Nursing Informatics

A Foundation for Nursing Professionalism

"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 purposes of comparison. If they could be obtained they would enable us to decide many other questions besides the ones alluded to. They would show subscribers how their money was being spent, what amount of good was really being done with it, or whether the money was not doing mischief rather than good."1

Consider this often quoted comment from Florence Nightingale, dated 1859. Here we are, 143 years later, and we are still largely unable to answer the questions posed by Ms. Nightingale. We are still having difficulty obtaining hospital records "fit for any purposes of comparison." Even in light of robust and powerful computer systems that can store and process reams of data, we still find ourselves applying "everywhere for information."

The reasons that we have been unable to concisely answer the Nightingale questions are quite complex. Some of the responsibility can be laid to insufficient methods for data collection, storage, and retrieval. Some of the reasons relate to computer systems that have been poorly designed. The larger challenge, however, is in the difficulty of representing nursing practice in a format that can be stored, manipulated, and managed by computers. To understand the relationship between computers and Nursing Informatics, one must understand the basic tenets- "...the core of the science of informatics is the commodities that computers process (data, information, knowledge) and not the computer itself."2 Nursing Informatics therefore is not about the computer. Calling a nurse informatician a computer nurse is like calling a critical care nurse a ventilator assistant. Computers are simply tools used in nursing informatics practice. The greatest struggle in nursing informatics is in the representation of nursing in language that a computer can use.

Computers are quite unforgiving. To a computer, data are a series of binary code, a string of 1s and 0s. Computers do not understand nuances or shades of gray. Computers have no capacity to understand the difference between subtle shades of cyanosis or the impact of family dynamics on health status unless these concepts are firmly and unconditionally defined, structured, and recorded in a format that a computer can use. Codifying nursing data for a computer to be able to use is incredibly difficult and controversial. Consensus is often impossible. Regardless, learning to represent "what nurses do"3 in a format amenable to a computer is necessary if nurses hope to see their practice represented in automated systems.

Medical doctors have managed, to an extent, to codify what they do. Upon closer examination of this coding however, it is discovered that "what they do" is really structured around reimbursement codes. Procedures and diagnoses are represented around CPT and ICD-9/10 coding structures. These codes become part of a billing event and soon become a part of an administrative or "claims based" data set. These data sets then become the fodder for not only billing, but also important policy and financial decisions.

Some nurses, particularly those who can bill for services, manage to find some utility in administrative/financial coding, but the vast majority of other nurses find themselves without a formalized way to represent "what they do" in electronic health records. This results in important nursing data being absent from the underlying patient record databases. In considering the prior assertion about decisions being made based upon digitized and easily available data (the "administrative" sets), nursing practice and nursing contributions often are not considered when important decisions are being made. Nursing remains largely invisible in healthcare databases and therefore absent for studies of effectiveness, quality, value, and error.

Efforts have been underway for decades as nurses have attempted to "name" what they do for use in automated systems. We are not there yet. There are pioneers in this domain, people such as Dr. Virginia Saba, and Dr. Harriet Werley, the NANDA consortium, and many more. Newer nurses have joined the ranks and made great progress, but nurses in general have not understood what is at stake in this "nursing naming game" for computerized medical record systems. This lack of understanding has been costly to nursing as a whole. Automated systems continue to be built, and nursing by and large continues to be invisible. It must be said that this is not because system developers deliberately want to exclude nurses. In contrast, most beg for nursing involvement. However, too few nurses are cross-trained in informatics, and the major underlying issue of our inability to code "what we do" still exists. If nurses cannot describe "what nurses do" within our own ranks, how can it be explained to a system developer?

It is believed however that by recognizing and acknowledging our weaknesses we can begin to address these gaps. These gaps are incredibly important as nurses look to impact upon the quality of care, improve efficiency, and decrease the rate of errors in healthcare-even as the nursing shortage increases. Nurses need to work smarter, and we must look to the data and information of nursing to inform and drive our practice. We cannot manage what we cannot measure-we cannot "fix" until we understand what is wrong. These are some of the factors that drove the dedication of this symposium of AACN Clinical Issues to focus upon the practice of Nursing Informatics.

Nursing Informatics practice, from both a historical and contemporary viewpoint, is described in an article by Zytkowski. This illuminating segment lays the foundation that gave rise to the phenomenal growth of the nursing informatics specialty and sheds light on the myriad of roles that await nurses who cross-train in informatics. Nancy Staggers, a doctorally prepared Nurse Informatician, provides an in-depth examination of Human Factors in information system design. Dr. Staggers work is focused upon what makes information systems work or not work for human users. She illustrates the fundamentals of interface design and how such design must hinge on how humans really work with systems for them to be usable, especially in critical care settings.

Although computing technology is not the backbone of Nursing Informatics, nurses have readily stepped up to apply such technology to their practice areas. Dr. Betty Chang and colleagues share a very unique and interesting perspective on the use of personal digital assistants (PDAs) in assisting adolescent patients with severe persistent asthma to manage their disease better. The article by Dr. Chang and colleagues illustrates the potential for enhanced communication between the nurse provider and the adolescent patient via "hip" technology. These authors assert that the use of a PDA has the potential to improve outcomes while allowing the adolescent to feel "independent."

In keeping with the potential for enhancing outcomes via the use of information technology solutions, Kerkenbush and Lasome provide another interesting perspective on the use of PDAs. In this creative application, the benefits of using a PDA for the maintenance of a diabetic diary over traditional approaches such as paper-based are provided. The review of prior studies in the use of PDAs by patients for recording elements of personal health found PDAs to be easy to use, easier to tally, and useful. Patients were prone to be "more honest" with the PDA than with a pencil/paper recording mechanism and they were more compliant with regimens. The end point of this article provides a compelling argument for nurses to "step up to the plate" and take an active role in the development and deployment of such innovative strategies to improve the health of patients. Rempher and Lasome, in the article entitled "Leveraging Palm Technology in the Advanced Practice Nursing Environment" demonstrate the use of PDAs in support of both differential diagnosis and diagnostic reasoning, reduction of medication errors, and development of effective treatment protocols for the advanced practice nurse. These three PDA application articles begin to illustrate how computers and creativity can be used by nurses to affect the care process.

Tooey and Mayo, two Health Science Librarians, also delve into the world of PDAs. This article provides perspectives on the origins of the PDA, the basics of handheld technology, and PDA assimilation into healthcare. Many resources, ideas and applications for the use of PDAs in nursing are provided. Tooey and Mayo also begin to broach the subject of privacy and confidentiality of personal health information (PHI) in the world of healthcare PDAs. The concepts of privacy, confidentiality, and security of PHI are the foci of the article by Roberts. This article reviews the current literature, presents a discussion of confidentiality and security as it applies to uniquely identifiable health information, and offers some "best practices" that can be used in daily practice. Attention is given to the Health Insurance Portability and Accessibility Act (HIPAA) and how this act impacts upon nursing practice.

Looking at the impact of NI on nursing practice, Dr. Chris Curran, from Ohio State presents a set of core informatics competencies for Nurse Practitioners. Dr. Curran asserts that while informatics competencies for general levels of nursing practice have been defined, role specific informatics competencies have not been characterized. In this article, a proposed list of informatics competencies for the role of the nurse practitioner has been developed and is presented with a call for further research. A further call for research is also found in the work by Dr. Kathleen Charters. Charters' article titled "Nursing Informatics, Outcomes, and Quality Improvement" provides a cogent argument that nursing informatics tools can (and should) be used by advanced practice nurses to examine their practice and detect the effect their actions have on patient outcomes. Charters believes that analysis of patient outcomes may lead to initiatives for quality improvement. She provides practical advice for how nurses can begin to master nursing informatics approaches to benefit nursing practice as a whole. This same concept is carried through by the work of Lyons and Richardson who discuss the application of clinical decision support systems and the impact of such systems on nursing practice.

Finally, Scherer et al and Scordo et al offer two interesting articles on educational aspects of informatics techniques for advanced practice nurses. Scherer et al. in their article titled "Acute Care Nurse Practitioner Education: Enhancing Performance Through The Use of Clinical Simulation" gives a fascinating glimpse into the University of Buffalo's experience of incorporating full-body patient simulators into the acute care nurse practitioner (ACNP) curriculum. The article by Scordo and colleagues is also focused upon education for ACNPs. This article reviews the introductory use of PDAs throughout ACNP graduate training with emphasis on clinical and classroom application. A very nice list of applications used in this curriculum is provided.

I hope this issue of AACN Clinical Issues sheds light on the practice of Nursing Informatics and raises awareness of the power and importance of nursing data and nursing involvement in the development, acquisition, and utilization of automated systems in healthcare.

References