols as well as treatment and diagnostics results.

Telehealth:• Telehealth includes the use of telephones and sophisticated

image transmission systems like ECG, faxes and remote camera imaging. Telehealth places the ambulance personnel in touch with the Emergency Department and it also operates to put the generalist “nurses and doctors” at the ED in touch with specialists. Telehealth is used to evaluate the stroke victims while they are in transit so appropriate therapy can be initiated quickly upon arrival at the ED. In similar fashion, a nurse practitioner in a remote ED might be guided via telephone in the proper procedure for inserting chest tubes so a man with a collapsed lung could be stabilized for subsequent transport to a major hospital. Finally, nursing informatics can be useful for interdepartmental communication such as ordering supplies from central supply, lab work, etc.

Clinical Information:

• In order for the nurse to ensure the patient is receiving the most up-to-date care for a variety of chronic conditions, the National Institute of Health (NIH) have an agency designed to offer such guidance. Clinical practice guidelines can be found at http://www.nhlbi.nih.gov/guidelines/index.htm. The practice guidelines found at this site provide management information for asthma, cholesterol, hypertension and obesity.

• Clinical practice guidelines for the management of diabetes mellitus and menopause can be found at http://www.aace.com/clinguideindex.htm. Further information can be found through the Medscape Nurses site and National Institute of Health- http://www.nih.gov.

SIGNIFICANCE OF NURSING INFORMATICS

I. Nursing informatics facilitates communication.

II. Nursing informatics allows articulation of organized information.

III. Nursing informatics leads to credibility.

BENEFITS OF COMPUTER AUTOMATION IN HEALTH CARE

EMR• Improved access to the medical ward: the EMR

can be accessed from several different locations simultaneously, as well as by different levels of providers.

• Decreased redundancy of data entry: for example, allergies and vital signs need only be entered once.

• Decreased time spent in documentation: automation allows direct entry from monitoring equipment, as well as point of care data entry.

• Increased time for client care: more time is available for client care because less time is required for documentation and transcription of physician orders.

• Facilitation of data collection for research: electronically stored client records provide quick access to clinical data for a large number of clients.

• Improved communication and decreased potential for error: improved legibility of clinician documentation and orders is seen with computerized information systems.

• Creation of a lifetime clinical record facilitated by information systems.

Other Benefits:• Decision support tools as well as alerts and

reminders notify the clinician of possible concerns or omissions. An example of this, is the documentation of patient allergies in the computer system. The health care providers would be alerted to any discrepancies in the patient medication orders.

• Effective data management and trend finding include the ability to provide historical or current data reports.

• Extensive financial information: can be collected and analyzed for trends. An extremely important benefit in this era of managed care and cost cutting.

• Data related to treatment such as inpatient length of stay and the lowest level of care provider required can be used to decrease costs.

TRENDS NURSING INFORMATICS:

Past Nursing Informatics

• Nursing informatics was first defined as the use of computer technology to support nursing, including clinical practice, administration, education and research.

• The first generation of nursing information systems was designed to speed paperwork and communication. In general, the systems accomplished this by transferring information to the computer, what nurses had done on paper and by telephone. These systems replaced paper records, filing cabinets and pneumatic tubes. Although this was helpful and effective in reducing the time spent on documentation and communication it did not address many of the fundamental issues for nurses’ use of data, information and knowledge to guide effective care (Executive summary, 2004).

• Until 1948, primary care remained in the home. With the development of Hill-Burton Act of 1948, money was provided for the building of hospitals and promoted a catalyst for change in healthcare. In the 1960’s, Medicare and Medicaid provided reimbursement for services to many individual patients and the health insurance industry grew. This provision of funding allowed many new innovations: new drugs, advanced surgical procedures, new technologies and equipment, and sophisticated diagnostic procedures. All of which led to the development of medical specialties, each treating a different part of the patient and creating its own records for what patient (Thede, 2003).

• It is not unusual to find a patient being treated by several physicians at the same time. These physicians share little information; they may duplicate tests or prescribe medications that are not compatible with those prescribed by another physician. The current healthcare system relies primarily on paper records that are oriented to episodes and providers (Thede).

• During the past four decades the U.S. government has played a major role in the development and promotion of telehealth through various agencies. Although interest waned as funds were depleted in the 1980’s, technological advancements made it a more attractive prospect. Federal monies and Agriculture Department’s 1991 Rural Development Act laid the groundwork for bringing the information superhighway to rural areas for education and telehealth purposes (Hebda, et al, 2001).

• The most aggressive development of telehealth consults for Armenian earthquake victims in 1989, while more recently the military has been working on several projects to feed medical images from the battlefield to physicians in hospitals for improved treatment of casualties (Hebda, et al, 2001).

Present Nursing Informatics

• Although the history of nursing informatics extends only some twenty years, the field is advancing rapidly as a scientific discipline and has significant implications for patient care (Executive Summary, 2004).

• As research in nursing informatics evolves, it has become apparent that the issues are far more complex than reducing time spent on paper work. The high-intensity generation, management, processing of data and knowledge are integral components of nursing care. Informatics gives nurses the means to carry out these aspects of care efficiently and effectively to improve outcomes for patients.

• Nursing informatics impacts nurses today. Today, evolving standards of practice increase the nurse’s accountability. The malpractice crisis has strengthened accountability and increased emphasis on complete and detailed nursing documentation. Changes in reimbursement methods are affecting nursing care delivery. Cost containment and consumerism place additional pressures on not only the individual nurse but also the entire nursing profession (Ball, et al. 2000).

Future Nursing Informatics

• Nursing informatics has arrived and the baby has started to walk. In the process, nursing informatics has introduced new challenges and opportunities along with new computer applications.

• Nursing informatics is a growing field for advancement and offers many potential areas for cost containment.

• Nursing informatics and managed care, make telehealth an attractive tool to save healthcare dollars: Telehealth may provide savings in the following areas: improved access to care, allowing clients to be treated earlier and with fewer interventions.

• Clients may receive treatment in their own community where services cost less, improving quality of care and improved continuity of care through convenient follow-up.

• Telehealth applications vary greatly and include client monitoring, diagnostic evaluations, decision support systems, storage and dissemination of records for diagnostic purposes, image compression for efficient storage and retrieval, research, voice recognition for dictation and education of healthcare professionals and consumers.

• Many providers expect that telehealth will revolutionize healthcare. It promises to improve speed and accuracy of communicating with medical providers to gather information and address concerns.

• Nursing informatics and telehealth will continue to grow and become commonplace (Hebda, et al, 2001).

• Telehealth is an expansion of telemedicine and unlike telemedicine (which more narrowly focuses on the curative aspect) it encompasses preventive, promotive and curative aspects. Originally used to describe administrative or educational functions related to telemedicine, today telehealth stresses a myriad of technology solutions. For example, physicians use email to communicate with patients, order drug prescriptions and provide other health services.

JOURNAL REFERENCES

• Exploring the impact of health information technology on communication and collaboration in acute care nursing.

• Nurses’ experiences using a nursing information system: early stage of technology implementation.

• The perfect role for nursing informatics: Nursing staff development.

USE OF COMPUTERS IN HOSPITAL AND COMMUNITY

CLINICAL IMPLICATION• Assessment:• Patient monitoring:• Documentation:• Nursing minimum data sheet: • Telemedicine:• Electronic Medical Records (EMR): Increased efficiency: Improved documentation: Improved quality of care: Improved security: Reduced documentation expenses:

ADMINISTRATION: • Provision of data required by the nurse

administrators to:• Define the cost of nursing services.• Evaluate quality assurance programme.• Demonstrate the cost effectiveness of nursing

care• Justify new roles for nursing in the health care

system

NURSING PRACTICE:• Enhance documentation by the nurse.• Provision of data to enable research directed at

examining relationship between data elements and nursing outcomes to identify optimal nursing care for use in practice.

• Facilitate nursing process through use of the NMDS in practice.

• Nursing workload measurement system: The three most widely used nursing workload measurements are: Project research in nursing: Medicus. GRASP (Grace- Reynolds application)

RESEARCH:• The advent of computerized data bases of literature helps

to search rapidly and to retrieve abstracts of literature immediately.

• Conduct online searches of data base.• Provides online full text information on legal, news,

business and general information.Eg: CINHAL, Medline, Science Direct.

• Preparation of research document:• Data gathering:

There are three types of computer assisted interviewing:– Computer self administered interviewing:– Computer assisted telephone interviewing:

• Data analysis:

EDUCATION:

The use of computer in nursing education includes:

• Computer assisted instruction:• Computer assisted interactive video

instruction:• Simulation:• Tutorials:

COMMUNITY SETTING:

The main uses of computers in community are: • Gathering of epidemiological and

administrative statistics.• Patient appointments- identification system.• Patient assessment and data gathering.• Monitoring.• Documentation.• Special need application.

PATIENT RECORD SYSTEM

DEFINITION• A ‘medical record’ is a patient record, consisting

of sufficient data written in sequence of events to justify the diagnosis and warrant treatment and end results. It must be adequately informative, highly scientific and legally protective.

• It may be defined as a clinical, scientific, administrative and legal document relating to the patient’s care.

IMPORTANCE OF MEDICAL RECORDS

• To the patientIt helps in the following ways:– It serves to document the history of the patient’s illness.– It serves to avoid omission and unnecessary repetition

of diagnosis and treatment measures.– It assists in the continuity of care in the event that

future illness requires attention in or out of the hospital.– It serves as evidence to support or to refute any legal

questions which may arise.– It assists the patient and authorities concerned in fixing

disability entitlements under the Workman’s Compensation Act.

• To the hospitalThe medical records from the basis of many phases of administrative efficiency:– It provides the management with statistical information

necessary for decision making with regard to utilization of resources, planning for administrative control and future references.

– It also furnishes documentary evidence for purposes of evaluation of hospital care in terms of quality, quantity and adequacy (medical audit).

– It protects the hospital in the event of legal questions (Torts suits).

• To the doctors– It assures the doctor of the quality and adequacy

of the diagnostic and therapeutic measures undertaken by him.

– It assures the doctor of the continuity of medical care.

– It helps the doctor in self evaluation.– It protects the doctor in case of legal suits.

• To the public health authoritiesIt provides a reliable mortality and morbidity statistics and thus helps the public health authorities to plan preventive and social measures to meet the needs of the community. Early warning of the incidence of communicable diseases is often obtained from hospital records.

• To medical education and researchSince recorded observations and case studies are the basis of all clinical research, medical records become invaluable in all research and teaching programmes.

CHARACTERISTICS OF GOOD PATIENT RECORDS

• Complete: Sufficient data to identify the patient, justify diagnosis and warrant treatment and outcome.

• Adequate: All necessary forms and all relevant clinical information.

• Accurate: Capable of quantitative analysis.

COMPUTERIZED PATIENT RECORD

Advantages of CPR:• Have the patient’s entire history.• Can flag drug reaction problems.• Can eliminate redundancy in record keeping.• Eliminate the need for taking repeated

histories.• Can, if utilized properly, reduce error.

Disadvantages of CPR:• Are very expensive to set up.• Are less secure.• Require standardized coding systems, which

force all users to use entries that the computer can understand.

FUNCTIONAL COMPONENTS OF A COMPUTER-BASED PATIENT-RECORD SYSTEM

• The five functional components are:• Integrated view of patient data• Clinical decision support• Clinician order entry• Access to knowledge resources• Integrated communication support

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