1. Collins, Sarah PhD, RN
  2. Sensmeier, Joyce RN-BC, MS, CPHIMS, FHIMSS, FAAN
  3. Weaver, Charlotte PhD, RN, MSPH, FHIMSS, FAAN
  4. Murphy, Judy BSN, RN, FACMI, FHIMSS, FAAN

Article Content

Healthcare policy is rapidly changing, and these changes have anticipated and unanticipated impacts to nursing and health information technology (HIT). Within healthcare, nursing as a profession continues to evolve, including innovations in nursing science. As patients rightfully expect expedient and full access to their data and technology is leveraged to achieve the Triple Aim, policies focused on HIT are being enacted at a more rapid pace than any time in history.1,2


As stakeholders and representatives of nursing informatics organizations in the United States, the Alliance for Nursing Informatics (ANI) routinely provides comments to federal policy proposals deemed relevant and important to our field. Comments provided are aligned with the ANI Vision, Mission, and Strategic Aims.3 The ANI vision is to transform health and healthcare through nursing informatics and innovation and its mission is to advance nursing informatics leadership, practice, education, policy, and research through a unified voice of nursing informatics organizations.


The ANI Strategic Aims focus on specific drivers and core values in healthcare:


* Drivers: affordability, evidence-based practice, healthcare reform, informatics as a tool, interoperability, meaningful use, and a roadmap for long-term care


* Core values: communication, consumer empowerment, innovation, interprofessional collaboration, leadership development, quality and safety, and transformation



Member organizations of ANI include the Healthcare Information and Management Systems Society (HIMSS), American Medical Informatics Association (AMIA), and the American Nurses Association (ANA), as well as other national and international organizations. The full list of ANI member organizations can be accessed at


In the first 6 months of 2016, ANI responded with comments to five proposed national policies that spanned a breadth of domains critically important to nursing informatics-patient safety, electronic documentation burden, nursing research, and interoperability. All policy responses and comments submitted on behalf of ANI can be found on the ANI Web site at Below, we provide a summary of each draft policy and the ANI responding comments from 2016.


Patient Safety

The National Quality Forum (NQF) released a public comment opportunity open through January 2016 regarding the HIT and Patient Safety Project for the draft report "Identification and Prioritization of Health IT Patient Safety Measures."4 The draft report provided a comprehensive framework for assessment of nine HIT safety measurement efforts, a measure gap analysis and recommendations for gap-filling, and best practices and challenges in measurement of HIT safety issues to-date. The ANI response commended this work and confirmed that clinical decision support (CDS), system interoperability, user-centered design, feedback and information-sharing, use of HIT to facilitate timely and high-quality documentation, and patient engagement are high-priority areas for safety measurement and provided recommendations for each. For example, it was noted that the CDS examples used in the report were narrow in scope, ignoring the critical nursing and patient decision making that occurs in practice. The response pointed out that the notion that risk-based CDS applications are "still somewhat aspirational goals" overlooks substantial work related to risk- and guideline-based CDS such as those completed by Dykes et al5 (falls prevention CDS) and Bowles et al6 (readmission reduction). The ANI recommended that user-centered design should focus on high-risk scenarios through simulation and must include patients, and accountability for usability should be shared among vendors and organizations. Measures to evaluate "good" clinical documentation should be clearly defined and prevent increased documentation requirements that are not based on sound safety evidence. The ANI recommended increased focus on technical solutions such as full integration of medical devices to allow nurses to function at their highest level of practice, rather than performing data entry tasks. A stronger emphasis on medication reconciliation was requested given high rates of medication errors and a lack of maturity of the market place. Finally, ANI encouraged harmonization with measures for meaningful use stage 2 and 3 and the addition of patient portals, mHealth, and telemedicine tools as data sources for measuring HIT Safety.


Electronic Documentation Burden

In January 2016, ANI responded to the draft "Senate HELP Bill to Improve Federal Requirements Relating to the Development and Use of Electronic Health Records Technology."7 An intent of the Bill was to decrease unnecessary documentation burden for healthcare providers. Specific language in the bill included that "A physician (as defined in section 7 1861(r)(1) of the Social Security Act) may delegate electronic medical record documentation requirements specified in regulations promulgated by the Department of Health and Human Service to a person who is not such physician if such physician has signed and verified the documentation." This language was interpreted by some as passing physician documentation burden on to nurses. The ANI provided comments that emphasized that the principles described in the bill should apply to all healthcare professionals, not only physicians. The response also stated that nurses should not be doing the work of other licensed health professionals, specifically documenting on behalf of physicians. There are potential negative impacts on registered nurses in the acute care setting if this were to occur and the documentation burden for nurses in acute care is already excessive. The ANI commended the intent of the bill-support for decreasing unnecessary documentation burden for healthcare providers-and recommended that the language should be more specific to protect nurses from being required to perform the work of physicians.


Nursing Research

In March 2016, the National Institute for Nursing Research (NINR) accepted comments on its draft 2016 Strategic Plan.8 The Strategic Plan provides specific guidance on the types of grant proposals that will be awarded funding from NINR. The draft 2016 Strategic Plan focused on Technology to Improve Health as a cross-cutting area crucial to the advancement of nursing science and future of nursing research. The ANI enthusiastically commended this focus. The ANI comments emphasized the importance of robust nursing data standardization, interoperability, systems for aggregating and analyzing nursing data, and standard approaches for integrating clinical nursing data from applications or point-of-care devices as a critical foundation for scaling and spreading innovative and applied technology projects funded by NINR within the healthcare domain. Specifically, ANI encouraged NINR to devote attention to research evaluating nationally recognized terminology standards, particularly LOINC and SNOMED-CT, implemented in the context of structured nursing documentation.


Interoperability Standards

In 2016, ANI responded to two federal policy proposals focused on Interoperability, both from the Office of the National Coordinator (ONC) for HIT. The first was an Interoperability Standards Advisory (ISA) seeking comments in March 2016.9 This advisory proposed new interoperability standards including four new proposed nursing categories: Nursing Assessments, Nursing Outcomes, Nursing Problems, and Nursing Interventions and Observations. The ANI response fully supported the inclusion of these nursing categories and provided recommendations for how they should be specified. The ANI confirmed that all ANA-recognized terminologies should be "mapped" to SNOMED-CT and endorsed the use of the Nursing Problem List Subset of SNOMED-CT. Specific comments recommended regrouping the categories from how they were originally proposed to instead group Nursing Observations and Assessments together (since Observations can be an Assessment) and include Nursing Interventions as a separate category. The ANI described best practices for terminology mapping for these nursing categories, noting that Observations are Assessment questions and those questions should be coded using LOINC.10 Observation (ie, Assessment) answers should be represented as values using SNOMED-CT. Nursing Interventions should be modeled with SNOMED-CT, as this model is consistent with International Organization for Standardization (ISO) 18104 and International Classification Nursing Practice (ICNP) models.11-13 Outcomes that are measurements should be coded as LOINC observations. Outcomes that are observed assessments that a patient state has improved should be coded using SNOMED-CT. Finally, ANI recommended increasing the breadth of coverage for LOINC assessment items to enable more comprehensive and consistent coding of these nursing concepts.


The second ONC policy request for comments related to interoperability occurred in June 2016. This Request for Information asked for input on how to define interoperability metrics as well as current and/or new potential data sources that could be used to measure interoperability more broadly, as required in the Medicare Access and CHIP Reauthorization Act (MACRA).14 The ANI comments recommended that interoperability metrics should also include other exchange partners and the measurement of information exchange and use should be extended outside of certified EHR technology and aligned with the Interoperability Roadmap as soon as possible. Other exchange partners should include consumers, behavioral health, school nurses, long-term care providers, and other health professionals. The ANI recommendations were based on the notion that interoperability should be focused on the "use" of clinical information that has been exchanged to provide access to longitudinal information for health care providers in order to facilitate continuity and coordinated care and improve patient outcomes. The ANI emphasized the importance of including the domains of behavioral health, population health, and long-term care in the context of interoperability metrics. Finally, ANI urged ONC to include the use of patient-generated data as a critical reconciliation-related metric for interoperability, given patients' centrality and ownership of their medication regimen.



The ANI is committed to providing a unified voice for nursing informatics in the health policy arena aligned with the ANI Vision, Mission and Strategic Aims. In the first 6 months of 2016, ANI provided policy comments that were aligned with a breadth of drivers and core values from the ANI Strategic Aim, including informatics as a tool, interoperability, meaningful use, a roadmap for long-term care, communication, consumer empowerment, innovation, interprofessional collaboration, quality and safety, and transformation. The ANI looks forward to reviewing future policy proposals and using the opportunity to provide endorsement, constructive feedback, and specific recommendations to enhance those proposals on behalf of the nursing informatics community to improve and advance care.



Thank you to the ANI members who served on a Task Force for developing comments on behalf of ANI: Carolyn Cordtz, Kelly Cochran, Vicky Tiase, Susie Hull, Kelly Wiseman, Luann Whittenburg, Marcy Stoots, Brenda Kulhanek, Patti Dykes, Laura Heermann Langford, Kandace Kelly, Cathy Ivory, Susan Matney, Cathy Ivory, and Mollie Cummins.




1. Payne TH, Corley S, Cullen TA, et al. Report of the AMIA EHR-2020 Task Force on the status and future direction of EHRs. J Am Med Inform Assoc. 2015;22(5): 1102-1110. doi:10.1093/jamia/ocv066. [Context Link]


2. Institute for Healthcare Improvement. The IHI triple aim. IHI Triple Aim Initiative. 2014. Accessed October 14, 2016. [Context Link]


3. ANI. Alliance for Nursing Informatics Website. 2016. [Context Link]


4. National Quality Forum. Identification and prioritization of health it patient safety measures. 2015:72. Accessed October 14, 2016. [Context Link]


5. Dykes PC, Carroll DL, Hurley A, Lipsitz S, Benoit A, Chang F. Fall prevention in acute care hospitals. JAMA. 2010;304(17): 1912-1918. [Context Link]


6. Bowles KH, Chittams J, Heil E, et al. Successful electronic implementation of discharge referral decision support has a positive impact on 30- and 60-day readmissions. Res Nurs Health. 2015;38(2): 102-114. doi:10.1002/nur.21643. [Context Link]


7. Senate HELP Committee. To improve federal requirements relating to the development and use of electronic health records technology. 2016:51. Accessed August 19, 2016. [Context Link]


8. National Institute for Nursing Research. NINR invites public comment on next strategic plan. 2016. Accessed August 19, 2016. [Context Link]


9. The Office of the National Coordinator for Health Information Technology. 2016 interoperability standards advisory. 2016:80. Accessed August 19, 2016. [Context Link]


10. Regenstrief LOINC(C) Mapping Assistant (RELMA). Indianapolis, IN: Regenstrief Institute; 2015. [Context Link]


11. ISO. ISO freely available standards. ISO Standards Main Portal. 2013. Accessed October 14, 2016. [Context Link]


12. Bakken S, Hyun S, Friedman C, Johnson SB. ISO reference terminology models for nursing: applicability for natural language processing of nursing narratives. IJMI. 2005;74(7-8): 615-622. doi:10.1016/j.ijmedinf.2005.01.002. [Context Link]


13. Park H-A, Lundberg C, Coenen A, Konicek D. Mapping ICNP version 1 concepts to SNOMED CT. Stud Health Technol Inform. 2010;160(pt 2): 1109-1113. [Context Link]


14. The Office of the National Coordinator for Health Information Technology. Request for information regarding assessing Interoperability for Medicare Access and CHIP Reauthorization Act of 2015. Fed Regist. 2016. Accessed August 19, 2016. [Context Link]