Historical Perspective of Nursing Informatics

Overview

Nursing Informatics

1. Evolved from the French word “informatics”

2. Referred to the field of applied computer science

3. Concerned with the processing of information such as nursing information

Computers

1. First introduced into healthcare facilities in the 1960s

2. For the processing of basic administrative tasks

3. The computer is an essential tool in HITsystems

Health Information Technology (HIT)

1. HIT is an all-encompassing term

2. Refers to technology that

a. Captures health information

b. Processes health information

c. Generates health information

3. Computerization affects all aspects of healthcare delivery including

a. Provision and documentation of patient care

b. Education of healthcare providers

c. Scientific research for advancing healthcare delivery

d. Administration of healthcare delivery services

e. Reimbursement for patient care

f. Legal and ethical implications

g. Safety and quality issues

4. A shift toward

a. Integrating multiple technologies and telecommunication devices

b. Invisible storage devices such as cloud storage

c. User-friendly, menu-driven, touchscreen manipulation methods

5. Computers in nursing are used for

a. Managing patient care information

b. Monitoring quality

c. Evaluating outcomes

d. Communicating data and messaged via the Internet

e. Accessing resources

f. Interacting with patients on the Web

g. Documenting and processing real-time plans of care

h. Supporting nursing research

i. Testing new systems

k. Developing data warehouses

l. Advancing the role of nursing in the healthcare industry and nursing science

MAJOR HISTORICAL PERSPECTIVES OF NURSING AND COMPUTERS

SEVEN TIME PERIODS

1. Prior to the 1960s

a. Developed in the late 1930s and early 1940s

b. Use in healthcare did not begin until the 1950s and 1960s

c. A few experts formed a cadre to adapt computers to healthcare and nursing

d. Computers in healthcare were used for administrative and accounting functions

e. Punch cards

2. 1960s

a. Use of computer technology began to be explored

b. Studies were conducted to determine how computer technology could be utilized

c. The nurses’ station was viewed as the most appropriate center for the development of computer applications

d. The mid-1960s presented nurses with new opportunities for computer use

e. Increased time devoted to documentation and a rise in medication errors prompted the investigation of emerging
computer-based information systems

3. 1970s

a. During the late 1960s through the 1970s, hospitals began developing computer-based information systems which
initially focused on (1) Physician order entry (2) Results reporting (3) Pharmacy (4) Laboratory (5) Radiology reports (6)
Information for financial and managerial purposes (7) Physiologic monitoring systems in the intensive care units

b. A few systems started to include (1) Care planning (2) Decision support (3) Interdisciplinary problem lists

c. Nurses were often involved in implementing systems

d. Interest in computers and nursing began to emerge in public and home health and education

e. In the 1970s, conferences helped public and home health nurses (1) Understand the importance of nursing data and
their relationship to new Medicare and Medicaid legislation (2) Provide information on the usefulness of computers for
capturing and aggregating home health and public health information

f. Hospitals and public health agencies embarked on investigating computers and nursing

g. The opportunity to improve education using computer technology also began

h. Early nursing networks helped to expand nursing awareness of computers and the impact HIT could have on practice

i. The Clinical Center at the National Institutes of Health implemented the Technicon Medical Information System (TDS)
computer system

j. TDS one of the earliest clinical information systems (called Eclipsys & Allscripts)

k. TDS was the first system to include nursing practice protocols

4. 1980s

a. The field of nursing informatics exploded and became visible in the healthcare and nursing

b. The nursing profession needed to update its practice standards and determine its data standards, vocabularies, and
classification schemes that could be used for the computerbased patient record systems

c. Many mainframe healthcare information systems (HISs) emerged with nursing subsystems

d. These systems documented several aspects of the patient record

f. The first Nursing Special Interest Group on Computers met for the first time during SCAMC (Symposium on Computer
Applications in Medical Care) in 1981

g. In 1985, the ANA approved the formation of the Council on Computer Applications in Nursing (CCAN)

h. CCAN became a very powerful force in integrating computer applications into the nursing profession

i. The first edition of this book published in 1986

5. 1990s

a. Advances in relational databases, client-server architectures, and new programming methods

b. Better application development at lower costs

c. Legislative activity in the mid-1990s paved the way for electronic health records through the Health Insurance
Portability and Accountability Act (HIPAA) of 1996 (public-law 104-19)

d. The complexity of technology, workflow analysis, and regulations shaped new roles in nursing

e. In 1992, the ANA recognized nursing informatics as a new nursing specialty separate Scope of Nursing Informatics
Practice Standards, and also established a specific credentialing examination for it

f. The demand for nursing informatics (NI) expertise increased

g. The ANA developed the Nursing Information and Data Set Evaluation Standards (NIDSEC) to evaluate and recognize
nursing technology rapidly changed in the 1990s (1) PCs became smaller (2) Computer notebooks became affordable (3)
Computers were linked through networks (4) The Internet became mainstream (5) The World Wide Web (WWW)
increased access to information

h. The purpose of Information systems was to guide the development and selection of nursing systems that included
standardized nursing terminologies integrated throughout the system

6. 2000s

a. More healthcare information became digitalized and newer technologies emerged

b. In 2004 an Executive Order 13335 (1) Established the Office of the National Coordinator (ONC) for Healthcare
Information Technology (HIT) (2) Issued a recommendation calling for all healthcare providers to adopt interoperable
electronic health records (EHRs) by 2014/2015

c. Wireless, point of care, regional database projects, and increased IT solutions proliferated

d. The use of bar coding and radio-frequency identification (RFID) emerged as a useful technology

e. Smaller mobile devices with wireless or Internet access increased access to information for nurses within hospitals
and in the community

f. The development and refinement of voice over Internet protocol (VoIP) provided voice cost-effective communication

g. The Internet provided a means for development of clinical applications

h. The nursing informatics research agenda promoted the integration of nursing care data in HIT systems that would also
generate data for analysis, reuse, and aggregation

7. 2010s

a. The impact of the Nursing Minimum Data Set (NMDS) demonstrated that continued consensus and effort was needed
to bring to fruition the vision and implementation of minimum nursing data into clinical practice

b. A new nursing informatics research agenda for 2008–2018 emerged as critical for this specialty

c. The new agenda is built on one originally developed and published by the National Institute for Nursing Research
(NINR) in 1993

d. During 2010, the ONC convened two national committees: (1) National Committee on Health Policy (2) National
Committee on Health Standards which outlined and designed the focus for the “Meaningful Use” (MU) legislation

e. Meaningful Use was designed to be implemented in at least three stages

g. In 2011/2012 MU Stage 1 was initiated focusing primarily on the Computerized Physician Order Entry (CPOE) initiative
for physicians

h. In 2012/2013 MU Stage 2 was introduced focusing primarily on the implementation of Quality Indicators

i. The Quality Indicators are used to guide hospitals in patient safety and if not implemented used as indicators subject
to financial penalties

j. It is anticipated that MU Stage 3 will be implemented in 2014/2015

k. The Center for Medicare and Medicaid Services (CMS) plans to increase reimbursement for the implementation of
“MU” regulations in their HIT and/or EHR systems through 2015

l. CMS may even penalize eligible providers and facilities who do not meet the proposed MU criteria

m. As the MU requirements increase they will impact on the role of the NI experts in hospitals

n. MU requirements ultimately on the roles of all nurses in the inpatient facilities, making NI an integral component of all
professional nursing services

Consumer-centric Healthcare System

1. There is a shift to a consumer-centric healthcare system due to escalating costs

2. Consumers are encouraged to be active partners in their care

3. A variety of technologies have evolved to enable consumers to have access to their health information

4. Consumers can choose whether to share this across healthcare providers and settings

5. Personal health records multiplied as either stand-alone systems or those tethered to EHRs

6. Consumers are more literate regarding healthcare information literacy and expect to become more involved in
managing their own health

Nursing Informatics Pioneers

History Project

1. In 1995, Saba initiated a history of NI at the National Library of Medicine, which consisted of the collection of archival
documents from the NI pioneers

2. The history project was initiated based on a recommendation by Dr. Morris Collen

3. In 2001, that the Nursing Informatics Working Group (NIWG) of the American Medical Informatics Association (AMIA)
became involved

4. The NI History Committee was established to take on this project

5. The committee solicited archival material from the known NI pioneers for a History of Nursing Informatics to be
housed in the NLM as part of its History Collection

6. In 2004, the rich stories of pioneers in nursing informatics were captured through a project sponsored by the AMIA-
NIWG

7. Pioneers were defined as those who “opened up” a new area in nursing informatics and provided a sustained
contribution to the specialty

8. Through multiple contacts and review of the literature, 145 pioneers and contributors were identified as having
shaped nursing informatics since the 1950s

9. Each identified pioneer was contacted to submit their nonpublished documents and/or historical materials to the
NLM to be indexed and archived for the Nursing Informatics History Collection

10. The catalogued document descriptions can be searched online: www.nlm.nih.gov/hmd/manuscripts/accessions.html

12. Videotaped stories from 33 pioneers were recorded

13. The 33 videotaped stories are available on the AMIA website: www.amia.org/niwg-history-page

14. The website also provides “use cases” for ideas about how to use the information for teaching and learning more
about the pioneers

15. These resources are particularly useful for courses in informatics, leadership, and research

16. They also are useful for nurses in the workforce who want to learn more about nursing informatics history

17. The early pioneers came from a variety of backgrounds as nursing education in nursing informatics didn’t exist in the
1960s

18. Almost all of the pioneers were educated as nurses, though a few were not

19. The pioneers had a vision that technology could make nursing practice better

20. The nursing pioneers influenced the evolution of informatics as a specialty from granular-level data through health
policy and funding

Nursing Standards Initiatives

Nursing Practice Standards

1. Nursing practice standards have been developed and recommended by the ANA

2. Nursing Scope and Standards of Practice that focused

a. On the organizing principles of clinical nursing practice

b. The standards of professional performance

3. Nursing Informatics Scope and Standards of Practice builds on

a. Clinical practice standards

b. Outlines further the importance for implementing standardized content to support nursing practice by specialists in
nursing informatics

Nursing Education Standards

1. Since the NLN’s Nursing Forum on Computers in Healthcare and Nursing was formed in 1985, it has supported the
integration of computer technology in the nursing curriculum

2. The American Association of Colleges of Nursing (AACN), revised The Essentials for Doctoral Education for Advanced
Nursing Practice and The Essentials of Baccalaureate Education for Professional Nursing Practice to require the use of
computers and informatics for both baccalaureate and graduate education

Nursing Content Standards

1. The nursing process data elements in EHRs are essential for the exchange of nursing information across information
systems and settings

2. Standardization of healthcare data began in 1893 with the List of International Causes of Death for the reporting of
morbidity cases worldwide

3. The standardization of nursing began with Florence Nightingale’s six cannons in her “Notes on Nursing”

4. In 1955, Virginia Henderson published her 14 Daily Patterns of Living as the list of activities and conditions that
became the beginning of nursing practice standards in the United States

5. In 1970, the ANA accepted the Nursing Process as the professional standards for nursing practice and which was
followed by the standardization of nursing content-data elements in 1973
6. Currently, the ANA has recognized 12 nursing terminologies

7. The ANA selected six of the ANA recognized nursing languages for inclusion in the NLM’s Metathesaurus of the
Unified Medical Language System (UMLS) and for inclusion in the Systematized Nomenclature of Medicine—Clinical
Terms (SNOMED-CT)

8. There are a large number of standards organizations that impact healthcare data content as well as healthcare
technology systems

Confidentiality and Security Standards

1. Increasing access through the electronic capture and exchange of information raised concerns about the privacy and
security of personal healthcare information (PHI)

2. Provisions for strengthening the original HIPAA legislation were included in the 2009 HITECH Act

Electronic Health Records from a Historical Perspective

The Institute of Medicine (IOM)

1. In 1989, the Institute of Medicine (IOM) convened a committee and asked the question, “Why is healthcare still
predominantly using paper-based records when so many new computer-based information technologies are emerging?”

2. Two major conclusions resulted from the committee’s deliberations.

a. First, computerized patient record (CPR) is an essential technology for healthcare and is an integral tool for all
professionals

b. Second, the committee after hearing from numerous stakeholders recognized that there was no national coordination
or champion for CPRs

The Computer-Based Patient Record Institute

1. Created in 1992

2. Given the mission to initiate and coordinate the urgently needed activities to develop, deploy, and routinely use CPRs
to achieve improved outcomes in healthcare quality, cost, and access

3. Developed the CPR Project Evaluation Criteria in 1993 modeled after the Baldridge Award

a. These criteria formed the basis of a self-assessment that could be used by organizations and outside reviewers to
measure and evaluate the accomplishments of CPR projects

b. The four major areas of the initial criteria (1) Management (2) Functionality (3) Technology (4) Impact

c. Provided a framework through which to view an implementation of computerized records

d. The criteria which provided the foundation for the Nicholas E. Davies Award of Excellence Program

4. The Davies Program evolved through multiple revisions

5. Under HIMSS management, the Davies Award of Excellence is offered in four categories

a. Enterprise (formerly Organizational or Acute Care), first offered in 1995

b. Ambulatory Care, started in 2003

c. Public Health, initiated in 2004 d. Community Health Organizations (CHO), first presented in 2008

Landmark Events in Nursing and Computers

Major Milestones

1. Computers were introduced into the nursing profession over 40 years ago

2. Major milestones of nursing are interwoven with the advancement of computer and information technologies
3. The increased need for nursing data, development of nursing applications, and changes, making the nursing
profession an autonomous discipline

4. There are currently several key events in which the NI community participates

a. Conferences

b. Symposia

c. Institutes

d. Workshops

5. Key events provide

a. An opportunity for nursing informatics novices and experts to network and share their experiences

b. Key events provide the latest information, newest exhibits, and demonstrations

HISTORY OF NURSING INFORMATICS IN THE PHILIPPINES

Origins

 Since 1998, several faculty members of the University of the Philippines began formal education and training. Dr.
Herman Tolentino took a post-doctoral fellowship in medical informatics at the University of Washington.

 Dr. Alvin Marcelo followed a year later for his training at the National Library of Medicine.

 Dr. Cito Maramba went to Coventry for his Masters in Information Sciences at the University of Warwick.

 They were later followed by other physicians such as Dr. Micheal Muin and Dr. Ryan Bañez.

 By the year 2003, a Master of Science in Health Informatics was proposed to be offered by UP-Manila College of
Medicine (major in medical informatics) and the College of Arts and Science (major in bioinformatics) and was later
approved to be offered starting academic year 2005-2006.

 In 1999, a study group was formed headed by the National Institute of Health of the University of the Philippines
Manila. This group identified international standards for health information and their adaptability in the Philippines. The
document is referred to as the "Standards of Health Information in the Philippines, 1999 version" or "SHIP99".
Representatives from various sectors collaborated on this project including the Philippine Nurses Association (PNA) in
the person of Ms. Evelyn Protacio.

 The Philippine Medical Informatics Society (PMIS) and its founders had strong influence in the development of health
informatics in the Philippines. The PMIA was officially registered under the Securities and Exchange Commission in 1996
by its board composed of eleven physicians. The organization was headed by Dr. Alvin Marcelo

CHED as a Catalyst

 The nursing community was still yet to follow its international counterparts in the adoption of information,
communication and technology in nursing practice in the Philippines.

 Despite the inclusion of Informatics course in the undergraduate curriculum which focused on basic desktop
applications, the need for genuine nursing informatics course had not yet been realized

 In 2008, Nursing Informatics course in the undergraduate curriculum was defined by the Commission on Higher
Education (CHED) Memorandum Order 5 Series of 2008. This was later revised and included as Health Informatics course
in CHED Memorandum Order 14 Series of 2009. This was first implemented in the summer of 2010.

Organization

 Early in 2009, Mr. Kristian R. Sumabat and Ms. Mia Alcantara Santiago, both nurses and graduate students of Master
of Science in Health Informatics at the University of the Philippines, Manila began drafting plans to create a nursing
informatics organization. In February 2010, they began recruiting other nursing informatics specialists and practitioners
to organize a group which later became as the Philippine Nursing Informatics Association.
Issues and Challenges

 Like many other disciplines, nursing informatics face many challenges while in its infancy stage.

 The inclusion of informatics as an integral part of the undergraduate curriculum has been one of the most influential
factors for the increased awareness and interest in this field of nursing.

 However, the contents of the curriculum was adapted from international materials which does not match the local
needs.

 A community-centered approach to the use of information, communication and technology in nursing practice must
be adapted to ensure the impact of the program in the local healthcare system.  Lack of certification and credentialing
programs in post-graduate levels are also absent with the scarcity of local nursing informatics experts.  This new field
has yet to gain acceptance and recognition in the nursing community as a sub-specialty

Future Direction

 Development of training, certification and credentialing programs are in the pipeline for the Philippine Nursing
Informatics Association.  Future partnerships with local and international nursing and health informatics organizations
have started as well.  Other programs are expected to be slowly delivered with PNIA's CORE X strategic platform which
stands for Competency, Organization, Recognition, Experience and Expertise.

 It is also a major thrust to support the use of health information standards in the Philippines and to have nursing
informatics specialists in every hospital in the country

THEORIES SUPPORTING NURSING INFORMATICS

 Nursing theories are about nursing practice—a nurse’s interactions or relationships with individuals, groups, or
communities (also known as patients or clients) focused on applying the nursing process.

 Novice to Expert. Patricia Benner and other nurse educators adapted this model to explain how nursing students and
professional nurses acquired nursing skills.

 Computer science is the study of algorithms for solving computation problems.

 Information science focuses on the gathering, manipulation, classification, storage, and retrieval of recorded
knowledge.

 Communication theory uses these core concepts and additional principles developed since then to analyze
information transfer and the effectiveness and efficiency of communications.

 Cognitive Science is the study of the mind—of how we think and it looks at our mental activities and processes.

 Systems theory relates to the properties of systems as a whole, focuses on the organization and interdependence of
relationships within a system.

 The study of behavior—the processes driving actions—is the focus of the Behavioral and Social sciences.

 Change processes entail not only structures and ways of doing tasks, but also the performance, expectations, and
perceptions of all involved parties.

 Learning is a process of acquiring knowledge, skills, attitudes, or values through study, experience, or teaching.

 Organizational Behavior where organizations are examined, using the methods drawn from economics, sociology,
political science, anthropology, and psychology.

 Management science uses mathematics and other analytical methods to help make better decisions, generally in a
business context.

 Group dynamics is a social science field that focuses on the nature of groups

MODELS IN NURSING INFORMATICS

 Models are representations of some aspect of the real world.

 Core phenomena are data, information, knowledge, and wisdom and the transformations that each of these undergo.

 It is important to remember that different models reflect different viewpoints and are not necessarily competitive,
that is, there is no one “right” model.

A. Grave’s and Concoran’s Model

 Proponent: Graves and Corcoran (1989)

 Their model placed data, information, and knowledge in sequential boxes with one-way arrows pointing from data
to information to knowledge.

 The model is a direct depiction of their definition of nursing informatics.

B. SCHWIRIAN’S MODEL

 Proponent: Patricia Schwirian (1986)

 A model of nursing informatics intended to stimulate and guide systematic research in this discipline.

 Four elements are: (1) Raw material (nursing-related information) (2) Technology (a computing system comprised
of hardware and software) (3) Users surrounded by context (nurses, students) (4) Goal (or objective) toward which
the preceding elements are directed

C. TURLEY’S MODEL

 Proponent: James P. Turley (1996)

 In which the core components of informatics (cognitive science, information science, and computer science) are
depicted as intersecting circles.

 Nursing science is a larger circle that completely encompasses the intersecting circles.  Nursing informatics is the
intersection between the discipline-specific science (nursing) and the area of informatics.

D. MCGONIGLE AND MASTRIAN’S FOUNDATION OF KNOWLEDGE MODEL

 Proponent: Dee McGonigle and Kathleen Mastrian

 The base of this model shows data and information distributed randomly.

 From this base, transparent cones grow upward and intersect.

 The upward cones represent acquisition, generation, and dissemination of knowledge.  Knowledge processing is
represented by the intersections of these three cones.

 Circling and connecting all of the cones is feedback.

E. TECHNOLOGICAL COMPETENCY AS CARING IN NURSING: A MODEL FOR PRACTICE

 A conceptual model that presents the link between technology and caring in nursing as coexisting harmoniously.
(Locsin, 1995)

FRAMEWORKS IN NURSING INFORMATICS

 Nursing frameworks were proposed to illustrate dynamic interactions occurring between nurses, computers, and
enabling elements that optimize a user’s ability to process information via computers.

 There were still limitations identified in the early models because they did not: a. Explicitly make the patient part
of the model b. Define the context c. Or include all elements of nursing’s metaparadigm (PHEN)
A. Judith A. Effken, PhD (2003) proposed the Informatics Research Organizing Model which emphasized all
elements of nursing’s metaparadigm including the system, nurse, patient, and health
B. Gregory L. Alexander (2007) proposed the Nurse—Patient Trajectory Framework.
 Alexander’s framework utilizes
a. Nursing process theory
b. Human factors
c. Nursing and patient trajectories as components of a framework that can be used to evaluate patient care
systems
d. The midrange framework specifically emphasizes the use of human factors approaches to link patient care
processes, nurse and patient trajectories, and nursing and patient outcomes
e. In this discussion, the framework has been modified to explore HCI in the context of nurse and patient
trajectories as technology is integrated into nurse-led systems
f. Examples of HCI design and research using this model will be used to achieve the objectives