Computer and Nursing
NURSING INFORMATICS as defined by ANA
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A specialty that integrates nursing science,
computer science and information science to
manage and communicate data, information and
knowledge in nursing practice
Nursing Informatics
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Nursing Informatics facilitates the integration of
data, information and knowledge to support
patients, nurses and other providers in their
decision making in all roles and settings.
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Computers were used in hospital setting for
business office functions
1960s
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The use of computer in nursing were questioned
“why computers?”
“ what should be computerized?”
Studies were conducted on how computers can be
utilized effectively in health care industry
Advancement of computer technology in health
care facilities
Introduction of Cathode ray tube (CRT) terminals
Online data communication
Real time processing
Computer
- Is an all encompassing term referring to information
technology (IT), computer systems and when they
are used in nursing, refer to nursing information
systems (NISs), nursing applications and or nursing
informatics (NI)
Computer & Nursing
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Computers in nursing are used to manage
information in patient care, monitor the quality of
care and evaluate the outcomes of care
Computers are also used to support nursing
research, test new systems, design new knowledge
databases and advance the role of nursing in the
health care industry
Historical perspective of Nursing and computers
According to:
1. Six time period
2. Four major nursing areas
3. Standards initiatives
4. Significant landmark events
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Six Time Period
PRIOR TO THE 1960s
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Only a few adapted computers to health care
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The nursing profession was undergoing changes and
these events provided the impetus for the
profession to embrace computers
User friendly machines
Hospital Information Systems (HISs) were
developed to process financial transactions
1970s
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Inevitable integration of computers to nursing
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Nurses began to realized the value of computer to
nursing profession
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Recognized the potential of computers in improving
the documentation of nursing practice, the quality
of patient care and the repetitive aspect of
managing patient care
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Results reporting
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Vital signs
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Other systems that document narrative nursing
notes via word processing
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Discharge planning
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Referrals for community health care facilities
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Microcomputer PC emerged that made technology
more accessible , affordable and usable to nurses
and other health professionals
1990s
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HIS mainframe were designed and developed
Developed computer based management
information systems (MISs)
1980s
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Informatics emerged in the health care industry and
nursing
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NI became an accepted specialty and many nursing
experts enter the field
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Use of computers in nursing became revolutionary
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New computer technologies emerged and
computer architecture advances
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Computer technology became an integral part of
health care settings, nursing practice and profession
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Policies and legislations were adopted promoting
computer technology in health care including
nursing
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NI was approved by ANA as a new nursing specialty
(1994)
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The need for computer based nursing practice
standards, data standards, nursing minimum data
sets and national data base emerged
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(NANDA International) The need for a unified
nursing language, nomenclatures, vocabularies,
taxonomies, and classification schemes
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Nsg administrators demand that HISs include
nursing care protocols and nurse educators use all
innovative technologies for patient education
Laptops and notebook computers
Workstations and local area networks (LAN) for
hospital nsg units
Wide area networks (WANs) for linking care access
health care facilities
Use of internet to link across the different systems
Web became the means for communicating online
E-mail, file transfer protocol (FTP) and WWW
protocols
High performance computing and communication
(HPCC)
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Need for nursing software evolved
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Computer based patient record systems (CBRSs)
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upgraded the standards, vocabulary and
classification schemes for CBRSs
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Many HISs mainframe emerged with nursing
subsystems
HISs nursing sub system:
Patients record on the ff:
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Order entry
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Emulating the KARDEX
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POST 2000
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Torrid pace of hardware and software development
and growth
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Wireless point of care
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Open source solutions
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Regional data base projects
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Increased IT solutions
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electronic patient record (EPR)
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Electronic health record (EHR)
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Smart cellular telephones
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Wireless tablet computers
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Personal digital assistants (PDAs)
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Critical care unit monitors
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Smart card in Europe
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Advancement of internet
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Voice over internet protocol (VoIP)
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Telenursing
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Legislations on the US healthcare industry
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Provider Identification Number (PIN)- safety and
security of patients
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Consolidated health information (CHI)
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National Health information Infrastructure (NHII)
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“electronic version of nursing practice”
NURSING ADMINISTRATION
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Most policy and procedure manuals are accessed
and retrieved by computer
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Workload measures, acuity systems and other
nursing department systems are online and
integrated with the hospital or patient EHR system
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Internet is being used by nurses to access digital
libraries, online resources and research protocols at
the bedside
4 MAJOR NURSING AREAS
NURSING PRACTICE
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It become an integral part of the EHR
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Patient care data & nsg care plan are no longer
separate subsystems of the computerized HISs but
rather integrated into one interdisciplinary patient
health record in the EHR
NURSING EDUCATION
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Most schools of nursing offer computer enhanced
courses, online courses or distance education
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They are becoming universities without walls where
students can attend a university anywhere in the
world without being present
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Campus wide computer systems are available for
students to communicate via e-mail,transfer data
files, and retrieve online resources of www sites
NURSING RESEARCH
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Computer use for analyzing nursing data
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Software program are available for processing both
quantitative and qualitative research data
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Databases supporting research emerged
nursing practice but also the standards of
professional performance
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Nursing process as the conceptual framework for
documentation of nursing practice
NURSING PRACTICE STANDARDS
JOINT COMMISSION ON ACCREDITATION OF HOSPITAL
ORGANIZATION (JCAHO)
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Stressed the need for adequate records on patients
in hospital and practice standards for the
documentation of care of nurses
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Acuity systems to determine resource use as well as
required care plans for documenting nursing care
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NURSING PRACTICE STANDARDS
JCAHO
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Required contents of the EHR such as what data
should be collected and how the data should be
organized in the electronic database
NURSING DATA STANDARDS
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Nursing data standards have emerged as new
requirement for EHR
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14th edition includes 13 nursing terminologies that
have been recognized by the ANA used for
documenting different aspects of nursing practice
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Critical care classification (CCC), Nursing
Information Classification (NIC)
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Online searching and retrieving information from
electronic bibliographic literature systems e.g. drug
data
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Large databases are used for meta-analysis to
develop evidenced based practice guidelines
Internet provides online access to the million of
web resources around the world
ANA is responsible for the recognition of
terminologies and for determining if they have met
the criteria to be included in the :
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National library of Medicine (NLM)
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Unified Medical Language systems (UMLS)
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SNOMED CT (College of American pathologists and
American Veterinary Medical Association, 1998)
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STANDARDS INITIATIVES
NURSING PRACTICE STANDARDS- ANA
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Standards of clinical nursing practice (1998) focused
not only on the organizing principles of clinical
HEALTH CARE DATA STANDARDS ORGANIZATIONS
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American National Standards Institute (ANSI)instituted to coordinate and approve voluntary
standards efforts in the US
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Health Care Informatics Standards Board (HISB)
LANDMARK EVENTS IN NURSING AND COMPUTERS
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European Standardization Committee (CEN)
The landmark events were described by:
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International Standards Organization (ISO)
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Early conference meetings
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American Society for Testing and Materials (ASTM)
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Early academic initiatives
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ASTME-31 Committee on healthcare informatics is
an accredited committee that develops standards
for health information systems designed to assist
vendors and users and anyone interested in
systemizing health information
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Initial ANA initiatives
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Initial National League for Nursing initiatives (NLN)
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Early international initiatives
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Initial educational resources
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Significant collaborative events
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Health Level Seven (HL7) an organization accredited
by the ANSI which was created to develop
standards for electronic interchange to clinical,
financial, administrative information among
independent health care oriented information
systems
SNOMED International another organization that
serves as an umbrella of the structured
nomenclatures and its merger with the read codes
form the national health service in the UK in 1999
SNOMED CT serves as the coding strategy and has
become a national standard for EHR which are
integrated in the UMLS and available in the public
The National Committee on Vital and Health Statistics
(NCVHS)
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workgroup on computer – based patient record
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Evaluated and recognized medical, nursing and
other health profession nomenclatures for the
Department of Health and Human Services (DHHS)
Electronic Health Record from a
Historical Perspective
Computer- Based Patient record (CPRI)
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a non profit membership organization founded in
1992
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A unique organization representing all stakeholders
in healthcare, focusing on clinical applications
information technology
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The first among nationally based organization to
initiate and coordinate activities to facilitate and
promote the routine use of computer-based patient
records (CPRs)
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CPR Systems Evaluation criteria in 1993
4 Major areas of the criteria:
1. Management
Early computer- based nursing applications
2. Functionality
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3. Technology
Nursing applications which influenced the industry
were subsystems or components of early HISs
focused on
4. Impact
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Early HISs
Nicholas E. Davies Award for Excellence Program
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Early ambulatory care information systems
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Early community health nursing information
management systems
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Early computer focused nursing projects
Named for Dr. Nicholas E Daviesan Atlanta –based physician, president elect of the
American College of Physicians and a member of
Institute of Medicine (OM) committee on improving
the patient record
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Early educational application
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Was killed in a plane crash just as the IOM report on
CPRs was being released
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Modeled after the Baldridge award
Impact to Value
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Intended to award and bring to national attention
excellence in the implementation of computerized
medical records
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From 1995 to 2001 applicants were asked to
provide examples of impact derived for the
organization from the EHR
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Founded on the belief that health care
organizations benefit when collective experiences
and lessons learned and shared
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All Davies winners cited improvement in care
documentation
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Four criteria revision and seen its terminology
updated from computerized patient record to
electronic medical record (EMR) and today’s HER
Quality of care enhancements through avoidance of
medication error, increased appropriateness of care
interventions and compliance with managed care
and disease protocols
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3 categories:
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Quality impact was noted on improved continuity of
care as medical records and plans of care were
available in detail for residents on call or weekend
triage nurses
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2002 applicants faced revised criteria in which the
impact section had been changed to value
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Healthcare facilities were expected to document
the business case of the EHR
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2003 organizational Davies winners also entered the
business justification on process improvement as
the driver for technological change
1. Organizational or Acute care in 1995
2. Ambulatory in 2003
3. Public Health 2004
How they define the effort?
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19 organizational Davies winners located
throughout the country started and completed their
implementation at different times and in different
departments of their facility under different types
of leadership
The winning organizations have clearly made EHR a
key component of strategic vision
How is the effort organized?
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A common element to all Davies winners is the
shared belief that information management is a key
tool for the clinical and business processes of the
hospital
Nurses need to participate in design review, serves
as champions, and provide local resources to ensure
the planned implementation will enhance their
ability to care for the patient
Change Management
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Many Davies Winners stressed the importance of
the operational planning for the EHR
implementation
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The positive effect must be echoed by medical,
nursing and administrative leadership
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Strong end user support for new systems was a key
factor for success
Still Expensive
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The cost of EHR is expensive
Organizations has set aside multiple millions from
their capital budgets to finance the cost of the
infrastructure, hardware and software all needed
for an EHR implementation
Focus on decision support
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An integral component of the EMR is the ability to
offer clinical support in the provider’s decision
making process
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2 forms of decision support:
1. Applications that are designed to facilitate evidence
based clinical practice
2. Found in alerts and reminders that warn clinicians
about patients variables
What’s different?
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3 organizations honored in the first yr of the
program all developed their own system
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Health Evaluation through Logical Processing
(HELP)-integrated rules-based patient centered
information system was created
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Clinical Information System (CIS) was needed
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2nd yr award winner developed Brigham integrated
computing system (BICS)
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An ambitious redevelopment of the hospital’s
information system that dated back in 1989
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All winners since 2000 have implemented
commercially sold multicomponent systems
procured from a variety of vendors
Technology
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Throughout the decade of Davies, new technologies
have merged and are being incorporated in the
systems
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The technology at any Davies winner is difficult to
precisely replicate due to data capture
6. No discrimination against field of endeavor
Open Source and Free Software
7. Distribution of License
Free Software
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8. License must not be specific to the product
means software that respects users' freedom and
community.
9. License must not restrict other software
it means that the users have the freedom to run,
copy, distribute, study, change and improve the
software.
OSS/FS Development Models/Systems
“free software” is a matter of liberty, not price.
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A program is free software if the program's users have
the four essential freedoms:
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The freedom to run the program as you wish, for
any purpose (freedom 0).
The freedom to study how the program works, and
change it so it does your computing as you wish
(freedom 1). Access to the source code is a
precondition for this.
The freedom to redistribute copies so you can help
others (freedom 2).
The freedom to distribute copies of your modified
versions to others (freedom 3)
10. License must be technology- neutral
Benefits of OSS/FS
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Open Source Software
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Is any software that satisfies the open software
initiative’s definition (OSI)
It is said to promote software reliability and quality
by supporting independent peer review and rapid
evolution of source code of software freely
available
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“OSI certified”
The software must be distributed under a license
that guarantees the right to read, redistribute,
modify, and use the software freely
Not only must the source code be available but also
the distribution terms must comply with the 10
criteria defined by OSI
10 Criteria by OSI:
1. Free Distribution
2. Source Code
3. Derived Works
4. Integrity of the Author’s source code
5. No discrimination against person or group
An electronic equivalent of generic drugs are
available
Royalty free, less expensive
Lack of propriety lock-in giving consumers a greater
choice
Secure, reliable/stable and capable of developing
local software
ISSUES in OSS/FS
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Licensing
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Licenses are legal and binding contracts between
the author and the user of a software component,
declaring that the software can be used in
commercial applications under specified conditions.
Without an open source license, the software
component is unusable by others.
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Copyright and intellectual property
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When source code, documentation and other
content is contributed to an OSS project, the
copyrights in those contributions typically remain
owned by the original copyright holders.
The risk of intellectual property infringement is
greater with open source software because it is
developed without the usual controls present in the
commercial software development process. Thus, if
a programmer downloads an open source program
to which a previous user has added infringing code,
the programmer would unknowingly be exposed to
liability for infringement, potentially resulting in an
injunction or legal damages.
OSI Certificate
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It is likened to a bazaar, growing organically from an
initial small group of traders establishing their
structures and beginning business
Starts off highly unstructured with developers
releasing early minimally functional code and then
modifying their programs based on feedback
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Total cost of ownership (TCO)
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Is the sum of all expenses directly related to the
ownership and use of a product over a given period
of time
OSS distribution can be obtained at no charge
Wheeler (2003)list of reasons why OSS/FS comes
out cheaper
There are no license fees
Less upgrade and maintenance costs due to
improved stability and security
Use older hardware more efficiently than propriety
systems, yielding smaller hardware costs and
sometimes eliminating the use of new hardware
Increasing number of users show it to be especially
cheaper in server environment
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Support and migration
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Making an organization-wide change from
proprietary software can be costly, and sometimes
the costs will outweigh the benefits.
Some OSS/FS packages do not have the same level
of documentation, training, and support resources
as their common proprietary equivalents, and may
not fully interface with other proprietary software
being used by other organizations with which an
organization may work (e.g., patient data, exchange
between different healthcare provider systems).
Migration from one platform to another should be
handled using a careful and phased approach.
The European Commission has published a
document entitled the “IDA Open Source Migration
Guidelines” (European Communities, 2003) that
provides detailed suggestions on how to approach
migration. These include:
o the need for a clear understanding of the
reasons to migrate,
o ensuring that there is active support for the
change from IT staff and users,
o building up expertise and relationships with the
open source movement, starting with
noncritical systems, and
o ensuring that each step in the migration is
manageable
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Business models
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Security and stability
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OSS/FS has better security record because of its
available source code(making easier for
vulnerabilities to be discovered and fixed)
Many OSS/FS have a proactive security focus
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Challenges in Migrating OSS/FS
• That there is lack of mature OSS/FS desktop
applications
• Many OSS?FS tools are not user-friendly and have a
steep learning curve
• File sharing between OSS/FS and propriety
applications can be difficult
3 Step Method for OSS/FS Decision Making
Defining the needs and constraints
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Issues to consider include range of features,
language, budget, implementation, time frame,
compatibility with existing systems and the skills
existing within the organization
2. Identifying the options
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A short list of 3-5 software packages that are likely
to meet the need can be developed from comparing
software packages
3. Undertaking a detailed review
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The final step is to review and choose a software
package from the shortlist
Open Source-Licensing
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Licensing- giving the user of something permission
to use, in this case here the software
e.g. End User Licensure Agreement ( EULA)
Copyright- is the exclusively granted or owned legal
rights to publish, reproduce, and or sell a work
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For OSS the work means the “source code”
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The person who create the work owns the copyright
and has the right to allow others to copy it or deny
that right
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OSS/FS licenses are designed to facilitate the
sharing of software and to prevent an individual or
organization from controlling ownership of the
software
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The open source community and in particular the
FSF have adopted a number of conventions, some
built into the licenses, to protect the IPR of authors
and developers
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“Copyleft” are legal instrument giving everyone the
rights to use, modify and redistribute the program’s
code or any program derived from it but only if the
distribution terms are unchanged
Types of OSS/FS
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1. GNU General Public License (GPL)
OPERATING SYSTEM: Linux OS
2. Berkeley System Distribution (BSD-style licenses
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Common OSS/FS Licenses
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GNU GPL: A free software license and a copyleft
license. Recommended by FSF for most software
packages (www.gnu.org/ licenses/gpl.html).
GNU Lesser General Public License (GNU LGPL): A
free software license, but not a strong copyleft
license, because it permits linking with non-free
modules (www.gnu.org/copyleft/lesser.html).
Presentation tools
Is a term that is increasingly used by many people
to cover a distribution of operating system and
other associated software components
WEB BROWSER:
Apache (under Apache Software Foundation)
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Are responsible for receiving and fulfilling request
from web browser
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The Apache HTTP server developed for Unix,
Windows NT, and other platforms is currently the
top web server
Modified BSD License: The original BSD license,
modified by removal of the advertising clause. It is a
simple, permissive non copyleft free software
license, compatible with the GNU GPL (www.osswatch.ac.uk/resources/modbsd.xml).
Mozilla (under Netscape Mozilla Public License)
W3C Software Notice and License: A free software
license and GPL compatible
(www.w3.org/Consortium/Legal/2002/ copyrightsoftware-20021231).
E-mail Server
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MySQL Database License:
(www.mysql.com/about/legal).
Word Processing/Integrated Office Suite
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Apache License, Version 2.0: A simple, permissive
non copyleft free software license that is
incompatible with the GNU GPL
(www.apache.org/licenses/LICENSE-2.0).
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GNU Free Documentation License: A license
intended for use on copylefted free documentation.
It is also suitable for textbooks and dictionaries, and
its applicability is not limited to textual works (e.g.,
books) (www.gnu.org/copyleft/fdl.html).
Public Domain: Being in the public domain is not a
license, but means the material is not copyrighted
and no license is needed. Public domain status is
compatible with all other licenses, including GNU
GPL.
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Web browser
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E-mail client
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Word processing or integrated office suite
Which is based on the source code of the formerly
proprietary StarOffice is an equivalent of Microsoft
Office with most of its feature
Some other OSS/FS Applications
1. BIND (domain name system (DNS) server-BIND) or
Berkeley Internet Name Domain
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Operating system
OFF/FS are among the primary drivers of e-mail
Open Office (OpenOffice.org)
OSS/FS Applications commonly used by Nurses
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Designed for standards compliance and with a large
number of browser features, including support for
hypertext markup language (HTML)
Is an internet naming system
google.com/opinoffice.org cannot function without
DNS
These servers take these human-friendly numeric
Internet protocol (IP) addresses and vise versa
without these servers, users would memorize
numbers such as 202.187.94.12 in order to use a
web site
The BIND server is an OSS/FS program developed
and distributed by University of California in
Berkeley
2. Perl-Practical Extraction and Reporting Language
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Is a high level programming language that is
- It aims to develop a practical, integrated healthcare
frequently used for creating CGI(Common gateway
information system (HIS)
interface) programs
- Is designed to integrate the different information
- Its modules and adds- on are available to do almost
systems existing in health care organization into
anything leading some to call it “Swiss army
one single efficient systems
chainsaw” of programming languages
4 Major Components
3. PHP Hypertext Preprocessor
• HIS- Hospital Information Systems
- Is an example of a recursive acronym a common
• PM- practice (GP) management
practice in the OSS/FS community for naming
• CDS- Central Data Server
applications
• HXP- Health Exchange Protocol
- Is a server side, HTML embedded scripting language
5. TORCH http://www.openparadigms.com
used to quickly create dynamically generated Web
pages
- A web enabled EHR application that aims to be
- PHP runs on every major OS, including Unix and
scalable up to multisite practices
Linux, Windows and Mac OS X and can interact with
all major Web servers
6. Open Infrastructure for Outcomes -OIO
4. LAMP- The Linux, Apache, MySQL ,PHP
http://www.txoutcome.org/
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Become popular in the industry as a way of cheaply
deploying reliable, scalable and secure Web
applications
The P in the LAMP can also stand for Perl or Python
OSS/FS Healthcare Applications
1. openEHR http://www.openhr.org
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Is an international non-profit organization that is
working toward the development of interoperable,
lifelong EHRs
Is a system to facilitate the creation of a flexible and
portable patient/ research records
7. OSCAR- Open Source Cluster Application Resources
http://www.oscar.sourceforge.net/
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Web based family practice system supporting the
needs of care delivery, teaching and research
Includes evidence-based decision support for family
practice
EU Funded Projects
2. FreeMD http://www.freemed.org
1. SPIRIT http://www.euspirit.org
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Is the flagship product of FreeMED Software
Foundation
A result of many yrs of work in developing an
OSS/FS electronic medical record (EMR) and billing
system which focuses on physicians and healthcare
providers
3. openEMR http://www.openemr.net
- Is a free open source medical clinic practice
management (PM) and (EMR) application
- Offers a range of functions including practice
management for patient scheduling and patient
demographics
4. CARE 2x http://www.care2x.com
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Is one of the few OSS/FS projects to have been
originated by a nurse (Elpidio Latorilla)
Aims to provide a virtual community and meeting
place and include resources and services for best
practice open source news and software
2. SMARTIE- http://www.smartie-ist.org
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Is to offer a comprehensive collection or suite of
selected medical software decision tools ranging
from clinical calculators up to advance medical
decision
3. OpenECG http://www.openecg.net
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Seeks to consolidate interoperability efforts in
computerized electrocardiography at the european
and international levels
4. PICNIC http://picniceuspirit.org
Organizations
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NI of IMIA
Is designed to develop the next generation regional
healthcare networks to support new ways of
providing health and social care
5. FOSS, Policy Support(FLOSSpols)http://www.flossproject.org/flosspols
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Special interest group in nursing informatics dealing
with OSS/FS
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Aims to play a leading role in informing the nursing
profession around the world about the potential of
the development of OSS/FS
Aims to work in 3 specific tracks government policy
toward OSS/FS gender issues in open source and
the efficiency of the open source as a system
Data and Data Processing
Organizations advocate on the use of OSS/FS within
health, healthcare, and nursing
1. Open Source Health Care Alliance (OSHCA)
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The oldest organizations formally established in
summer 2000
DATA
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2. International Medical Informatics Association (IMIA)
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Aim to work with other OSS/FS organizations to
explore issues around the use of OSS/FS within
healthcare and health informatics
INFORMATION
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3. The American Medical Informatics Association
(AMIA),
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The mission of the AMIA-OSWG
(www.amia.org/workinggroup/open-source) is to
act as the primary conduit between AMIA and the
wider open source community. Its specific activities
include providing information regarding the
benefits and pitfalls of OSS/FS to other AMIA
working groups, identifying useful open source
projects, and identifying funding sources, and
providing grant application support to open source
projects.
4. International Medical Informatics Association
(IMIA),
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The IMIA established an Open Source Health
Informatics Working Group in 2002. It aims to work
both within
IMIA and through encouraging
joint work with other
OSS/FS organizations to
explore issues around the use of OSS/FS within
healthcare and health informatics
5. European Federation for Medical Informatics (EFMI)
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raising awareness within health and nursing
communities of the possibilities of OSS/FS,
Are raw uninterrupted facts that are without
meaning
E.g. patient’s weight is recorded as 140 lbs.
Is presentation of facts figures, concepts, or
instructions that may be stored, communicated,
interpreted or processed by manual or automated
means
Is the result or output or processing, manipulating
and organizing data in a way that adds a knowledge,
respond to a specific need, and show significance
and meaning to the person receiving it
APPROACHES TO ORGANIZING DATA
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Sorting
Classifying
Summarizing
Calculating
DATABASE
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The process of organizing data/ information
o E.g. folders, checkbook, phonebook
An organized collection of related data
EXAMPLES OF DATABASE
Database for Class notes:
1.Data- Notes and handouts
2. Folders and Cabinets -are the DBMS
3. Labels and design on the folders and file cabinet- are
the database system design
FACTORS AFFECTING FINDING DATA IN DATABASE
3 interacting parts
•
•
•
•
•
•
Data
DBMS configured software program
Query language used to access the data
-
Functions:
How the data are named (indexed) and organized
The size and complexity of the database
The type of database
INFORMATION SYSTEM
-
Are used to process data and produce information
In healthcare: manual, automated and human
information processing system
o
Store, Update, Retrieve, Report.
DBMS
TYPES OF DATA
Advantages of automated DBMS:
1. Conceptual data- classified in terms on how this
data will be used
1. Decrease data redundancy
-
e.g. financial data, patient data, human resource
data
2. Computerized data – data can be numbers or letters
or combination of both
-
it is used to build the physical database within the
computer system
CONCEPTUAL DATA TYPES
1. Based on the source of the data- e.g. lab procedures,
lab data and the x-ray department data
2. Increase data consistency
3. Improve access to all data
STRUCTURE:
Fields, Records, and Files
STRUCTURE OF DBMS: FIELD NAMES
-
-
Usually reflect the type of data that are stored in
the related fields
o E.g. L- name refers to last name of patient
FIELD ATTRIBUTE- is the specific datum for that field
in that record, each row represents a record
2. Based on the event that the data are attempting to
capture- e.g. assessment data, intervention data,
outcome data
COMPUTER BASED DATA TYPES
1. Alphanumeric data- includes letters and numbers in
any combination
2. Numeric data- used to perform functions including
adding, subtracting, multiplying and dividing
3. Logic data- data limited to 2 options e.g. yes or no/
true or false
DATABASE MANAGEMENT SYSTEM
STRUCTURE OF DBMS: RECORD
-
Is a specific datum for a particular field.
-
E.g. EMR
STRUCTURE OF DBMS: FILES
-
Is a set of related records that have the same data
fields
-
A database is consist of several files
-
Are computer programs used to input, store,
modify, process and access data in database
-
DBM software must first be configured to manage
the data specific to the project
2 TYPES OF FILES
-
This process is called DATABASE SYSTEM DESIGN
1. Data files- contain data that have been captured
and stored on a computer using software program
o
o
E.g. nursing informatics.doc (extension indicates the
software program created the file)
E.g. saved as “text only” the standard extension is
TXTnsg.informatics.txt
2. Processing files- consists of a computer program or set of
instructions that, when executed, causes the computer to
open or start a specific computer program.
o
e.g. My computer- list of files and folders
COMMAND FILES
-
Are set of instructions that perform a set of
functions as opposed to running a whole program
E.g. AUTOEXEC.BAT, CONFIG.SYS
DATABASE MODELS
-
-
-
A database model is the basis or foundation that
determines how one stores, organizes, and accesses
or manipulates the data.
elements), their relationships, a primary key for
each entity, and so forth.
DEVELOPING CONCEPTUAL AND LOGICAL MODELS
When planning a small database for personal use,
developing the conceptual and logical model is an
important step. There are several questions that can be
helpful in thinking through this process.
1. How will the database be use?
2. What data elements used to be in the database to
produce the desired output?
3. What are easy to remember logical names for each
of the data fields?
4. What approach will be used to create a unique
identifier for each record in the database?
5. Is each of the tables designed so there are no
unnecessary overlapping of data?
American National Standards Institute (ANSI) and
the Standards Planning and Requirements
Committee (SPARC) model (1975) identified the
views/models in 1975
DATABASE MODELS: PHYSICAL DATA MODELS
According to these documents, there are three
main phases to database design: conceptual design,
logical design, and physical design
-
-
DATABASE MODEL: CONCEPTUAL MODELS
-
-
Includes a diagram and narrative description of the
data elements, their attributes and the relationship
between the data
It defines the structure of the whole database in
terms of the attributes of the entities (data
element) relationships, constraints, and operation
o
E.g. drug order- name of med, dose,
frequency, units etc..
DATABASE MODEL: LOGICAL MODELS
-
This model describes the data in more detail
without paying attention to the actual physical
implementation or design of the database
-
.
-
It defines the structure of the whole database in
terms of the attributes of the entities (data
Includes each of the data elements and the
relationship between the data elements, as they
will be actually physically stored on the computer.
There are four primary approaches to the
development of a physical data model. These are:
• hierarchical
• network,
• relational, and
• object oriented.
PHYSICAL DATA MODEL: Hierarchical database
-
-
Compared to inverted trees
All access data starts at the top of the hierarchy or
at the root
The table at the root will have pointers called
branches that will point to cable with data that
relate hierarchically to the root.
Each table is referred to as NODE
E.g patient record- nodes to lab, radiology and
medication
PHYSICAL DATA MODEL: Network Model
PHYSICAL DATA MODEL: Object -Oriented Model
-
Developed from hierarchical models
-
-
It represents many to many relationships however
the presence of multiple links between data make it
more difficult if data relationship change and
redesign is needed
This was developed because the relational model
has a limited ability to deal with binary large objects
or BLOBs
-
BLOBs are complex data types such as images,
sounds, spreadsheets or text messages
-
E.g. Amoxicillin-Antibiotic
All antibiotics have certain attributes
It can be stored in antibiotic and can inherit all attribute
DATABASE LIFE CYCLE
System process of DBMS
PHYSICAL DATA MODEL: Relational Database Models
-
Consists of a series of files set up as tables
-
Each columns represents an attribute
-
Each row is a record
-
Another name for row is “tuple”
-
The intersection of a row and the column is a cell
-
The datum in the cell is the manifestation of the
attribute for that record
-
STEPS:
o Initiation - Occurs when a need or problem
is identified and the development of a
DBMS is seen as a potential solution
o Planning and Analysis - Begins with the
assessment of the users view and the
development of the conceptual modelWhat
are all the information needs of the
department? How is the information used?
o
o
o
Detailed System Designs - Begins with the
selection of the physical model:
hierarchical, network, relational, to objectoriented
Implementation - Includes training the
users, testing the system, developing a
procedure manual for use of the system, -it
outlines the rules piloting the DBMS and
finally going “LIVE”
Evaluation and maintenance - Initial or
Early evaluation may have limited value.
The 1st evaluation should be informal and
focused on trouble shooting specified
problem. Once the system is up and running
and the users have adjusted they will have a
new appreciation of its value
COMMON DATABASE OPERATIONS
1. Data Input Operations
-
Are used to enter new data, update data in the
system, or change/modify data in the DBMS
2. Data Processing Processes
2. Outcome measurements and quality improvement
-
Are DBMS-directed actions that the computer
performs on the data once entered into the system
3. Clinical research and professional education
-
It this processes that are used to convert raw data
into meaningful information
3. Data Output Operations
-
Includes online and written reports
-
The approach to designing these reports will have a
major impact on what information the reader
actually gains from the report
DATA WAREHOUSES
-
-
is a large collection of data imported from several
different systems into one database. The source of
the data includes not only internal data from the
institution but can also include data from external
sources.
For example: one can import standards of practicerelated data into data warehouse and use it to
analyze how the institution achieved a variety of
standard related goals.
4. Reporting to external agencies (JCAHO)
5. Market trend analysis and strategic planning
6. Health services management and process
reengineering
7. Targeted outreach to patients, professionals and
other community groups
DATA ANALYSIS AND PRESENTATION
-
Data Analytics
-
PURPOSES OF DATA WAREHOUSES
•
An organization’s decision to develop a data
warehouse is based on several goals and purposes
•
The developer makes types of decisions in building
the warehouse to provide a more consistent
approach to making decisions based on the data.
•
A data warehouse makes it possible to separate the
analytical and operational processing
it is defined here as the process one uses to make
realistic, quality decisions using the available data.
The data and their analysis guide the decisionmaking process.
Dashboard
-
is a visual display of the most important information
needed to achieve one or more objectives,
consolidated and arranged on a single screen so the
information can be monitored at-a-glance”
(iDashboard, 2013,)
-
Available for clinical performance indicators such as
unit census, length of stay, and so forth; for hospital
performance indicators such as admissions, income,
and utilization; for patient performance indicators
such as average length of stay and drug error rates;
for physician performance indicators such as
number of patients seen; and for nursing
performance indicators: such as pain assessment,
staff turnover rates, educational levels, and
pressure ulcer prevalence.
FUNCTIONS OF DATA WAREHOUSE
1. Must be able to extract data from the various
computer systems and import the data into the
data warehouse
2. Must function as database able to store and process
all the data in the database
3. Must be able to deliver the data in the warehouse
back to the users in the form of information
With the ability to collect increasing amounts of
data, the ability to obtain new information and
insights is growing exponentially. In turn the tools
that one uses for data analytics and information
presentation such as dashboards take on new
importance.
DATA QUALITY
Data Stewardship
Data from data warehouse can be used and support a
number of activities:
1. Decision support for caregivers at the point of care
-
is the aspect of data governance that focuses on
providing the appropriate access to users, helping
users to understand the data, and taking ownership
of data quality
Responsibilities of a Data Steward:
•
Ensures the quality of data
•
The keeper of the data
•
Must work with the department that generates the
data to ensure its quality
•
Works with caregivers and administrative personnel
to develop naming standards, entity and attribute
standards, rule specifications, data security
specifications and retention specifications
WHY HEALTHCARE DATA STEWARDSHIP IS SO
IMPORTANT IN NURSING*
1. Good data warehouse architecture promotes good
data stewardship. In nursing this means standard
nursing languages that are consistent with and
integrated into other standard languages in healthcare
as well as standard nurse-sensitive quality indicators.
2. Good data warehouse tools promote good data
stewardship. In nursing, access to data is usually based
on who has clinical responsibility for the delivery of
care. As a result a top nursing administrator may have
access to all patient data. But this may not be the
person who can best interpret the implications of the
data for meeting specific patient needs. Not only do we
need good data warehouse tools but we also need
clinical nurse leaders who can access these data and the
skills to use the tools for analyzing nursing data and
meeting patient needs.
3. Good data stewardship creates a well-informed and
thriving user base. Nurses are knowledge workers but
only if they have access to the data and the information
in that data can they apply that knowledge in meeting
the needs of patients, families, and the community of
patients with similar needs.
DATA/INFORMATION/ to Knowledge (KDD)
•
•
•
•
The process of extracting information and
knowledge from large scale databases
Knowledge discovery (KDD) or D2K
AGL- mining of imaging data
D2K uses powerful automated approaches for the
extraction of hidden predictive information from
large databases
Data Mining Process
1. Predicting- discovering variables that predict or
classify a future events
2. Discovery- discovering patterns, associations, or
clusters within a large dataset
3. Deviation- Discover the norm via pattern
recognition and then discover deviations from the
norm
The CRISP-DM model cycle of data mining
1. Understanding the business
2. Understanding the data
3. Data preparation
4. Modeling
5. Evaluation
6. deployment
The Nelson Data to Wisdom Continuum
1. Data- naming, collecting and organizing
2. Information- organizing , interpreting
3. Knowledge- interpreting, integrating,
understanding
4. Wisdom- understanding, applying , applying with
compassion
The Internet: A Nursing Resource
THE INTERNET
-
Network of computer networks
-
Provides the ability for computers attached in some
way to one of the wires or cables on the system to
send and receive information from other computers
in the network
-
The openness and worldwide dimensions of the
internet have the power or democratize
communications and level the playing field of
access to information
•
It is the results of dividing messages into smaller
pieces , each individually addressed
1962
•
Dr. J.C. R.Licklider was chosen to lead a research to
improve military use of computer technology
•
ARPANET named after its DoD pentagon sponsor
the ARPA was installed at the University of
California, Los Angeles
•
Within a few months other nodes were established
at Stanford Research Institute, University of
California, Sta. Barbara and University of Utah
USE OF INTERNET TO NURSES
1973
•
A constant source of up-to-date professional
information
•
Transition Control Protocol and the Internet
Protocol (TCP/IP) were taken by Vint Cerf and Bob
Kahn
•
Provides access to information that previously was
available only in large medical and nursing libraries
•
Any computer or network agreed to used these
protocol could join ARPANET
•
To network with colleagues all over the world share
their knowledge and learning from each other , thus
broadening the body of nursing knowledge
Mid-1980s
•
•
To search for information about approaches to
specific nursing intervention
The sheer scope of the internet and speed the
spread of information will cause nursing care
standards to expand from community and regional
to national and international
HISTORY OF THE INTERNET
1952
•
When US launched “sputnik”
•
The creation of the Advanced Research Project
Agency (ARPA) by *resident Eisenhower
•
ARPA worked with the RAND Corporations to solve
the problem of how US authorities could
communicate after a nuclear war
•
The creation of “packet switching”
•
A device that had no central authority and would be
assuemd at all times to be unreliable
•
Invented by Paul Barran
•
Many networks had adopted the standards, and a
world internet became a reality
•
Mid-1990s commercial networks such as
CompuServ and Prodigy became a part of the
internet
WHO CONTROLS THE INTERNET?
•
It has NO OWNERS, censors, bosses, board of
directors or stockholders
•
Any computer that obeys the protocols which are
technical, not social or political can be an equal
player
•
An example of a true, modern, functional anarchy
ISOC
-
The internet has Voluntary groups that develop and
coordinate standards, resources and day to day
issues of the operation
-
Overall organizing force is ISOC
-
An international non-profit , professional
membership organization with no governmental
allegiances
-
Composed of over 150 organizations and 16,000
individual members that represent over 180 nations
throughout the world
File Transmission Protocol (FTP)
-
THE TECHNOLOGY BEHIND THE INTERNET
PROTOCOL
-
An agreed on format for doing something
INTERNET PROTOCOL
Which permits users to send all types of electronic
files over the internet and telnet which allows users
to access a distant computer as though they were
sitting in front of it
Domain Name System (DNS)
-
A way of computers on the internet in identifying
each other to perform a required task
It permits us to give globally unique “names” in
networks and computers
•
Determine how data will be transmitted between
two devices
-
•
The type of error checking that will be performed
BENEFITS
•
How data compression, if any is accomplished
-
•
How the sending computer will signal that it has
finished sending a message
A name is easy to remember than the long string of
members that makes up the IP address, which is
assigned to each computer on the network
•
How the receiving computer will signal that it has
received a message
-
A name allows for a change of physical location that
is transparent to the user
-
Paul Mockapetris pioneered the protocols that
allow the DNS to work
Transmission Control Protocol (TCP)
-
Allows computers to connect to a network and
exchange data
-
A series of characters (usually letters) makes up
each domain name
-
Carries out the task of breaking messages into the
small packets
-
Labels are separated by dots
-
Makes certain that the packets, also called
datagrams, are all received and are in the correct
order
-
When packets are lost or reordered TCP will detect
this and transmit and or reorder the packets as
necessary
-
Presents an abstraction to user applications, which
allows them to exchange streams of data without
worrying
Internet Protocol (IP)
-
I8s the lower level protocol
-
Responsible for making decisions about these
packets and routing them
Top Level Domain (TLD)
-
The right most label in a domain name
-
Each country as of 2003 has a two- letter TLD
-
e.g. Canada –CA: Great Britain- UK, Germany is DE,
Philippines is PH
-
Fastest growing TLD is .net- 45%
-
Largest domain is .com-33%
Current Top Level Domain
.AERO- for the air transport industry
.BIZ- for businesses
.COM- commercial business organization
Hypertext Transmission Protocol (HTTP)
.COOP- for cooperatives
-
. EDU- Restricted for a 4 year degree granting
institutions in north America
Supports the World Wide Web (WWW)
.GOV- restricted in the U.S. federal government
.INFO- for all users
-
.INT- Restricted to organization that were established
by international treaty
Gopher System
MIL- restricted to military
-
Find resources on the internet
.MUSEUM- for museums
-
Under this system a client computer is one that has
software that allows it to retrieve files from a
distant computer
-
While a server is a computer that has software that
allows it to respond to a client by sending a
requested file
-
Provided users a menu of items available on
internet servers globally
.NAME- for individuals
.NET- for network resources
. ORG- for nonprofit organization
.PRO – for professions
Other names
•
•
•
Some computer have more than 1 name
Each TLD has a responsibility to groups within their
domain who may have further delegated naming
responsibility
After the universal resource locator (URL) there is a
forward slash(/) and more names these refer to the
path to the particular document and the name of
the document
Internet Corporation for Assigned Names and numbers
(ICANN)
-
-
Created in October, 1998 http://www.icann.org
Responsible for the technical coordination of the
internet
Non-profit, private sector corporation which is a
coalition of business, academic, technical, and user
communities
Has assumed the technical functions previously
handled by other groups including the Internet
Coordinates assignment of identifiers that must be
globally unique for the internet to operate this
includes domain names, IP address, and protocol
parameters and port numbers
They pooled the information from their searches
and made it available to users to other sites
Veronica and Jughead
-
Search programs that allow users to search the
global indices on subjects of interest
File Transfer Protocol (FTP)
-
-
The method used by early internauts (a moniker for
users of the internet) to upload files to and
download files from distant computers
It uses the Internet’s TCP/IP protocols for the
transfer of data
Used to upload or post files to a web site
Uploading a File
-
Refers to the process of moving a file from the
user’s computers to another
Downloading a File
-
Is the transfer of file from another computer to the
user’s computer regardless of the physical distance
between the two computers
Telnet
How large is the Internet?
-
•
•
A terminal emulation program that is part of the
TCP/IP protocols
-
Internet allows a computer to behave like a
terminal for a distance computer regardless the
type of the computer that either the target or
originator of the telnet session
-
A log in and a password are required to begin a
telnet session
-
Behind the scenes to connect their subscribers to
propriety forums on the internet
•
•
2001- 109 million hosts in 230 countries
Unlimited number of people with unlimited number
of network gateways
46-67% growth rate annually
Projected to have 63 new host and 11 new domains
in mid 2005
Archie
-
File locator software
-
Often used to control web servers remotely
-
Small icons or smileys used o denote a mood
Discussion groups:
-
1. Newsgroups- are a sort of worldwide bulletin board
that is accessed using a software called a
newsreader
Originally intended to be viewed by tilting the head
to the left
-
Originated when e-mail programs were only text
based
2. Online Forums- set by organizations to allow
members ,or anyone depending on how the forum
is organized, to share ideas
Some commonly used abbreviations
3. Mailing Lists
BTDT- been there done that
Threading
BTW- by the way
-
CTS-changing the subject
-
The subject is automatically assigned from a subject
time when a reply to a subject is made
Allows users to select topic which they will read
messages
E-mail
-
Use to send message to many users
-
First e-mail software appeared in 1972
-
Allows to user to list, selectively read, files, forward
and respond to messages
AFK- away from keyboard
DQMOT- Do not quote me on this
FTF-Face to face
FWTW- For what its worth
HTH- Hope this helps
IMHO- In my humble opinion
LOL- Laughing out loud
OTOH- on the other hand
-
The largest network application
WYSIWYG- What you see is what you get
-
Made freely available to anyone who wanted it
E-mail Etiquette
-
Applications are developed including files of
information, or pictures
•
Using all capital letters are considered “Shouting”
-
Most popular e-mail companies: Netscape, Yahoo
and Hotmail
•
Always use a subject for your e-mal
•
Don’t use “Hi”, “Info”, “As requested” “Important”
common use in e-mail infected with virus
•
E-mails should be signed, signature File: name and
e-mail address
•
Health Insurance Portability and Accountability Act
of 1996 (HIPAA)- includes confidentiality statements
•
Set an option in your computer for “automatic
reply”
E-mail Address
-
e.g. Clara.Barton@Redcross.org
-
Has two parts separated by the @ sign
-
First part is the username, user ID or login name
-
2nd part is the Name of computer followed by
domain name
Emoticons and Abbreviations
Organizing received files:
Emoticons –
•
-
typing a character s available on a standard
keyboard to form a picture
Create a folders for received messages to clear your
mailbox for messages that you still have to attend
to and allows you to keep messages you want
File Attachments
Finding a List
•
•
L-soft International- a company that produce a
software that is used to operate the majority of lists
•
This company has an automatically generated
searching database of listserv lists that can be
accessed at http:// www.Isoft.com/catalist.html
•
It contains more information about almost 70,000
public lists in the internet
•
Nursing discussion groups and mailing lists:
http://nursing.buffalo.edu/mccartny/nursing_discu
ssion_forums.html
•
•
Plain text File- ASDCH file that can be read by all email software and all word processors
TEXT FILES- have no formatting, text placement
cannot be determined by the individual who
created a file
PROPRIETY FILE- a file that is created by a word
processor or other application program
CAUTIONS and SUGGESTIONS
•
“spam” mails-unwanted e-mail from an unknown
source, often with the intent selling something
•
In Sending e-mail message to more than one
person , consider putting all the addresses on the
blind copy line
List etiquette
Be aware that some companies are selling e-mail
address
•
•
•
Mailing List
-
Developed in 1980s
-
Eric Thomas developed a software that automated
many of a functions necessary to maintain a list
-
Software is Free to anyone
-
Called Listserv
-
Set up to provide an arena for discussion on a
specific topic
•
•
•
•
Remember that any message that you post to a list
will be sent to all members of the list
Do not add unnecessary traffic to the list with
replies that do not really contribute to the
discussion
When you reply to a posting make sure you either
use the “reply” with history” function
When sending a message use descriptive subjects
Avoid sending file attachments
If you are unable to read e-mail messages for a
while either unsubscribe or use the “no mail
function”
The World Wide Web
-
Tim Berners-Lee inventor of WWW
-
“Owned” by an individual who manages the day- today affairs of the list
-
Named as the “top 20 thinkers of the twentieth
century” by time magazine
-
To reply a list message is automatically sent to the
list
-
Was given Knight Commander of the Order the
British Empire Honor
-
Defined the idea of web is that it should be
collaborative space where you can communicate
through sharing of information
-
Web Browser- a client program that translates files
to the image you see on the screen
List Fundamentals
-
Have 2 addresses
-
1st address- is used to described to the list,
unsubscribe or use some of the functions that the
software makes available
-
Important to save the welcome message so that it
can be referred to when needed
-
File messages in a folder
-
2nd address- is one that subscribes use to post a
message to the mailing list
How the WWW Functions?
Browser-allows any computer to be a web client
-
Allows to receive, interpret, and send to the client
computer
HTTP- enables the transmitting and interpretation of all
types of files, not just text
-
a type of system which permits objects to be linked
to one another
The internet as an Information Source
•
URL- address for a web site, contains the name of the
computer where you are seeking in located along with
other specifics to locate it
You are able to do a search and find an answer to
the question in just a minute or two
•
Web is still vastly unorganized
URL
•
As the number of Web sites increases, the potential
number of sources to search also increases
•
Deciding which type of search service to use should
depend on the topic
-
e.g. http://www.acutari,mil/nightangale/notes,htm
-
transmission protocol
-
Computer name
•
Top search engines: Google, Alta Vista, Yahoo, MSN
-
Domain name
•
-
Directory
Cookies- is a piece of text information, which is
placed on a client’s browser by a website visited
-
free name
Uses of the web
Organizations evaluating Health Information
•
Health Information Technology Institute (HTII)Assess the quality of health information
•
Health on the Net (HON)- conducts surveys of
internet use related to health
•
Opens the world to you
•
You can use libraries throughout the world
•
Easy to access information
•
•
Utilization Review Accreditation Commission(URAC) evaluate web sites
One can search library catalogs, databases, indexes
of journals and dissertations
•
•
Use search engine to find other sources available
Health Internet Ethics-Hi-Ethics,Inc- concerned with
the privacy, security , credibility and reliability of
health information
•
Print journals to the table of contents , abstract, to
the full text are available
•
•
You can check your hometown page
National Quality Measures Clearinghouse- (NQMC)provides access to a large number of evidencebased quality measures
•
Major newspapers have website
Getting on the information Superhighway
Uses of Web to nurses
•
Makes professional information easily accessiblee.g. BON
•
Nursing organizations- PNA
•
Organizations that offers post-graduate courses,
seminars and training
•
Excellent tutorials available online
•
Information about specific hospital
•
DSL- Digital subscriber lines
•
ISP- Internet Service Providers-companies that
provide access to the internet
•
IAP- Internet Access Providers same as ISP
•
Wi Fi- Wireless Fidelity-which uses radiowaves to
connect to the internet
Criteria for Assessing the quality of health Information
on the Internet
1. Credibility- source of the info, date, useful, relevant,
process
2. Content- examine the hierarchy of evidence,
presence of original source, provide disclaimer
3. Disclosure- purpose of site, reason, what will they
do with the info
medical reference, drug interactions, and
synchronization of schedules and tasks
4. Links- quality of links
SMARTPHONE
5. Design- accessible, easy to navigate, searchable
-
6. Interactivity- allow feedback and exchange of
information
-
7. Caveats-clearly state its function, primary info,
trying to see products/services
-
Wireless Devices
PERSONAL DIGITAL ASSISTANT (PDA)
-
A handheld device that combines computing,
telephone/fax, Internet and networking features.
-
A typical PDA can function as a cellular phone, fax
sender, Web browser and personal organizer.
-
PDAs may also be referred to as a palmtop, handheld computer or pocket computer.
-
Incorporated handwriting recognition features and
voice recognition technologies.
-
PDAs are available in either a stylus or keyboard
version.
-
Apple Computer, which introduced the Newton
MessagePad in 1993, was one of the first
companies to offer PDAs. Shortly thereafter, several
other manufacturers offered similar products.
-
One of the most popular brands of PDAs was the
series of Palm Pilots from Palm, Inc.
-
As technology changed the world of mobile devices,
the PDA has become obsolete as devices like touchscreen smartphones and tablets grow in popularity.
PDA as mHealth (mobile health) tool
•
•
•
•
The concept of mHealth can be traced to the early
1990s when the first 2G cellular networks and
devices were being introduced to the market.
A major standards breakthrough occurred in 1997,
enabling Wi-Fi capable barcode scanners to be used
in hospital inventory management.
Shortly thereafter, clinicians began to take an
increasing interest in adopting technologies.
Nurses began to use personal digital assistants
(PDAs) to run applications like general nursing and
A cell phone that allows you to do more than make
phone calls and send text messages.
Can browse the Internet and run software programs
like a computer.
Use a touch screen to allow users to interact with
them.
Apps including games, personal-use, and businessuse programs that all run on the phone.
SMARTPHONE as mHealth tool
•
•
•
•
•
Smart phones allow consumer and patients to use
mobile health applications.
Most mobile apps are available through mobile
store platforms like Apple App Store, Google Play
for the Android.
There are also more than 100 apps approved by the
FDA for use in healthcare (Aitken & Gauntlett,
2013). Users use these apps to track or manage
their health. Used health apps were for exercise,
diet, or weight apps.
Prevention/healthy lifestyles, symptoms or selfdiagnosis, finding a healthcare provider or facility,
education post-diagnosis, filling prescriptions, and
compliance. The majority of apps were in the
overall wellness category (prevention and healthy
lifestyles) with diet and exercise being the dominant
apps.
In terms of functionality, most apps were limited in
their functions, with most providing just
information. According to the report (Aitken &
Gauntlett, 2013, p. 8), “there is a subset of apps
with impressive functionality (e.g.
electrocardiogram (ECG) readers, blood pressure
monitors, blood glucose monitors).”
TABLET COMPUTER
-
A small light notebook computer with the
ability to provide input using a stylus
periodically fully discharged and then fully
recharged cycling
PDA and Wireless Devices
Personal Digital Assistant (PDA)
-
Comes with a miniature keyboard and a stylus for
data entry
3. Alkaline rechargeable Battery-perform best when
allowed to discharge to half of their original charge,
and then are recharged
-
Possible to add an external portable keyboard
PDA OS
-
It has many characteristics as smartphones but tend
to have a longer battery life
•
Palm OS
•
Windows Mobile
•
Blackberry
Smartphone
•
Hiptop
-
•
Linux
•
Symbian
-
Designed to work as stand- alone computer and as a
device that communicates with other computer
a hybrid device combining wireless telephone, email, Internet access and PDA organizer functions
Desktop Computer vs Smartphone Physical
Characteristics
Notebook/laptop vs.Tablet vs. PDA Physical
Characteristics
Wireless Devices
•
card
•
Wireless Local Area Network-WLAN
•
Wireless Fidelity (Wi Fi)
•
Infrared
•
Plugged into a computer
•
Bluetooth
Why use PDA?
✓ Allow a nurse to manage and organize time
effectively
✓ Readily available when needed
✓ Document data as you collect it
✓ Improve patient care by bringing information at the
point of care
✓ Applications specifically developed to assist
healthcare providers in the clinical setting
✓ Gather data as the time of visit
Battery Life
1. Lithium Battery- do not tolerate being stored for
long periods at full charge. They perform best when
recharged after a partial discharge
2. Nickel Battery- do not tolerate being left for long
periods on a trickle charge. They perform best when
✓ Support documentation requirements for billing
and reimbursements
✓ Accurately bill for office visits and procedure
✓ An effective method to track patients
PDA Generic Functions and their application to Clinical
Practice
•
Review appropriate drug doses for a less familiar
drugs
•
•
Check for drug interactions
•
Review the latest evidence based management
guidelines for a particular problem
•
Utilize applications for differential diagnosis and
clinical decision –making including management
Address Book-allows multiple categories such as
attending physicians, nursing units, clinics, and staff
members
•
Calculator- available medical calculations
•
Datebook- allows the nurse to keep track of his or
her schedule
•
Memo pad- place to compose memos
•
Notepad- useful in jotting quick notes
•
To do list- create multiple list s and keep track of
tasks to be done
•
Infrared- sharing of information (beaming) enables
transmission of information of files from a PDA
Add on Software
•
•
•
E-book
Applications designed to connect to a WLAN
Wireless e-mail application
General Freeware, Shareware and Commercial
Applications
1. Document viewers-allows the viewer to download
and read text files
- E.g. Adobe reader for Palm OS and Acrobat reader
for Windows Mobile or Symbian
2. Graphics Viewer- for image viewing, for individuals
practicing in specialties where images are basic
requirements
- e.g. Firepad picture viewer
3. Database Programs- read data files and create
databases
- e.g. HanDbase, Jfile, Filemaker Mobile
4. Web browsers-may function as off-line HTML
document readers using Wi Fi
- E.g. AvantGo
Clinical Applications by functions
•
Ready access to relevant information at the point
of care
•
Mobility
•
Ability to check on signs and symptoms that
could indicate a medical emergency
Clinical Application by Category
1. Pharmacology databases- information about drug
information, and some bundled applications
- e.g. Epocrates Rx- freeware that includes adult and
pediatric indications, dosing, contraindications,
adverse reactions, mechanism of action and a
program that allows user to check for drug
interactions using a list up to 30 drugs
- E.g. Epocrates RxPro- pharmacology database,
alternative medicine information integrated into
the pharmacology database, an infectious disease
database updated quarterly, differential diagnosis
applications, summary tablets such as GCS and
medical calculator
- e.g. Mobile Micromedex-by subscription, general
drug information
- Lexi-Complete-subscription that offer 15 databases
- Lexi-interact- 2 programs developed for assessment
of drug interactions
2. Medical Calculator-applications available to assist
providers who use standard formulas for
calculations of BMI, creatinine clearance etc.
- E.g. Medcalc and MedMath, PregCalc,
StatCholesterol
•
-
Clinical Decision support tools- epocrates ID John
Hopkins Antibiotic Guide, Stanford Guide to
Antimicrobial therapy, Infectious Disease Notes,
TheraDoc Antibiotic Assistant, FIRST-Consult
4. Patient-Tracking Software-handheld patient
management tool that allows the provider to track
a variety of patient information
- E.g. PatientKeeper, Palm Patient
- Limiting Factor-lack of communication with other
HIS such as Lab or Xray dept.,CIS does not support
PDA data sharing
5. Billing and Coding applications-are designed to
document charges for patient visits, procedure and
medical diagnosis
- Allows coding of Evaluation and Management (E&
M), International Classification of Disease
(ICD)codes, and Current Procedural Technology
(CPT)codes
- E.g. PocketBilling, Stat E& M
If PDA hangs, the user should be able to do a rest
and not loose data
Electronic Health Record Systems
HPIAA Applications
•
•
•
•
Electronic transactions
Code sets
Security unique identifiers
privacy
IOM DEFINITION OF HER
-
Asynchronous Communication and PDA
-
Require an ID and Password
-
Application that will wipe any information on the
event the user incorrectly enters an ID and
password a set number of times
Key capabilities of EHR
-
Synchronous Communication and Wireless Device
-
Encryption- process of protecting all transmitted
identifiable health information in the PDA
The data exchanged is Encrypted when it leaves and
is Decrypted when it arrives at its destination
The set of components that form the mechanism by
which patient records are created, used, stored and
retrieved. A patient record system is usually located
within a healthcare provider setting. It includes
people, data, rules and procedures, processing and
storage devices, and communication support
facilities
-
Evaluation to Clinical Applications
Longitudinal collection of electronic health
information for and about persons, where health
information is defined as information pertaining to
the health of an individual or healthcare provided to
an individual
Immediate electronic access to person and
population –level information by authorized users
Provision of knowledge and decision support that
enhances the quality, safety, and efficiency of
Patient care
Support of efficient processes for healthcare
delivery
•
Understanding the goal of the nurse in selecting and
using the software
-
•
Software must be compatible with the OS of the
PDA
Department of Veterans Affairs (VA)
•
The user should comfortably enter information
using stylus
•
They should be a way to install and backup
applications
•
Computerized patient record system (CPRS) was
created in 1990
•
Provided a single place for healthcare providers to
review and update a patient’s health record and
order medications , special procedures, x-rays,
nursing orders, diets and laboratory tests
•
Created 4 goals to achieve the vision of using IT to
improve healthcare
CPRS features
NCVHS
•
A checking system that alerts clinician if an order
they are entering could cause a problem
-
•
A notification system that immediately alerts
clinicians to clinically significant events
•
A visual posting system that alerts healthcare
providers to issues specifically related to the patient
on the opening of the patient’s electronic chart,
including crisis notes, adverse reactions and
advance directives
•
A template system that allows the healthcare
provider to automatically create reports
•
A clinical reminder system that electronically alerts
clinicians when certain actions such as
examinations and laboratory tests need to be
performed
•
Remote data viewing to allow clinicians to see the
patient’s medical history at all the VA facilities
where the patient was seen
Department of Defense (DO)
•
•
•
Composite health care system II (CHCS II) was
developed in 2004
Physician order entry capability that enables them
to order lab tests and radiology examinations and
issue prescriptions electronically
Pharmacy data transaction service links military
treatment facilities, mail order and network
pharmacies
Indian health Service (IHS)
In 2002 it presented the concept of infrastructure
that emphasizes health-oriented interactions and
information sharing among individuals and
institution rather than simply the physical, technical
and data systems that make those interactions
possible.
Agency for Healthcare Research and quality (AHRQ)
-
2003-2004 unveiled a major HIT portfolio, with
grants, contracts, and other activities to
demonstrate the role of HIT in improving patient
safety and quality of care.
-
Funded demonstration grants to establish and
implement interoperable health information
systems and data sharing to improve the quality,
safety, efficiency and effectiveness of health care
for patients and populations.
Centers for Medicare and Medicaid Services
-
Has initiated several pilot projects to promote
health IT,
-
In May, 2004, CMS awarded a 100.000 dollars
grants to the American Academy of Family Physician
for a pilot project to provide comprehensive
standardized HER
Connecting for Health
-
Addressing the barriers to development of an
interconnected health information infrastructure
eHealth initiative
-
An independent, nonprofit affiliated organization
established to foster improvement in the quality,
safety, and efficiency of healthcare through
information and IT
•
Resource and Patient Management System (RPMS)
was developed in 1970s
•
Patient Care Component(PCC) has been in place in
1980s
Institute of Medicine (IOM)
IHS- HER
-
Has championed the advantages of use of IT to
improve healthcare
-
The computer- based patient record was revised
and republished in 1997
•
Office of the National Coordinator for Health
Information Technology (ONCHT)
•
EO 2004 created the ONCHT to coordinate HIT
efforts in the federal sector
Certification Commission for health information
technology
•
Passive feedback systems that present-patient –
specific data in an organized fashion
-
HIMSS and AHIMA and NAHT have joined together
to form this group
•
Tests results
•
Charges
-
The goal of the group is to support Goal 1, Strategy
2”Reduce risk of EHR investment
•
Reference materials
Health level seven (HL7)
•
Progress notes
-
•
Active feedback systems to provide clinical decision
making tools
•
Provision of specific assessments or
recommendations through alerts and reminders
Known for its large body of work in the production
of technical specification for the transfer of
healthcare data.
The Role of Technology in the
Medication-Use Process
Advantages of CPOE
• Can improve quality patient outcomes and
safety by a variety of factors such as increasing a
preventive health guideline compliance
• Provide preventive care by encouraging
compliance with recommended guidelines
• Identifying patients needing updated
immunizations or vaccinations
• Suggesting cancer screening and diagnosis
reminders prompt
• Reductions in the variation in care to improve
disease management by improving follow-up of
newly diagnosed conditions
Computerized Prescriber Order Entry (CPOE)
•
Reminders system to improve patient management
-
•
Automating evidence- based protocols
•
Adhering to clinical guidelines
•
Providing screening instruments to help diagnosis
disorders
•
Improve drug prescribing and administration by
improving antibiotic usage
•
Medication refill compliance can be increased using
reminder systems to increased adherence to
therapies
A system used for direct entry of one or more types
of medical orders by a prescriber into a system that
transmits those orders electronically to the
appropriate department
Features of CPOE
•
Acute care setting
•
Ambulatory care setting
•
Access records and enters records from their office
or home
•
Prescriber selectable standardized single orders or
order sets
•
Improved drug dosing especially those drugs that is
based on laboratory results
•
Implementation of organization-specific lists of
medications or formulary
•
Reductions in ADEs
•
Reduced errors of omissions
•
Eliminated Handwriting and interpretation issues
•
Fewer hands-offs if cpoe was linked to the
information systems in ancillary departments
-
•
Fewer loss of misplaced orders and faster delivery
time
-
•
Eliminated the need for staff members in those
departments to manually enter the orders into their
information systems
patient’s bar code wristband to confirm their
identity
Prior to medication administration each bar coded
package of medication to be administered at the
bedside is scanned.
The system can verify the identity with their
medication profile in the pharmacy information
system and electronically record the administration
of the medication in an online MAR
Features of bar code-enabled point-of-care technology
•
Access to pertinent literature and clinical
information knowledge bases
•
Increased accountability and capture of charges for
items such as unit-stock medications
•
Increase efficiency, productivity and cost
effectiveness
•
Up-to-date drug reference information from online
medication reference libraries
•
Reduce the cost in providing healthcare
•
•
Allow for instantaneous capturing of charges and
therefore enhancing revenue
Customizable comments on alerts (look alike soundalike drug names)
•
Improve communication by decreasing the amount
of time needed for referral system
Monitoring the pharmacy and the nurses response
to predetermined rules or standards
•
Reconciliation for pending or stat orders
•
Capturing the data for the purpose of retrospective
analysis of aggregate data
•
Verifying blood transfusion and laboratory
specimen collection identification
•
Benefits of CPOE to nurses
•
•
•
•
•
•
•
•
More time with patients due to enhanced
productivity due to reduced frequency in contacting
prescribers
Reductions in time wasted in transcribing duplicate
orders for the same medications or tests
Greater standardization of orders
Lessening the need to understand and adhere to
diverse regimens and schedules
Improved efficiency when ordering tests or
procedures
Less need to enter voice orders into the system as
prescribers gain access to the system from other
units
Orders would be usually executed faster
Medications will be accessible more quickly and
patients receive prompt care
Bar code-enabled point-of-care technology
-
-
-
The system helps to verify that the right drug is
being administered to the right patient at the right
dose by the right route and at the right time
On admission patients are issued an individualized
bar code wristband that uniquely identifies their
identity
When a patient is to receive a medication, nurses
scans their bar coded employee identifier and the
5 significant negative effects
•
Nurses were sometimes caught “off guard” by the
programmed automated actions
•
The BPOC seemed to inhibit the coordination of
patient information between prescribers and nurses
when compared to a traditional paper-based
system
•
Nurses found it more difficult to deviate from the
routine medication administration sequence with
the BPOC system
•
Nurses felt that their main priority was the
timeliness of medication administration because
BPOC required nurses to type in an explanation
when medications were given even a few minutes
late
•
Nurses used strategies to increase efficiency that
circumvented the intended use of BPOC
Error that can occur in using BPOC system
Problems in using ADC
•
•
Choosing of the wrong medication from an
alphabetic pick list
•
Extra dose- an extra dose maybe given when there
are orders for the same drug to be administered by
a different route
High- alert medications placed, stored and returned
to ADCs are problematic
•
•
Storage of medications with look-alike names
and/or packaging
Wrong drug- in administration of wrong drug which
has not been labeled with a bar code
•
•
Wrong dose- in situations where the nurse has
difficulty in scanning medication and proceeds to
scan the medication twice
Development of workarounds for ineffective or
inefficient systems can be devastating for patients
safety
Issues in using ADCs
•
Omissions- after the patient’s bar code armband
and medication have been scanned, the dose is
inadvertently dropped into the floor
•
Unauthorized drug- an order to hold a medication
unless a lab value is at a certain level such as an
aminoglycoside
•
Charting errors-distinguish the indication for the
administration of the medication
•
Wrong dosage form- certain drug shortages may
force a pharmacy to dispense a different strength
and concentration
•
•
•
•
Automated Dispensing Cabinets
Consider purchasing a system that allows for
patient profiling so pharmacists can enter and
screen drug orders
Carefully select the drugs that will be stocked in the
cabinets
Place drugs that cannot be accessed without
pharmacy order entry and screening in individual
matrix bins
Place drugs that cannot be accessed without
pharmacy order entry and screening in individual
matrix bins
•
Use individual cabinets to separate pediatric and
adult medications
•
Periodically reassess the drugs stocked in each unitbased cabinet
✓ The device require a staff to enter a unique log on
and password to access the system using a touch
screen monitor or by using a finger print
identification
•
Remove only single dose of medication ordered
•
Develop a check system to assure accurate stocking
of the cabinets
✓ A nurse can obtain patient-specific-medications
from drawers or bins that open after a drug is
chosen from a pick list
•
Place allergy reminders for specific drugs such as
antibiotics and opiates and non-steroidal antiinflammatory drugs NSAIDs
Rationale of wide acceptance of ADC
•
Routinely run and analyze override reports to help
track and identify problems
✓ A computerized point-of-use medicationmanagement system that is designed to replace or
support the traditional unit-dose-drug delivery
system
✓ Improving pharmacy productivity
✓ Improving nursing productivity
Smart infusion pump delivery system
✓ Reducing costs
-
Are primarily used to deliver parenteral medications
through IV or epidural lines and can be found in a
variety of clinical settings
-
Smart pumps includes comprehensive libraries of
drugs, usual concentrations, dosing units and dose
limits
✓ Improving charge capture
✓ Enhancing patient quality and safety
-
-
-
Software that incorporate institution-established
dosage limits, warnings to the practitioner when
dosage limits exceeded and configurable settings by
patients type or location
Software that enables to provide an additional
verification of the programming of medication
delivery
System that can allow organizations to configure
unit-specific profiles, which include customized sets
of operating variables, programming options and
drug libraries
Issues in implementation of technology
•
Outlining goals for the type of automation to be
implemented
•
Developing a wish list-of-desired features and
determining which one, given budgetary constraints
are practical
•
Investigating systems that are presently available
•
Analyzing the current workflow and determining
what changes are needed
•
Identify the required capabilities and configuration
of new system
•
Sell the benefits and objectives of automation to
staff
•
Development of an implementation plan
SECOND TYPE OF STANDARD
-
Involves specification of data structures and content
and would include such standards as message
formats and core data sets
THIRD TYPE OF STANDARDS
-
Addresses the interpretation of that data as
information including how it should be acted on
within a particular context
Healthcare Data Interchange Standards
-
Address primarily the format of messages that are
exchanged between computer systems, documents
and architecture, clinical templates, user interface,
and patient data linkage
Message Format Standards
•
Medical device communication
•
Digital imaging communications
•
Administrative data exchange
•
Clinical data exchange
NCVHS
•
•
•
•
•
Uniform data standards for patient medical record
information (PMRI)
Digital Imaging Communication in Medicine
Standards (DICOM)
National Prescriptions Drug Programs (NCPDP)
SCRIPT
Institute of Electrical and Electronic Engineers
HealthCare Data Standards
Institute of Electrical and Electronic Engineers
DATA STANDARDS
-
Medical Information Bus (MIB)
-
-
Support real time continuous, and comprehensive
capture and communication of data from bedside
medical devices such as those found in intensive
care units, or and er departments
-
Include physiologic parameter measurements and
device settings
Used to describe those standards having to do with
the structure and content of health information, it
may be useful to differentiate data, information and
knowledge
Types of standards
FIRST TYPE OF STANDARD
-
Equipment specifications such as processor type or
network transmission protocols
National Electrical Manufacturers Association (NEMA)
-
Develop a generic digital format and a transfer
protocol for biomedical images and image related
information
Accredited Standards Committee (ASC) X12N
-
Developed a broad range of electronic interchange
(EDI) standards to facilitate electronic business
transactions to the healthcare arena
Logical Observation Identifiers Names and Codes
(LOINC)
-
National Council for Prescription Drug Programs
(NCPDP)
-
-
Develops standards for information processing for
the pharmacy services sector of the health care
industry.
5.1 was named as the official standard for pharmacy
claims with HIPAA
RxNorm
-
Is a clinical drug nomenclature produced by NLM in
consultation with the Food and Drug Administration
(FDA)
-
Provides standard names for clinical drugs (active
ingredients strengths dose form) and for dose form
as administered
Standardized Terminologies
-
Ability to represent concepts in an unambiguous
fashion between both the sender and receiver of
the message
International Statistical Classification of Diseases and
Related Health Problems: Ninth Revision and Clinical
Modifications
•
ICD9-CM- the sole classification used for morbidity
repo9rting in the US since 1979
•
Been adopted for number of purposes including
data collection, quality of care analysis, resource
utilization, and statistical reporting
•
ICD classification system for mortality and morbidity
which is used worldwide
•
Encompasses nomenclature structures
•
The US version ICD-10-CM
Unified Medical Language System
-
Is a listing of descriptive terms and codes for
reporting medical services and procedures
Systemized Nomenclature of Human and Veterinary
Medicine International, Clinical Terms (SNOMED)
-
Is a comprehensive, multiaxial nomenclature and
classification system created for indexing human
and veterinary medical vocabulary , including signs
and symptoms, diagnosis and procedures
Specialized vocabularies, code sets and
classifications systems for almost every practice
domain in health care
Data content standards
-
A minimum set of items with uniform definitions
and categories concerning a specific aspect or
dimension of the healthcare system which meets
the essential needs of multiple users
-
A standard data element with a uniform definition
and coding convention to collect data on persons
and on events or encounters
National Uniform Claim Committee Recommended
Data Set for a Noninstitutional Claim (NUCC)
-
Current Procedural Terminology, Fourth Revision (CPT4)
-
Provides a set of universal names and numeric
identifier codes for laboratory and clinical
observations and measurements in a database
structure
Organized in 1995 to develop, promote and
maintain a standard data set for use in noninstitutional claims and encounter information
Standard Guide for Content and Structure of the
Computer-Based-Patient record (ASTM E1384-96)
-
The American Society for testing materials (ASTM)
is one of the largest SDOs in the world and
publishes over 9,000 standards covering all sectors
in the economy
Concept of a secure patient centered HER
✓ Safeguards personal privacy
✓ Rises standardized medical terminology that can be
correctly read by any care provider
✓ Eliminates the danger of illegible handwriting and
missing patient information
✓ Getting authorization to refer a patient to a
specialist
✓ Can be transferred as patient’s care requires over a
secured communications infrastructure for
electronic information exchange
✓ Filing a claim for insurance reimbursement
Integrating the Healthcare Enterprise (IHE)
-
Provides a detailed framework for implementing
standards, filling the gap between standards and
their implementation
✓ Requesting additional information to support a
claim
✓ Coordinating the processing of a claim Coordinating
the process of a claim across different insurance
companies
Standard Coordination Efforts
✓ Notifying the provider about the payment of the
claim
-
6 areas of interest NCVHS
Developed at the international, regional and
national levels to try and create a synergetic
relationship between their member organizations
International Organization Standards (ISO)
-
An organization that develops and publishes
standards internationally
European Technical Committee
-
CEN TC 251
Works to develop a wide variety of standards in the
area o9f healthcare data management and
interchange
•
Message format standards that contain PMRI
•
Medical terminology related to PMRI including data
element definitions
•
Business case issues related to the development
and implementation of uniform data standards
•
National healthcare Information Infrastructure
(NHII) Data quality, accountability and integrity
related to PMRI
•
Inconsistencies and contradictions among state
laws that discourage or prevent the creation,
storage, communication of PMRI
American National Standards Institute (ANSI)
-
serves as the coordinator for voluntary standard
activity in the US
-
The US representative to ISO and is responsible in
bringing forward US standards to that organizations
Consolidated Health Informatics
-
The goal is to develop and implement standard
means of exchanging and managing health
information across federal health providers
Object Management Group
Goal of Strategic Action
-
Representative of different approach in standards
development
Goal 1 -Inform Clinical Practice
-
An international consortium of over 800
organizations, primarily for profit vendors of
information systems technology, who are interested
in the development of standards
Health Insurance Portability and Accountability Act
✓ Enrolling an individual in a health plan
✓ Paying health insurance premiums
✓ Checking insurance eligibility
o
Incentivize HER adoption
o
Reduce risk of HER investment
o
Promote HER diffusion in rural and underserved
areas
Goal 2- Interconnect Clinicians
o
Foster regional collaborations
o
Develop a national health information network
o
Coordinate federal health information systems
Goal 3- Personalize Care
Guideline 2: Anticipate failures
o
o
o
•
Features that are transparent to software
applications should be implemented to detect
faults, to fail over to redundant components when
faults are detected, and to recover from failures
before they become catastrophic.
Security features to discover malicious attacks
Encourage use of PHRs
Enhance Informed consumer choice
Promote use of telehealth systems
Goal 4- Improve population Health
o
Unify public health surveillance architectures
•
o
Streamline quality and health status monitoring
Guideline 3: Anticipate success
o
Accelerate research and dissemination of evidence
Dependable Systems for Quality Care
Dependability
-
Is a measure of the extent to which a system can
justifiably be relied on to deliver the services
expected from it.
•
•
Guideline 4: hire meticulous managers
•
6 attributes of dependability
1. System reliability- the system consistently behaves
in the same way
2. Service reliability- required services are present
and usable when they are needed
5. Responsiveness- The system responds to user input
within as expected and acceptable time period
6. Safety- the system does not cause harm
5 fundamental guidelines that can help increase
dependability of healthcare system
Guideline 1: Architect for dependability
-
-
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Architecture should be developed from the bottom
up so that no critical component is dependent on a
component less trustworthy than itself
the architecture are the physical and logical
networks that support the enterprise and provide
the “pipes” that carry data from system to system
Safety and security functions
Good system administrators meticulously
monitor and manage system and network
performance, using out of hand tools that do
not themselves affect performance
Guideline 5: don’t be adventurous
•
•
3. Confidentiality- Sensitive information is disclosed
only to those authorized to use it
4. Data Integrity- data are not corrupted or destroyed
The system planning process should anticipate
business success and the consequential need
for larger networks, more systems, new
applications, and additional integration
For dependability, one should use only proven
been in production, under conditions, and at a
scale like the intended environment
The enterprise with a requirement for
dependable system should not be the first (or
second) to adopt a new technology
Healthcare architectures
•
Are among the most complex- a loose collection
of departmental systems that are unaware that
each other exist
Hipaa- 8 security regulation for dependability
1. Security Management, including security analysis
and risk management
2. Assigned security responsibility
3. Information Access management, including the
isolation of clearinghouse functions from other
clinical functions
4. Security awareness and training
5. Security incident procedures, including response
and reporting
6. Contingency planning, including data backup
planning, disaster recovery planning and planning
for emergency mode operations
•
Before adopting any new idea, they watch someone
else try it, and then perhaps they may try it
themselves
7. Evaluation
•
Wireless networking and handheld computers can
serve as a good example of technologies that are
not yet mature enough for safety-critical
applications
8. Business associate contracts that lock in the
obligation of business partners in protecting health
information to which they may have access
5 physical safeguards
1. Access control, including unique user identification
and an emergency access procedure
2. Audit controls
Nursing Minimum Data Set Systems
Nursing Minimum Data Standards (NMDS)
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3. Data integrity protection
4. Person or entry authentication
5. Transmission security
3 broad categories of NMDS
Anticipating failures
•
Medical technology and prescription drugs as
well as clinical treatment protocols, are
required to undergo extensive validation before
they can be used in clinical practice
Anticipating success
•
•
Healthcare organizations expect their software
applications, computer systems and networks to
work
Providers assume their systems will work as well as
any other medical equipment despite the fact that
many of the software applications they are running
on the same kind of PCs that have failed them at
home
IT management
•
•
Many provider organizations truly do recognize the
criticality of IT to their business success
They have hired IT managers who appreciate the
important role of IT in a healthcare environment
and who recognize the need for dependable
systems that can anticipate and recover from
failures
Adventurous technology in healthcare
•
Healthcare clinicians including nurses, historically
and typically are very resistant to change,
Is a standardized approach that facilitates the
obstruction of these minimum, common, essential
core data elements to describe nursing practice
from both paper and electronic records
1. Nursing care
2. Patient or Client Demographics
3. Service Elements
Aim of NMDS
-
Is not to be redundant of other data sets, but rather
to identify what are minimal data needed to be
collected from records of patients receiving nursing
care.
8 benefits of NMDS
1. Access to comparable, minimum nursing care, and
resources data on local, regional, national, and
international levels
2. Enhanced documentation and nursing care
provided
3. Identification of trends related to patient or client
problems and nursing care provided
4. Impetus to improved costing of nursing services
5. Improved data for quality assurance evaluation
6. Impetus for further development and refinement of
NISs
7. Comparative research on nursing care, including
research on nursing diagnosis, nursing
interventions, nursing outcomes, intensity of
nursing care, and referral for further nursing
services
8. Contributions toward advancing nursing as a
research-based discipline
the challenges as well as opportunities of global
technological innovations
•
Testing evidence-based practice improvements
•
Empowering the public internationally
National Information & Data Set Evaluation Center
(NIDSEC)
-
Develops and disseminates standards related to
nomenclature, clinical associations, clinical data
repositories, and system characteristics/ decision
support/ contextual variables pertaining to the data
sets in information systems that support the
documentation of nursing practice
Nursing Management Minimum Data set (NMMDS)
Data elements
The 18 elements are organized into 3 categories
1. Environment
INFORMATICS THEORY
MODELS FOR NURSING INFORMATICS
Models- are representations of some aspect of the real
world.
Theories, Models, Framework- guide nursing
informatics learning activities for both students and
faculty.
Foundational Documents Guide NI Practice
•
2. Nursing Care
3. Financial Resources
Nursing Management Minimum Data set (NMMDS)
-
Is the minimum set of items of information with
uniform definitions and categories concerning the
specific dimension of the context of patient/client
care delivery
•
•
International Nursing Minimum Data set (i-NMDS)
-
Includes the core, internationally relevant, essential
minimum data elements to be collected in the
course for providing nursing care
i-NMDS will support:
•
Describing the human phenomena, nursing
intervention, care outcomes and resource
consumption related to nursing services
•
Improving the performance of healthcare systems
and the nurses working within these systems
worldwide
•
Enhancing the capacity of nursing and midwifery
services
•
•
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Code of Ethics for Nurses with Interpretive
Statements- a complete revision of previous ethics
provisions and interpretive statements that guide
all nurses in practice, be it in in the domain of
patient care, education, administration, or research.
(Published by ANA)
Nursing Social Policy Statement provided a new
definition of Nursing.
Nursing is the protection, promotion and
optimization of health and abilities, prevention of
illness and injury, alleviation of suffering through
the diagnosis and treatment of human response
and advocacy in the care of individuals, families,
communities, and populations. (ANA, 2003)
Nursing: Scope and Standards Practice -further
reinforces the recognition of Nursing as a cognitive
profession
the measurement criteria are associated with each
15 standards and include data information and
knowledge management activities as core work for
all nurses.
the cognitive work begins with critical thinking and
decision-making components of the nursing process
that occur before nursing actions begins.
Informatics and Healthcare Informatics Definitions
Addressing the nursing shortage, inadequate
working conditions, poor distributions and
inappropriate utilization of nursing personnel, and
Informatics- is a science that combines a domain
science, computer science, information science, and
cognitive science.
Healthcare Informatics-integration of healthcare
sciences, computer science, information science ad
cognitive science to assist in the management of
healthcare information.
Healthcare Informatics and subdomains of Healthcare
Informatics
Models
•
Nursing Informatics- is the use of information
technologies in relation into any nursing functions
and actions of nurses (definition as proposed by
Kathryn Hannah
•
Nursing Informatics- is the specialty that integrates
nursing science, computer science and information
science in identifying, collecting, processing, and
managing data and information to support nursing
practice, administration, education, research, and
the expansion of nursing knowledge. (Modified
definition by ANA from Graves and Corcoran)
•
Scope and Standards of Nursing Informatics
Practice includes the expanded definition of
Nursing Informatics.
•
Nursing Informatics- is a specialty that integrates
nursing science, computer science, and information
science to manage and communicate data,
information, and knowledge in nursing practice. NI
facilitates the integration of data, information, and
knowledge to support patients, nurses, and other
providers in decision making in all roles and settings
Models for Nursing Informatics
•
Graves and Corcoran’s model placed data,
information, and knowledge in sequential boxes
with one-way arrows pointing from data to
information to knowledge. The management
processing to each of the three boxes. This model is
direct depiction of their definition of knowledge.
•
(1986)- Patricia Schwerin -proposed a model of
nursing informatics intended to stimulate and guide
systematic research in the discipline.
•
The model provides a framework for identifying
significant information needs, which in turn can
foster research.
•
There are four elements arranged in a pyramid with
a triangular base.
Turley Model
•
(1996)- Turley model core components of
informatics (cognitive science, information science,
and computer science) are depicted as intersecting
circle. Nursing science has a larger circle completely
encompasses the intersecting circles
Data, Information, Knowledge
•
•
•
•
Data, Information, and knowledge are overarching
concepts for Nursing informatics.
Data- discrete entities that described objectively
without interpretation.
Information- reflects interpretation, organization,
or structuring data. It is the result of the processing
data.
Data Processing- it occurs when raw facts are
transformed through the application of context to
give those facts meaning.
COMPETENCIES
•
•
•
1.
2.
3.
4.
5.
•
•
Knowledge- is information that is synthesized so
that relationships are identified and formalized
ANCC- developed and maintains the nursing
informatics certification examination.
Test Content
Human Factors System Life Cycle (system planning,
analysis, design, implementation and testing,
evaluation, maintenance, and support)
Information Technology (hardware, software,
communication, data representation, and security)
Information Management and Knowledge
generation (Data, Information, Knowledge)
Professional Practice, trends, and Issues (roles,
trends, issues, and ethics)
Models and Theories (foundation of Nursing
Informatics, nursing and healthcare data sets,
classification system and nomenclatures, related
theories, and sciences)
Healthcare Information and Management System
Society (HIMSS) – recently established a
certification program that maybe of interest to
nursing informatics.
Certifications available includes
1. CPHIMS (Certifies Professional in Healthcare
Information & Management system
2. CHS- Certified in Healthcare Security
3. CHP- Certification in Healthcare Privacy
manipulate data for the primary purpose of providing
healthcare and health related services.
• NCVHS- identified patient medical information
necessary for EHR
1. Personal Health dimension – includes personal
health record of individual, family, directories of
healthcare and public health service providers
2. Healthcare provider Dimension- promotes quality
patient care, access to complete data 24 hrs. for 7
days/wk., decision support programs, and practice
guidelines.
3. Population Health Dimension- information on the
health population and influences on that health.
TERMINOLOGIES
•
•
•
•
•
•
•
4. CHPS-Certified in Healthcare Privacy and Security
Electronic Health Record
•
•
-
EHR – any information related to the past, present,
or future physical/mental health or condition of an
individual. (ASTM)
the information resides in electronic system used to
capture, transmit, receive, store, retrieve, link, and
•
NANDA (E-mail: info@nanda.org)- classification of
nursing diagnosis in a taxonomy. (Has 167
recognized nursing diagnosis)
Nursing Interventions Classifications (NIC)- describe
the treatments nurses perform, updated linkages
with NANDA diagnosis and core interventions
identified.
Nursing Outcome Classification (NOC) –researched
based outcome to provide standardization of
expected patient, caregiver, family, and community
outcomes for measuring the effect of nursing
intervention,
Clinical Care Classification (CCC)- researched based
nomenclature designed to standardize the
terminologies for documenting nursing care in all
clinical care settings.
Omaha System- It includes an assessment
component, intervention component and outcome
component. (Problem Classification Scheme,
Intervention Scheme, and Problem Rating Scale for
outcome)
SNOMED CT- is a core clinical terminology
containing over 357,000 healthcare concepts with
unique meaning and formal logic-based definition.
ABC codes- provide a mechanism for coding
integrative health interventions by clinicians by
state location for administrative billing and
insurance claims.
Patient Care Data Set- (PCDS)-includes terms and
codes for patient problems, therapeutic goals, and
patient care orders.
Logical Observation Identifiers Names and Codes
(LOINC)- 32,000 terms. Includes codes for
observations at key stages for nursing process,
•
•
assessment, goals, and outcome. Results for
hematology, serology, microbiology, and toxicology.
International Classification for nursing Practice
(ICNP)- includes nursing phenomena, (nursing
diagnosis), nursing actions, and nursing outcome.
Nursing Management Minimum Data set (NMMDS)
- terms to describe the context and environment of
nursing practice, nursing delivery, care delivery
method, personnel characteristics, and financial
resources.
Organization as Resources
•
1.
2.
3.
4.
5.
6.
7.
Membership and active participation in professional
organization demonstrate compliance in the
provision 8 & 9 of Code of Ethics for Nurses
American Medical Association- dedicated for the
development and application of medical informatics
in the support of patient care, teaching, research,
and healthcare administration.
Healthcare Information and Management system
Society- its members are responsible in the
developing many of today’s innovations in
healthcare delivery and administration, including
telehealth, CPR, EHR, community information
networks and wireless healthcare computing.
National League for Nursing- its mission is to
advance quality nursing education that prepares the
nursing workforce to meet the needs of diverse
population in an ever-changing healthcare
environment.
Society for Health System- enhance the career
development and continuing education of
professionals who us industrial and management
engineering expertise for productivity and quality in
healthcare industry.
Association for Computing Machinery- major force
in advancing the skills for information technology
professionals and students worldwide.
ARMA- provide education, research, and
networking opportunities to information
professionals to enable them to use their skills to
leverage the value of od records, information, and
knowledge to organizational success.
American Society for Information Science- as the
society for information professionals leading the
search for new and better theories, techniques, and
technologies to improve access to information.
ADVANCED TERMINOLOGY SYTEM
The Vocabulary Problem
1. The development of multiple terminologies has
resulted in overlapping content, areas for which no
content exist, and large number of codes and terms.
2. It is often developed to provide sets of terms and
definitions of concepts for human interpretations with
computer interpretation as only secondary goal.
3. Knowledge that is eminently understandable to
human is often confusing, ambiguous, or opaque to
computers and consequently, current efforts have often
consulted in terminologies that are inadequate in
meeting the data needs of today’s healthcare system.
Concept Orientation
•
Concept oriented approaches-understanding
definitions of and relationships among things in the
world(objects), our thoughts about things in the
world(concepts) and the labels we use to represent
and communicate our thoughts about things in the
world (terms)
Concept Oriented
•
•
•
Concept- (i.e., thought or reference): unit of
knowledge created by a unique combination of
characteristics- an abstraction of a property of an
object or set of objects.
Object- (i.e., referent)- anything perceivable or
conceivable.
Term- (i.e., symbol)-verbal designation of a general
concept in a specific subject field- a general
concepts correspond to two or more
Components of Advanced Terminology System
•
•
•
Terminology Model- concept- based representation
of a collection of domain specific terms that is
optimized for the management of terminological
definitions.
Schemata – reflect plausible combinations of
concepts e.g., “dyspnea” may be combined with
“severe” to make “severe dyspnea”
Type Definitions- are obligatory conditions that
state only the essential properties of a concept.
e.g., a nursing must have a recipient, an action, and
a target.
Advance Terminology System
Advanced Terminological Approaches in Nursing
-
Representation Language (Ex. GALEN, GRAIL, KRSS,
OWL)
•
Ontology languages –represents classes (referred to as
concepts, categories, or types) and their properties
(also referred to as relations, slots, roles, or attributes)
-
Computer-Based Tools- representation language maybe
implemented using description logic within a software
system or by a suite of software tools.
Advanced Terminology
•
•
•
First Generation Terminology- system consist of a
list of enumerated terms, possibly arranged as a
single hierarchy. (e.g., NANDA)
Second Generation- include an abstract
terminology model or terminology model schema
that describes the organization of the main
categories used in a particular terminology or set of
terminologies. (e.g., ICNP)
Third Generation- grammar that defines the rules
for automated generation and classification of new
concepts.
Advantages of Advanced of Terminology System
•
Two Important Facts of Knowledge Representation
for computer-based system that support clinical
care:
1. Describing concepts
2. Manipulating and reasoning about those concepts
using computer-based tool.
ADVANTAGES from First Facet:
1. Nonambiguous- representation of concepts
2. Facilitation of Data Abstraction without loss of
original data.
3. Nonambiguous mapping among terminologies.
4. Data reuse in different contexts.
ADVANTAGES FROM 2ND FACET include:
1. Automated classification of new concepts and an
ability to support multiple inheritance of defining
characteristics. (e.g., “acute postoperative pain”)
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ISO 18104:2003- an international standard covering
reference terminology models for nursing
diagnoses.
this was developed to harmonize the plethora of
nursing terminologies in use around the world.
the terms and definitions taken from ISO Health
Informatics- integration of reference terminology of
nursing. www.iso.org
Uses of Terminology Model
1. Facilitate the representation of nursing diagnosis
and nursing action concepts and their relationships
in a manner suitable for computer processing.
2. Provide a framework for the generation of
compositional expressions from atomic concepts
within a reference terminology.
3. Facilitate the mapping among nursing diagnosis and
nursing actions among various terminologies.
4. Enable the systematic evaluation of terminologies
and associated terminology models for purposes of
harmonization.
5. Provide a language to describe the structure of
nursing diagnosis and nursing action concepts to
enable appropriate integration with information
models.
•
GALEN- concept oriented approach program.
Supports the authoring, maintenance, and quality
assurance of other kinds of terminologies.
• GRAIL – an ontology language for representing
concepts and their interrelationships.
• Tools used in GRAIL:
1. A computer-based modelling environmentfacilitated the collaborative formulation of models
and allows authoring of clinical knowledge at
different level of abstraction.
2. Terminology Server- a software system that
implements GRAIL. Its functions include:
a. internally managing and representing the model.
b. resting the validity combination of concepts.
c. Constructing valid composed concepts.
d. Transforming composed concepts into canonical
form
e. Automatically classifying composed concepts
into the hierarchy.
•
5. Training
SNOMED RT- is a reference terminology optimized
for clinical data retrieval and analysis.
6. Implementation
Functionality:
1. Acronym resolution, word completion, term
completion, spelling correction, display of t form of
the authoritative form of the term entered by the
user and decomposition.
7. Evaluation
Clinical Information System Committee Structure and
project staff
•
2. Automated classification
3. Conflict management, detection, and resolution
An illustration of a potential mapping using an advanced
terminology system between nursing activity concepts
from two existing terminology system.
•
The Nursing administrator in conjunction with the
information system management team works to
develop a committee structure and participation to
best guarantee success of the project.
Transition Management- is a series of “deliberate
planned intervention undertaken to assure
successful adaptation/assimilation of a desired
outcome into organization.” (Douglas and Wright)
Clinical Information System Steering committee
•
The CIS steering committee generally includes
representatives from the following areas.
1. Hospital administration/hospital finance
2. Nursing Administration
3. Medical Staff
4. Information system departments at
manager/director level
5. Major ancillary departments (lab, radiology,
pharmacy, dietary, records, accounting)
IMPLEMENTING AND UPGRADING
CLINICAL INFORMATION SYSTEM
CLINICAL INFORMATION SYSTEM
6. Health Information management (medical
records)
•
7. Legal affairs
•
1.
2.
3.
4.
CIS – assist clinicians with the data necessary for
decision making and problem solving.
Major CIS Requirement for Nursing
Administer a nursing department
Assist the management of nursing practice.
Assist nursing education
Support nursing research
8. Outside consultants (as needed)
9. Other appointed members
The Steering committee is charged with providing
oversight guidance to the selection and integration
of a new CIS into the organization.
The Planning Phase
•
Planning phase
8 Phases of Design, Implementation and Upgrading
1. Planning
2. System Analysis
3. System Design/System Collection
4. Testing
•
Project Team- it is led by an appointed project
manager and includes a designated team leader for
each of the major departments affected by the
system selection, implementation, or upgrade
proposed.
•
The Objectives of the project team are:
•
1. Understand the technology and technology
restrictions if any of a proposed system.
2. Understand the impact of intradepartmental
decisions.
3. Make decisions at the intradepartmental level
for the overall good of the CIS within the
organization.
4. Become the key resource for their application.
Project Manager
-
•
is responsible in managing all aspect of the project.
It includes software application development,
hardware, and networks as well as oversight
management of the interfacing and conversion task.
Departmental Teams
1. To thoroughly understand the department’s
information needs.
2. To gain a full understanding of the software
features and functions.
3. To merge the new system’s capabilities with the
department’s operations
•
o
o
o
B. Feasibility study – helps identify the information
needs, objectives, and scope of the project. Helps
analyzing multiple parameters and by presenting
possible solutions whether the proposed system
outweigh the cost.
It seeks to answer:
Ex. What’s the real problem to be solved or goal to
meet?
What is the estimated cost?
What are the known limitations and risk to the
project?
Planning Phase- Feasibility Study
1. Statement of the Objectives- outcome oriented
and stated in measurable terms.
2. Environmental Assessment- project is evaluated
relative to organizations competitions. The impact
of legal, regulatory, and ethical considerations is
reviewed.
3. Determination of information needs- needs
assessment and outlines the high-level information
required by the users.
4. Determination of Scope-the scope of the proposed
system.
4. To assist in the system testing effort.
5. Development of Project Timeline- the project
workplan, the steps required for each phase are
outlined in sufficient detail.
5. Participate in developing and conducting end-user
education.
6. Recommendations- based on the finding of the
feasibility study.
6. Provide high level support during initial activation.
Planning Phase- Documentation
•
•
C. Documentation and Negotiation of a Project
Scope Agreement
•
The project scope agreement is drafted by the
project team and submitted to the projects steering
committee.
•
•
D. Allocation of Resources
It considers the following when planning for
resources:
Present staff workload
Human resources
Cost of operation
Relationship of implementation events with nonproject events (ex. JCAHO reviews)
Anticipated training cost.
Space availability
The Planning steps involves:
1. Definition of the Problem
2. Feasibility study
3. Documentation and negotiation of project scope
agreement.
4. Allocation of resources
•
-
A. Definition of the Problem
essential to it is the precise statement of the goal
and outcome
Ex. Unfair nurse staff assignments may relate to
invalid patient classification tool (inaccurate
grouping of patients)
1.
2.
3.
4.
5.
6.
7. Current and anticipated equipment requirements
for the project team.
The Key Role of the nurse administrator
•
Nurse executive involvement plays a critical role in
the success of CIS implementation or upgrade.
Business plan features the following:
1. An executive summary
1.1. Workflow Document-data collected into logical
sequencing of task and subtask performed by end user
includes the following:
1.1.1 List of assumptions about the process or
work effort.
1.1.2 A list of the major task performed by the
user.
2. An introduction
1.1.3 A list of subtasks and steps the user
accomplishes and outlines.
3. An environmental assessment of the CIS in use by
similar hospital.
•
4. An analysis of nursing department culture, policies,
and information needs.
1. Written documents, forms, and flow sheets
2. Policy and procedure manuals
5. An overview of the design and implementation plan
describing the objectives, strategy, equipment
needs, staffing projections etc.
6. Financial plan projecting staffing, budget, expenses,
capital expenditures and miscellaneous
expenditures.
3. Questionnaires
4. Interviews
5. Observations
•
System analysis phase
•
•
•
it is the second phase of developing a CIS – is a “fact
finding phase”
All data requirements related to the problem
defined in the project scope agreement are
collected and analyzed to gain a sound
understanding of the current system, how it is used
and what is needed in the new system.
5 Steps
1. Data collection
•
Data analysis- provides data for development of an
overview of the nursing problem and or stated goal
defined in the project scope agreement.
•
Data Review- The third step in the analysis phase is
to review the data collected in the feasibility study,
the workflow documents, and the functional
specification and provide recommendations to the
project steering committee for the new system.
-
The review focuses on resolving the problems and
attaining the goals defined in the feasibility study
based on the best methods or pathways derived
from the workflow documents and the functional
design.
System Proposal Development- the final step in
the system analysis stage is to create a system
proposal document.
4. Benefits identification
5. System Proposal Development
1. Data
-
Collecting of data reflecting the existing problem or
goal as the first step in system analysis phase.
As a result of data collection two documents were
created.
Functional Design Document – is the overview
statement of how the new system will work. It
outlines the human and machine procedures, the
input points, the processing requirement, output
from the data entry and major reports generated
from the system.
Functional design- is a concise description of the
functions required from the proposed computerized
system and describes how the application performs
its task. Then database structure will be
determined.
•
2. Data Analysis
3. Data Review
Multiple Sources of Data for completing a workflow
document.
•
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•
It sets forth the problems and/or goals and the
requirements for the new system’s overall design.
It outlines the standards, documentation, and
procedures for management control of the project,
and it defines the information required, the
necessary resources, anticipated benefits, a
detailed workplan, and projected costs for the new
system.
The system proposal document answers four
questions:
1. What are the major problems and goals under
consideration?
2. How will the proposed CIS solution correct or
eliminate the problems and/or accomplish the
stated goals?
3. What are the anticipated costs?
4. How long will it take?
•
the system proposal describes the project in
sufficient detail to provide a management level
understanding of the system or application without
miring in minutiae.
•
The format of the final system proposal includes the
following information:
1. A concise statement of the problems and/0r
goals
2. Background information related to the problem
3. Environmental factors related to the problem
for both the functional and the technical
components of the system.
- Three major steps in the system design phase:
1. Functional specifications
- Use the functional design document developed in
the system analysis phase of a CIS and builds on the
design by formulating a detailed description of all
system inputs, outputs, and processing logic
required to complete the scope of the project.
It further refines what the proposed system will
encompass and provides the framework for its
operation.
- Commercial software vendors provide manuals,
usually application-specific, include an introduction,
a section for each pathway, and technical section.
- The hospital’s departmental and project teams
produce the organization’s functional specification
by evaluating the available commercial software’s
functions with the workflow documents and making
decisions on the pathways and functions to be used
by the institution.
2. Data Manipulation and Output
- The design team creating the new application often
works closely with the programmers, adjusting in
the design and specification based on new
perspectives, programming logic, and technologies.
3. Technical specifications
Technical manager works on the four major areas
1. Hardware
- the ability to operate the new application on
multiple hardware platforms is often desired.
- Ex. terminals., handheld devices, printers,
upgrade a network, building computer rooms
a. Competition
2. Application Software
b. Economics
-
establishing technical specifications outlining
the operational requirements for the new
system.
-
specifications detail the procedures required to
maintain the application software
c. Politics
d. Ethics
4. Anticipated benefits
5. Proposed solutions
6. Budgetary and resource requirements
7. Project timetable
The system design phase
-
The design detail of the system and the detailed
plans for implementing the system are developed
3. Interface System
-
defines those programs and processes required
to transmit data between two disparate system.
Clinical
component
System
Registration
System
2. Integrated system test- total system is tested;
this includes interfaces between systems as well as
interplay between applications within the same
system.
Laboratory, Pharmacy
Pt. demographic,
insurance, admission
Radiology,
appointment
scheduling
3. Final testing- is within the end user training
Document system
Discharge, transfer
data
Critical care system,
documentation system,
patient accopunting
•
•
4. Conversions
-
conversion of data from legacy system to the
new system
determining the conversion requirements and
developing and testing the conversion programs
Training phase
•
Training takes place before and during the
activation of the new system.
•
Two training takes place: project team and selected
members of the departmental team and the end
user training
4. Implementation planning
•
Last step in system design to establish detailed
implementation workplan.
•
Workplan identifies a responsible party, and a
beginning date and end date for each phase, step,
task, and subtask.
•
This plan coordinates all task necessary to complete
the development of new software, implement a
new system and upgrade a current system.
The Testing Phase
•
The new system or commercially available must be
tested to ensure that all data are processed
correctly, and the desired outputs are generated. To
ensure if programs are written correctly, the ff are
done.
1. Unit testing- conducted by individual
programmers
2. Alpha testing-done by system assurance group
within the development organization
3. Beta testing- occurs at the first client site
•
When commercially available software, the ff are
recommended.
1. Functional test-departmental teams test and
verify databases.
Documentation begins with the final system
proposal
Several manuals are prepared like user’s manual, a
reference manual, and operator’s maintenance
manual.
Implementation phase
•
•
•
•
•
•
Describes series of events required to begin using
the system or application in the production or live
environment and details the necessary computer
and software maintenance operations required to
keep the system running.
Activation approaches
Parallel
Pilot
Phased-in
Big bang theory
Evaluation phase
•
•
•
Describes and assesses, in detail the new system
performance identifying the strength and
weaknesses of the implementation process.
Determine whether it has accomplished the stated
goal
If it continuously meets the need of the users.
Practice Application
Historical Perspective
•
Nightingale spoke about the critical importance of
nursing informatics in the patient care
“In attempting to arrive at the truth, I have applied
everywhere for information, but in scarcely an instance
have I been able to obtain hospitals records for any
purposes of comparison. If they could be obtained, they
would enable us to decide many other questions
besides the one alluded to. .... (Nightingale 1859)
Key Tenets of Nursing Informatics as Identified by ANA
• Clinical and non-clinical aspects of practice;
importance of human factor in decision making
• The focus on delivering the right information to the
right person at the right time
• Concerns about and commitment to ensuring the
confidentiality and security of health care data and
information and advocating privacy
• The central emphasis on the improvement of the
quality of patient care, welfare of the health care
consumer, and patient outcome.
• The importance of collaboration with other areas
within healthcare informatics.
Nursing Informatics: An Evolving Definition
•
•
2001ANA Scope and Standards of Nursing
Informatics defines Nursing Informatics as:
“Nursing Informatics is a specialty that integrates
nursing science, computer science, and information
science to manage and communicate data,
information, and knowledge to support patients,
nurses and other providers in their decision making,
in all roles and settings. The support us through the
use of information, structures, information
processes and information technology.
Essential Elements of nursing Informatics: Dynamic
Interactions
Goal of Nursing Informatics
• Improve the health of populations, communities,
families, and individuals by optimizing information
management and communication.
• It includes technology in the direct provision of
care, establishing administrative systems; managing
and delivering educational experiences; supporting
lifelong learning, and supporting nursing research.
Informatics Competencies: Beginning to Experienced
• Computer Literacy skills- basic computer skills
needed to use word processor; access a database;
create a spreadsheet; communicate with e-mail,
and interact with clinical documentation system
• Information Literacy Skills- it includes determining
the extent of information needed, evaluating
information and its sources critically, incorporating
information to one’s knowledge base;
understanding the economic, legal, and social issues
involved with the use of information and using
information in ethical and legal ways.
• Informatics Competencies: Beginning to
Experienced
• General Informatics Competencies- identifying,
collecting and recording data relevant to nursing
care of patients;; analyzing and interpreting patient
and nursing information; using application of
informatics as integral part of nursing process;
implementing institutional and public policies
regarding privacy, confidentiality and security of
information.
According to Kerfoot (2000)
• IQ is a core competency for leaders.
• Technical IQ as “not only knowing about specific
functioning of technology, but also the
interrelatedness between the technology, people
and system that interacts with this technology and
how this translates into outcomes”
Problem Solving an Organizing Framework
•
Other Studies:
•
the most frequently used were remoting monitoring
devices, online consumer tools and handheld
devices.
Other Studies/Survey Conducted
• 31% were using decision support tools
•
•
•
•
•
•
•
•
•
Assessment
Involves using data, information, and knowledge to
clarify the presenting issue or problem.
Diagnosis
For identifying and evaluating possible solutions to
information issues. It includes developing functional
and technical specifications on identified needs,
designing new models for informatics-based
solutions considering costs and return on
investment of informatics solutions.
Identification of outcomes and Planning
It includes all activities related to the identification
of an appropriate informatics solution and planning
for its application.
Implementation
The informatics specialist acts as a process
consultant and project manager for all interventions
and activities related to the informatics application.
Evaluation –evaluates the efficiency and
effectiveness of decisions, plans, activities, and
applications.
Information Technology and the Actual Work of
Nurses
• A Pattern of underutilization
o Survey conducted by McNeil et al. in the use of
technology in the Nursing Schools.
• 65% of the respondents are Nursing Administrators,
directors, Deans, Managers
• 28% were nurse educators
Undergraduate
Graduate Programs
Accessing electronic
resources (50%)
Accessing electronic
resources (38%)
Computer based patient
record (46%)
Computer based patient
record (36%)
Ethical use of information
system (46%)
Evidenced-based
practice(33%)
Findings in the 3 Major Practice Area
• The survey results showed the ff:
o 94% Uses Computers at work site in the
o HMO
o 77% in private clinics
o 71% in private practice
Researchers concluded that:
- NPs underused of computer applications that could
improve client’s care in their practices
- Lack of availability of computers
A Pattern of Underutilization
• Researchers concluded that:
- There is lack of awareness to nursing informatics
and exploding technology (Hooper 2003)
- Lack of computer training to harness the potential.
The ability to use the IT was affected by lack of
practical knowledge about the adaptability of
software. (Alpay and Russel)
- Automated information system is seen is both a
goal and survival strategy in the healthcare
environment today.
Nursing Documentation
- ANA House of Delegates passed another resolution
to “develop nursing classifications specifically aimed
at diagnosis, interventions and nursing sensitive
patient outcomes and support activities directed
toward the inclusion of nursing data elements in
healthcare database.
-
-
Recognized Terminologies that Support Nursing
Practice by ANA:
1. NANDA
7. PCDS
2. NIC
8. PNDS
3. HHCC
9. SNOMED CT
4. OMAHA system
10. NMDS
5. NOC
11. ICNP
6. NMMDS
12. ABC codes
In the world “prove it” health care, if something
isn’t coded, it doesn’t exist. If nursing contribution
to patient outcome can’t be established, nursing
becomes invisible again. Nursing needs a
standardized language to describe its unique
function. (Simpson 2003)
Care Planning
- Computer- based patient record facilitates the
automation of the nursing care process.
-
-
-
According to Meadows (20020) “The ability to
electronically record, integrate, and analyze data
and information enables nurses to quickly move to
the synthesis of nursing knowledge and the
development of nursing wisdom, which they can
then apply to patient care”
Allan and Englewright (2000), described care
planning process that include a mix of individual
patient data and data that can be used for decision
making such as facility standards of care, age
specific guidelines, care area standards of practice,
specific problems identified by different discipline
and physician’s order.
The results from the system are useful to process
improvement, performance evaluation, and
strategic planning.
Care Planning Process by Allan and Englewright
Decision Making with Administrative Data
• Without-day to-day information on patient flow and
acuity, resources use, staffing levels, cost and
budgetary balance, they have little support for cost
control and input into budgetary decision making.
• CLASSICA – a new Norwegian decision support
system focused on financial management, resource
allocation, activity planning, and budgetary
monitoring and control.
Decision Making with Expert System
• CDSS include programs that involve artificial
intelligence. (AI)
• Expert system has components that attempt to
imitate human expertise by making inferences.
Two Types of AI
1. Expert system - solve problem by trial and error
rather than using algorithms. It has the potential to
capture and preserve expertise only if the
procedural knowledge of experts can be articulated.
2. Machine learning - concerned with construction of
programs that learn from experience.
• This type of technology is “push technology” can
recognize predictive, discriminative, or explanatory
pattern in individual patient and make comparisons
across groups of patients.
• According to Lyons and Richardson
• “Nurses are human and fallible. CDSS does not
forget and misplace information. It is unresponsive
to stress and does not get distracted.”
CDSS contains
• Synchronous alerting- it occurs when an order is
entered into COE system. Clinicians received
feedback that can avoid duplicate testing or
highlight additional testing.
• Asynchronous alerting- give important but delayed
feedback. It has capacity to detect adverse events
that occur overtime.
Kosko (1999) suggested that innovations in what he
calls “fuzzy thinking”-concepts without exact bordersand computer technology which mimics the
organization of neural networks used by our brain as an
operating platform will bring new and even more
revolutionary system to healthcare.
Outcome Management
• A look of outcome management provides a
powerful illustration of how nurses use informatics
in daily practice to evaluate the relationship
between patient goal attainment and nursing
interventions.
•
OMAHA System: Problem Rating scale Outcome
- the rating system was designed to measure
problem-specific knowledge, behavior, and status
throughout the time of service.
- used to assess client progress in relation to
nursing intervention & judge effectiveness of plan
of care.
Discharge Planning
- Discharge planning- provides continuity of care
from the home to the hospital and back to the
community, another care facility, an outpatient
department, or home.
- Increase use of PDA and different modalities closely
coordinate communication among healthcare
providers that can result up-to-date discharge plans
at the time of discharge.
Progress in Practice
Some Findings (see p 331)
• 1990- time saved, less paperwork, fewer telephone
calls
• 1993- no improvement in quality documentation.
• 2001- improvement in BP documentation,
completeness of nurse assessment of patient
outcome, & nursing intervention done.
• 2001- most useful applications were obtaining
medical records, entering electronic client record
information, pattern of underuse
Critical Care Application
Information technology in the critical care
environment has several major capabilities.
•Process, store, integrate physiologic and diagnostic
information from various sources.
•Present deviations from preset ranges by an alarm
or alerts
•Accept and store patient care documentation in a
lifetime clinical repository
•Trend data in graphical presentation
Provide clinical decision support through
alerts, alarms, and protocols.
DEVELOPMENTS- Information Technology
Capabilities and Applications in Critical Care Settings
Provide access to vital patient information from any
location, both inside and outside of the critical care
setting.
Comparatively evaluate patients for outcome
analysis
Present clinical data based on concept-oriented
views
Device Connectivity Infrastructure
PHYSIOLOGIC MONITORING SYSTEM
Basic components of Physiologic Monitor
Sensors (pressure transducer, electrodes)
Signal conditioners- to amplify the display device
(oscilloscope, paper reorder)
Computer processor to analyze data and direct
reports (e.g., paper reports, storage of graphic files,
summary reports)
Evaluation or controlling component (e.g., notice on
the display screen, alarm signal)
Physiologic Monitoring System
Tsien and Tackler found out that 86% of alarms
were false positive alarms resulting from in order of
incidence; bat format or connections, poor contact
of sensors, motion artifact, probe disconnection,
measurement during arterial clamping or flushing.
Hemodynamic Monitors
Hemodynamic monitoring can be used to:
Measure hemodynamic parameters
Closely examine cardiovascular function
Evaluate cardiac pump output and volume status
Recognized patterns (arrhythmia) and extract
features
Assess vascular system integrity
Evaluate the patient’s physiologic response to
stimuli
Continuously assess respiratory gases
Continuously evaluate blood gases and electrolytes
Estimate cellular oxygenation
Continuously evaluate glucose levels
Store waveforms
Automatically transmit selected data to a
computerized patient database.
Hemodynamic Monitors
Hemodynamic Monitoring can be:
Invasive (e.g., PAC)
Noninvasive (pulse oximetry, Doppler)
The PAC has come under recent and
persistent criticism concerning its safety like
infection, hemorrhage, and embolism.
This prompted the formation of Pulmonary
Artery Consensus Conference Organization
(PACCO) that warranted improvement on
the clinical and technical aspect.
Hemodynamic Monitors
•Thermodilution- become the standard
methodology for assessment of cardiac output;
however, the accuracy of this is highly-user
dependent.
thermal filament (embedded in the
catheter) is
intermittently heated, thus sending pulses of heat
energy
into the rt. Ventricle. This can be repeated in a
programmable intervals.
Hemodynamic Monitors
Thoracic Electrical Bioimpedance
4 sensors are embedded on the sides of the necks
and thorax.
signal detected by sensor is proportional to the
impedance of the path travelled by the electricity in
the thorax
As the heart beats the blood within the thorax
changes, the measured impedance changes, thus
permits measurement of stroke volume indices of
contractility such as acceleration and velocity.
Hemodynamic Monitors
Pulse Oximetry – is a non-invasive method of
measuring arterial oxygen saturation that also uses
spectrophotometry
pulse oximeter emits light of different wavelength.
The light is emitted to pulsatile arteriolar bed then
detected by photosensor.
provides a measure of oxygen delivered to the
tissue, mixed venous oxygen saturation (SVO2)
provides a measure of the amount of oxygen used
by the patient.
Thermodilution test result
Thermodilution
Detection Surveillance- the criteria for a normal ECG
are programmed into the computer. (e.g., R-R
interval, QRs duration, occurrence of PVC’s etc.)
Diagnostic or interpretive –after ana.log signals, the
program analyzes and diagnoses of ECG and
generates an analyses report.
Clinical Care Information system
CCIS is a system designed to collect, retrieve, and
manipulate all data related to care of the critically ill
patient.
CCIS is its ability to integrate information from a
variety of sources and to manipulate that
information in a meaningful way.
CCIS should include data and information from
bedside devices, medications, orders, physical
assessment findings gathered from the clinical
team; and comprehensive plans of care to guide
patient care.
Clinical Care Information system
CCIS functions to assist Critical Care Nurses:
Patient Management
1.1Admission, transfer, Discharge data
1.2 Prognostic scoring system (APACHE, TISS, MPM)
2. Vital Sign Monitoring
2.1cardiohemodynamics
2.2 Graphic displays of most data
2.3 Easy viewing of information from common
group
2.4 monitor and device that can interface to CCIS
4. Diagnostic Testing Results
5. Clinical Documentation to support the process
of
physical assessment findings.
5.1. Patient Assessment flowsheet
PAC
Hemodynamic Monitors
•Telemetry- a device monitoring that allows for the
continuous monitoring outside of the ICU.
physiologic data are sent by a transmitter to an
antenna system that is distributed around nursing
unit and displayed on the monitor screen at
telemetry station.
patient wears the transmitter which is attached via
electrodes for monitoring of ECG.
Hemodynamic Monitors
Telemetry
Arrhythmia Monitors
Arrythmia Monitors has the ff components, Sensor,
signal conditioner, cardiograph, pattern recognition,
rhythm analysis, diagnosis, written report.
2 Types
Arrhythmia Monitors
Interpretive system searches the ECG complex for
five parameters.
Location of QRS
Time from the beginning to the end of the QRS
Comparison of amplitude, duration, and rate of QRS
complex with all limbs leads
P and T waves
Comparison of P and T waves with all limbs leads
Clinical Care Information system
CCIS functions to assist Critical Care Nurses
5. Clinical Documentation to support the process of
physical assessment findings.
5.1. Patient Assessment Flowsheet (e.g., shift
assessment
flowsheet can be created)
5.2 Neurologic Flowsheet (e.g., pupillary reaction,
Glasgow Coma Scale, pain ratings, motor strength,)
5.3 All disciplines can document patient assessment
findings.
(Nurses, physicians, therapist)
5.4 Alerts automatically generated for patient at
high risk
for fall, pressures, ulcers, and other factors.
Clinical Care Information system
CCIS Functions to assist Critical Care Nurses
5.5. Automatic calculation of physiologic indices like
cardiovascular, respiratory, neurologic, and other
indices.
6. Decision Support
6.1Provides alerts and reminders to guide caregiver
in the
documentation process.
6.2 Alerts on policies/protocols (e.g., restraint
management, ventilator weaning, pain
management)
7. Medication Management
7.1 the use of barcode scanning, and e-MAR
integrated to
CCIS can facilitate the medication process.
Clinical Care Information system
CCIS Functions to assist Critical Care Nurses
7.2 Medication administration flowsheet
incorporate the
use of bar code, thus ensuring five rights of
medication.
7.3 Calculation of intravenous medication dosage,
IV
rates, I & O, hyperalimentation.
8. Interdisciplinary plans of care
8.1. Supports multidisciplinary documentation and
panning of patient care.
8.2. Special flowsheet incorporating treatment and
intervention. Nurse can enter explanatory note
describing the patient response or reason for not
delivering specific treatment and intervention.
Future Developments
Thinking beyond critical care environment to
facilitate integration of information between each
of the patient care settings
Reinforce the need to use standard language
between patient care settings.
Neural networks are computer simulations of the
brain that are capable of converting incoming
activities into outgoing activities.
Predictive ability of neural network could be used to
recognized patterns of symptoms, signs, and lab
data diagnostics of particular pathologic process.
The use of voice in controlling technology
Using wireless approach portable bedside monitor
to pt. needs without buying monitor to every
bedside.
Clinical Care Information system
8.3. Workflow Management solutions that help
orchestrate all caring processes for patient by
pushing task to individual worklist and notification
when task failed.
9. Provider Order Entry
9.1 Electronic entry and communication of patient
orders, combined with rules and alerts related to
evidenced based care helps providers in managing
quality care.
Community Health Application
Community Health Application
The focus is on the population as a whole even though
nursing care is directed to individuals, families or
groups.
The standards of CHN incorporate health promotion,
health maintenance,, health education, health
management, coordination and continuity of care using
a holistic approach.
CHN is practice in Public health department, ambulatory
care settings, group practices, outpatient clinics, freestanding community-based clinics and in homes.
Community Health Application
Applications examples may include population focused,
continuity of care needs and billing of services for
documenting home healthcare assessment to create
home health-related group. (HHRG)
Community Health Nursing system Development
Many of the early system focused on regulatory system,
billing applicatins, and statistical reporting related to
community health.
4 Domains of MIS
Public health that focus on population intervention
related to epidemiologic and/or mortality and
morbidity trends.
Home health that focused on skilled nursing care for
individuals in the home and aggregated populations
related to outcome care delivery.
Special population community (i.e mental health)
Outpatient care that focus on intermittent, episodic or
preventive care for individuals and the outcome
related to interventions.
Home Health
Medical and Medicaid Legislation
The enactment of the Medicare and Medicaid
Legislation, reimbursement for home care services is
allowed.
It expanded the demand of home health services and
Home health agencies (HHA’s) and increased
information needs fro computer system.
Home health system captured patient demographic
data, visits, accounts, payables and journal entries for
the purposes of producing standard reports, billing
forms, regulatory documents ,Physician plan of
treatment, visit summaries and financial balances.
Balanced Budget Act
Balance Budget Act of 1997 moved beyond billing
information, statistical information and the tracking of
clinical data.
The HHA relied on a 80 category case mix adjuster to set
payment rates based on 23 responses from questions
from OASIS (Outcome Assessment Information Set
OASIS information is required to be transmitted to the
state regularly with billing notification to CMS.
Public Health
Public health Professionals focus on:
1.Preventing, identifying,investigating and
eliminating community health problems.
2. Assuring that the community has access to
competent personal healthcare services.
3. Educating and empowering individual to
adopt more healthy behavior.
Public Health Challenges
Public Health Challenges:
1. Bioterrorism
2. Recognizing the need to evaluate
prevention activities to improve the quality
of life.
3. Reduce cost
4. Integrate public data to individual data
5. The need to monitor community-wide
interventions by health departments.
IT System allow the ff:
1. Relational database that facilitate retrieval
of data for multiple purposes.
2. Manipulation of data to create information
and knowledge.
3. Point of care devices, computerized patient
record.
4. Clinical Repositories as a strategic resource
for quality and practice
5 Electronic Interfacing system to facilitate sharing of
data.
Data Sets
Data Set- minimum data set of items of information
with uniform definition and categories, concerning the
specific dimension of the service or practice setting that
meets the essential information need of multiple data
users within the scope of the service
Criteria that Define Data Set
Utility for multiple users
Terms that can be defined and measured
Common or shared language that is universally
understood
Relevance to local and national needs
Data Sets
5. Uniformity with other applicable data
sets
6. Data can be coded for computer processing
7. Data has portability to other data sets.
8.Data can be structured in the compliance with HIPPA
9. Data can be collected easily and accurately through
the functions of service delivery.
Selected Data Sets
The National Association of Home Care and Hospice
publishes data elements and definitions so that entities
involved in the home care and hospice data collection
can use this definitions when constructing survey and
questionnaire.
OASIS ( Outcome and Assessment information Set)
Group of items that represents the core items of
comprehensive assessment for an adult home health
patient and forms the basis for measuring the outcome
of purposes of OBQI( Outcome-based Quality
Improvement)
Selected Data Sets
Outcome-Based Quality Improvement
It includes outcome analysis and outcome
enhancement.
Outcome Analysis –component begin with the home
care agencies transmitting OASIS data to repository
which then produces outcome, case mix and adverse
advent reports on an annual basis.
Outcome enhancement- allows the agencies to use the
data for OBQI activities at the agency level and will
assist the medicare survey and certification process by
providing specific information regarding the individual
HHA.
Health Plan Employer Data and Information Set (HEDIS)
HEDIS is a set of standardized performance measures
designed to ensure that purchasers and consumers
have the information for reliably comparing the
performance of managed healthcare plans. (ex p.363)
Vocabulary Languages
The Language, vocabulary or taxonomy enables
capturing, sharing and aggregating health data across
health sites.
It serves as vehicle to format messages that are
exchanged between computer system, and the coding
and the classification scheme used within the messages.
Vocabulary Languages
Intensity Classification
Classifying the intensity of patient needs for home care
services depends on the factors like physical well being,
environment, level of independence, self care ability
and skill level of patient or caretakers.
HHA’s have moved to episodic reimbursement for all
medicare patient and to some capitated non-medicare
patients based on patient condition and services.
Vocabulary Language
Clinical Care Classification System
Is standardized language/vocabulary consisting of two
interrelated taxonomies- the CCC of Nursing Diagnosis
and CCC of Nursing Interventions.
CCC Nursing Diagnosis consist of 182 nursig diagnosis
which uses 3 modifiers
a. improve patients condition
b. stabilize patient’s condition
c. support patients deteriorating condition
Vocabulary Language
CCC Nursing Intervention consist of 198 nursing
interventions that uses 4 modifiers.
a. assess or monitor
B. care or perform
c. teach or instruct
d. manage or refer
Clinical Care Pathway
• CCP is used to identify the interventions and type
actions needed for each encounter or visit for the
episode of care.
Vocabulary Language
Clinical Care Pathway
- The 21 care components are used to correlate
the assessment data for a medical condition.
OMAHA System
Researched based comprehensive taxonomy designed
to generate meaningful data following routine
documentation of client care.
3 Components
1. problem Classification Scheme
2. Intervention scheme
3. Problem Rating Scale for outcome
Vocabulary Language
OMAHA
•The problem classification scheme is a
vocabulary for CHN
• Each problem described by list of signs
and symptoms
•The problem maybe referenced as health
promotion, potential /deficit/ impairment/
actual.
• The intervention scheme uses 4 broad
categories: health teaching, treatment, case
management, and surveillance.
• Outcome rating scale measures concepts of
knowledge,
behavior and status.
COMMUNITY HEALTH INTENSITY RATING SCALE
Community Health Intensity Rating Scale (CHIRS)
A prototype classification tool that included 15
parameters that represented the same home health
domains as the OMAHA system – Environment,
Physiological, Psychosocial and Health Behavior.
The ratings were as follows: 1- minimum requirement,
2-moderate requirements, 3-major requirement, 4extreme requirement
SHIRS –(School Health Intensity Rating Scale)
Enhance school nurse ability to make judgements about
student health care needs.
Community Health System
Community Health system specifically developed and
designed for use by community health agencies, local
and state health departments, community health
programs and services.
Typically Used system in the Community Health System
Categorical system
Screening Programs
Client Registration system
MI’s
Statistical Reporting system
Special Purpose system
Community Health System
Categorical System
- generally counts, track and identify the health
status of registered client.
Support data processing and tracking specific
programs ( e.g Family Planning Program, MCH)
Screening Programs
Used to detect individuals afflicted with a specific
disease or predisposing health condition.
Community Health System
Registration system
designed to identify state/local residents/clients eligible
for CHN services in clinics and homes.
• Management System
- focus on the management of statistical and
operational
needs of the agency and professionals.
Provides the framework for collecting and reporting
statistical as well as financial data needed for the
management of health personnel/client and programs.
Community Health System
Statistical Reporting System
- Community Health computer applications that have
been developed to collect and process statistical
information primarily for state/local health department
such as epidemiologic data and immunization data.
Community Health System
Public Health Information Network
- The Current development of public health
information network will enable consistent exchange
of response, health, and disease tracking data between
public health partners through defined data and
vocabulary standards.
- Five key components
includes detection and
monitoring, analysis, information, resources and
knowledge management, alerting and communication
and response.
Community Health System
Special Purpose System
It is developed to collect statistical data for
administering a specific program.
Provide the statistics needed to obtain funds from
federal state/local for categorical programs.
• National Electronic Disease Surveillance system
(NEDSS)
- Detect outbreak rapidly & monitor health of the
nation.
Facilitate electronic transfer of appropriate information
from clinical to public health department.
Reduce provider burden in the provision of information
Enhance the timeliness and quality of information.
Community Health
SCHOOL HEALTH SYSTEM
These are another type of special purpose systems.
computerized systems have emerged to improved data
collection and monitor and evaluate health of school
age students.
Includes healthcare plans, student activity records,
medication logs, appointment scheduling, and referral
tracking.
To provide an opportunity for collecting health related
data on the students and employees in the school and
communicating that data in a meaningful way.
Community Health
HOME HEALTH INFORMATION SYSTEM
Home health system are designed to support home
healthcare, hospice, and private duty programs
provided by HHAs, such as VNAs, hospital-based
programs, proprietary agencies and other non-for-profit
HHAs.
Originally, home health systems were primarily
designed to collect and process data in order to prepare
the documents required by HCFA and third party payers
for the payment of home healthcare services.
Home Health Information System
TIME-SHARING SYSTEMS
Are computer based systems developed by service
bureaus/vendors that are shared by many HHAs.
Preparing the billing and financial statements , OASIS
reports, PPS reports, and other required reports. The
bureaus develop manuals, provide training sessions and
support ant other technological needs for their users.
Home Health Information System
STAND-ALONE SYSTEMS
The commercial vendor generally develops the software
for processing the data, maintains, updates and
supports all software programs.
Home Heath Information System
PORTABILITY OF DATA
Is another important aspect of home health. point of
care technology uses a computer input device to input
and retrieve clinical data at the point of care in the
home.
The data can then be transferred remotely to the main
database through a client server.
Home Health Information System
POINT OF CARE SYSTEMS
Also offer software aided care planning and critical
pathways allowing for care delivery based on evidenced
based practice standards to reach desired clinical
outcome.
Laptop systems or personal digital assistants (PDAs) are
designed to collect and transmits patient data.
Home Health Information System
REIMBURSABLE MODELS
Reimbursement model and fee per visit models still in
use for private pay or managed care payers.
The functions are primarily designed to furnish
information essential for reimbursement of services
provided to patients eligible for Medicare, Medicade,
and other third party payers.
Home Health Information System
SCHEDULING SYSTEMS
To schedule the clinicians providing services with the
patients requiring the visit matching the clinician
capacity with the required patient care.
These systems can also track personnel by scheduling
on and off duty time as well as generate payroll.
TELEMEDICINE
TELEMEDICINE
Is being implemented to replace face to face home
visits.
Technologies may include:
Telemonitors with peripheral biometric attachments for
remotely monitoring biophysical parameters.
Videophone with two way audio video connectivity
which allows for the visualization of client activity.
In home messages devices with disease management
education advice and vital sign monitoring.
Video cameras for monitoring all aspects of care
delivery particularly focusing on wound management
and home care aide supervision.
Telemedicine
PCs with internet connectivity for supervised
communication.
Video conferencing that allows clinicians, physicians,
and other healthcare providers to communicate about
patient specific care.this applicability is important for
hospice care as interdisciplinary team conference are a
requirement of service delivery.
COMMUNITY HEALTH TELEMEDICINE SYSTEMS
INTERNET APPLICATION-using access to a computer
terminal with internet applications can be used by
patients:
Assist in self diagnosis and preventive medicine.
Reduce unnecessary outpatient visits.
Provide self directed triage and.
Eliminate the “worried well”.
THIS LEADS TO THE FOLLOWING BENEFITS:
Improved patient and provider satisfaction.
Patient time savings in tracking and receiving
information.
Reduced need to see a healthcare provider “face to
face”.
Increased reliance on computer based information .
Reduced information calls.
More cost effective care.
TELEMEDICINE DEVICES
HHAs are increasingly using devices that allow
healthcare providers to communicate with patients in
their home.
Electric healthcare allows rural professionals to “see”
(via two way interactive video) more clients without
having to make “home visits thus saving travel time and
ultimately cost.
The home assisted nursing care network (HANC) is a
system produced by HealthTech services of Northbrook
,IL.HANC is a programmed computer stationed in the
patients home.
COMMUNITY HEALTH NETWORK SYSTEMS
Is an innovative ambulatory care system specially
developed to provide services by computer.
They include the following:
Download the patient record from hospital to the home
database.
Enter a series of question about symptoms using expert
system logic until the pathways are concluded.
Track self care and depending on the responses to
questions, call or make an appointment with a clinician.
Provide additional information on the condition if self
care is chosen to assist the client to resolve the
problem.
HOME HIGH-TECH MONITORING SYSTEMS
Are using computers to link patients at home to
healthcare facilities.
Ambulatory Care System
Ambulatory Care System
Executive Order 2004
•President George Bush created the position of a
National Health Information Technology Coordinator to
develop a nationwide interoperable
health information technology infrastructure.
• This is to improve the coordination of care and
information among hospital, laboratories, physician,
offices and other ambulatory health care providers
through an effective infrastructure for the secure and
authorized exchange of health care information
4 Major Goals
• Goal 1: Inform Clinical Practice
• Goal 2:Interconnect Clinicians
• Goal 3: Personalize Care
• Goal 4: Improve population health
Where Ambulatory Clients are being Treated
There are organizations that fit within the umbrella of
Ambulatory Care Settings
They include ambulatory clinics, and surgery centers,
single and multi-disciplinary group practices,
diagnostics laboratories, health maintenance
organizations, independent physician associations,
birthing centers, and college and university health
services.
Applications Necessary in the Ambulatory Environment
Applications needed in the ambulatory are similar to
the in-patient arena. Registration, billing, accounts,
payable, patient and staff scheduling and managed care
functionality are the major application areas.
Financial Benefits
Cost effective and timely bill submission process
resulting in decreased days in accounts receivable and
the reduction of rejected claims.
A correct bill must be properly submitted to the correct
payor.
Some organizations provide integrated credit card
payment applications so that patient may use credit
card.
Claims submitted o the payor maybe electronic or
paper.
Administrative Benefits
Implementing automated information system include a
reduction in the size of the record room, reduce time
spent finding and delivering charts, increase in privacy
of data, formats that are legible and comply with legal
regulations and the promotion of the quality assurance
and improve patient satisfaction.
Automated ambulatory care records are the ability for
home access by physician and nurse practitioners,
alerts for incomplete data and the integration of clinical
data.
Clinical Benefits
Automated healthcare record provide a problem list,
automated ambulatory care provider order entry
(ACPOE), a medication record, vital signs , progress
notes, results from lab dept., flow sheet, growth charts,
immunization records, medication allergies, profiles,
alerts and reminders and a follow-up system.
A patient master index is the basis for collection of allpatient related data.
A master patient index is a central repository for
patient/member information across the enterprise
including sophisticated tools for querying, updating,
and managing index.
Regulatory Requirements
Accounting for cost can be aided by information
technology system.
The Resource based relative value scale ( RBRVS)
procedure fee pricing is model designed by the
Department of Health and human Services.
Each procedural terminology(CPT) code has a relative
value associated with it. The payor will pay the
physician on the basis of a monetary multiplier for the
relative value unit (RVS)
Regulatory Requirements
CODING SCHEME used for Ambulatory Environment
Current Procedural Terminology codes( CPT)- describe
medical procedures performed by physician and other
health providers. It assist in the assignment of
reimbursement amounts to providers by Medicare
carriers.
2. ICD-9 -designed for classification of morbidity and
mortality information for statistical purposes..
Diagnoses and procedures coded determine the
diagnoses related group (DRG) that controls
reimbursement by CMs and most other payors.
Regulatory Requirement
HCFA HPCS- is a collection of codes that represent
procedures, supplies, products, and services which
maybe provided to Medicare beneficiaries and to
individuals enrolled in private health insurance
program.
- it is designed to promote uniform reporting and
statistical
data collection and medical procedures, supplies,
products
and services.
• NDC system identifies pharmaceuticals in detail
including
the packaging.
Regulatory Requirement
Medicare Ambulatory payment classification
system(APC)- is a prospective payment system for
hospital out patient service.
HEDIS- is standardized, comprehensive set of indicators
used to measure the performance of a health plan.
OASIS- provide comprehensive assessment for an adult
home care patient and measure patient outcome for
quality improvement.
Administrative Application of
Information Technology for Nursing
Managers
Nursing Management Today: Challenges, chances,
choices
Three major issues have an administrative impact on
the workplace, the profession, and the future of nursing
managers and administrators.
These issues are:
The nursing shortage
Increased demand for patient safety
The for visibility
The Nursing Shortage
Three primary factors are contributing to the current
shortage, including:
Steep population growth and an aging population,
which are increasing the need for healthcare services.
A diminishing pipeline of new students in nursing.
An aging nursing workforce. Forty percent of all RNs will
be older than age 50 by the year 2010.
Increased Demand for Patient Safety
The United States recorded 750,000 medical errors with
a death rate of between 44,000 and 90,000. according
to international statistics, one in every 300 errors will
result in a serious, and possibly fatal, adverse effect.
Increased Demand for Patient Safety
Organizational performance
Clinical effectiveness
Patient satisfaction
Service quality
Appropriateness of care
Patient responses to treatments
Cost of services
Efficiency of services delivered
Outcomes measurement can relate to any of the
following areas:
The Need for Visibility
Nursing must have a way to substantiate its role in the
healthcare process and its vitality to outcomes. In the
world of “prove-it” healthcare, if it is not documented,
it was not done.
Nursing Management’s Administrative Needs
In 2002, the American Healthcare Association (AHA)
commissioned PricewaterhouseCoopers (PwC) to survey
some of the American hospitals about their patient care
and paperwork experiences (AHA,2002).
The results were disturbing:
In the emergency department, every hour of patient
care requires 1 hour of paperwork.
For surgery and inpatient acute care, every hour of
patient care requires 36 minutes of paperwork.
For skilled nursing care, every hour of patient care
results in 30 minutes of paperwork.
For home healthcare, every hour of patient care results
in 48 minutes of paperwork.
Nursing Management’s Administrative Needs
IT advances have become an integral link to staff
development and continuing education, and nursing
administrators now use informatics applications to
assist with staffing, managing budgets, and
disseminating information.
Nursing Management’s Administrative Needs
The chapter focuses on two levels of nursing
administrators: nurse managers and nurse executives,
which the American Nurses Credentialing Center
defines as follows (ANCC,2003):
Nurse manager: Nurses who hold an administrative
position at the nurse manager level are responsible for:
The proper allocation of available resources to provide
efficient and effective nursing care.
Providing input into executive-level decisions and
collaborating with the nurse executive and others in
organizational programming and committee work.
Implementing the philosophy, goals, and standards of
the healthcare organization.
Implementing clinical nursing services within their
defined areas of responsibility.
Planning, organizing, implementing, and controlling the
care of individuals and aggregates across the spectrum
of healthcare settings.
Nursing Management’s Administrative Needs
2. Nurse executive: The nurse executive is responsible
for:
Managing organized nursing services and the
environment in which clinical nursing is practiced.
Ensuring that standards of nursing practice are
established and implemented, and are consistent with
standards of professional organizations and regulatory
agencies.
Evaluating care delivery models and of services
provided to individuals and aggregates.
Fostering a climate for practice that enhances
productivity, job satisfaction, and professional
development.
Applications and Implications of Information
Technology for Nursing Management
Rapidly changing technologies and dramatically
expanding knowledge are influencing how nursing
students acquire, apply, and evaluate new knowledge.
Definition of a Nursing Information System
Software system that automates the nursing process
from assessment to evaluation, including patient care
documentation. It also includes a means to manage the
data necessary for the delivery of patient care. e.g.,
patient classification, staffing, scheduling and costs.
Applications and Implications of Information
Technology for Nursing Management
Nursing administration fulfil its pivotal role to measure,
monitor, and manage services by providing accurate
answers to several key questions about nursing service:
How often and when are services provided?
What is the cost of services?
What level of service is required?
What resources are required to provide specific levels
of service?
What is the result of services performed?
Nursing administrators are also increasingly responsible
for effective management of financial and patient care
data to:
Demonstrate compliance with standards set by the
JCAHO and other standard setting organizations.
Document conformity to state and federal government
regulations.
Manage credentialing.
Develop risk management programs to reduce
organization liabilities , identify legal risk and minimize
financial liability in legal matters.
Recruit and retain qualified staff.
6. Support the personnel , information and technologic
infrastructure necessary to further organizational goals.
7. Assure customer (patient) satisfaction.
8. Establish patterns of care benchmarks and outcomes
necessary for evaluating past and forecasting future
patient care quality.
9. Ensure effective and efficient use of facility
equipment , service , and financial resource utilization.
10.Determine case mix in terms of patient diagnosis ,
age and other variables to optimize third-party payer
reimbursement.
11. Assure follow-up care of chronic patients and asses
efficiency of that care.
12. Satisfy data requirement of managed care contracts.
13. Demonstrate organizational efficiency ,
effectiveness , and performance to optimize
competitive.
The “Real” cost of Administrative system
The true cost of automation accounts to the ff:
1. Cost of the hardware and software. It is the least
costly element given the costly declining technology.
2. Cost of Education: A system is only effective if nurses
use it and get necessary training.
3. Intellectual Resources: Nursing management should
serve as advisors, directors and influencers of the
technology that nursing uses.
Implications of Manual Data
Increased Administrative Cost
-the value consumes as much as 20% of that total US
healthcare bill in controlling administrative data and
documenting practice to monitor quality.
● Compromised Quality
- 30% of information required to make diagnosis,
treatment decisions at the time decision needs to be
made.
Potential Savings of Automation
$12.7 billon reduction of annual cost to hospitals by:
Reducing cost associated with adverse medical
reactions.
Decreasing Nursing Clerical time
Reducing cost associated with record maintenance.
Curtailing malpractice cost
Hastening retrieval of valid and reliable information for
research.
Improving internal and external review of records.
How Nursing Benefits from Information Technology
Strategic
Operational
Tactical
Benefits of Using IT( see p. 450)
1.Expanded use of nursing Practice
2. Improved planning
3. Enhanced recruitment and retention
4. Improved evaluation of care provided.
Etc.
Computer Applications for Nursing Administrators &
Managers
Nurse Managers Data Needs
Allocating available resources to provide efficient and
effective nursing care and services.
□ Patient Classification system
□ Acuity system
□ Staffing and scheduling
□ Budgeting and payroll
□ Patient billing, inventory, claims etc.
Computer Applications for Nursing Administrators &
Managers
2. Putting an input into executive-level decision and
collaboration with the nurse executive. Implementing
the philosophy, goals and standards of healthcare.
□ Unit activity report
□ Utilization review
□ Shift summary reports
Computer Applications for Nursing Administrators &
Managers
3. Planning, Organizing and controlling care of
individuals and across spectrum of healthcare.
□ census
□ Poison control
□ Allergy and drug reaction
□ error reports/ incident reports
□ Infection control
□ Training and education
Nurse Executives Data Needs
Managing organized nursing services and collaborating
healthcare organizations.
□ Forecasting and planning
□ Financial planning
□ Hospital expansion
□ Preventive maintenance
□ Planning system
Nurse Executives Data Needs
2. Ensuring standards of nursing practice in accordance
to professional organizations and agencies.
□ Quality assurance
□ Regulatory reporting
□ Consumer surveys
□ Evidence-based practice
Nurse Executives Data Needs
3. Evaluating care delivery models of services provided
□ Personnel files
□ Risk pooling
□ Costing nursing care
□ case mix
Evidence-based Nursing
Evidence–based nursing is the process by which nurses
make clinical decisions using the best available research
evidence, their clinical expertise and patient
preferences.
From administrative standpoint, the use of evidence in
nursing will improve care and demonstrate effective
and efficient care delivery.
Know About Selecting a System
New Breed clinical information system: Fusion of best
practices into clinical care by ensuring the right
information is collected and disseminated.
Open systems: Integrating multiple care sites, multiple
caregiver constituencies and multiple episodes of care
via local or wide area network.
Patient-centered care: Increasing concern about patient
safety.
The Future Computerized Nursing Admnistrative System
Mobile technology
Wireless local area network and PDA
Picture archiving “ film-less clinical environment
Single Sign On (SSO)-allows user to enter one name and
password to access multiple applications
Virtual reality uses computers and multimedia
peripherals to produced simulated clinical setting of the
future. From remote controlled robotic surgery and
nanotechnology, to voice activation documentation and
telehealth kiosk.
Translation of Evidence Into Nursing Practice
Fundamentals of Clinical Practice
2 Goals of Evidence-based Health
Efficiency
Effectiveness
• Once quality tools are automated and timely
information is readily available across disciplines,
continuous
quality
improvement,
utilization
management and patient-centered care will be
systematized and delivery of effective and efficient will
be transparent.
• EBP provides an approach to coping with the
constantly changing knowledge based about what
works best in the healthcare.
Fundamentals of Clinical Practice
EBP is a systematic approach to clinical decision making
that uses the best evidence available in decision making
about patient care.
3 Components of EBP
Critical Appraisal of this relevant research Evidence
Healthcare Practitioner Clinical Expertise
Patient values and preferences
Fundamentals of Clinical Practice
Foundation of EBP is a Systematic Review of the
Research Literature.
The review gathers the evidence in a systematic way so
that all relevant evidence is included to prevent biases
in the information derived from the studies.
The Randomized Control Trial is considered the “gold
standard” which indicate that it is the most appropriate
design in evaluating effectiveness of intervention.
A systematic review needs clearly defined questinos
that indicate population interest and relevant outcome
of intervention.
Explicit rules are developed of what studies to be
included and excluded from literature review.
Systematic Review
Most systematic reviews are based on computerized
searches and some hand searches to some publications
and unpublished publications.
Results of studies maybe pulled using meta analytic
techniques to give a summary statistics that indicates
the effect size of the intervention across multiple
studies.
Some databases of systematic reviews are available
such as Cochraine Database of systematic Review and
Evidence Reports publishes on the Agency for
Healthcare research and Quality ( AHRQ).
Systematic Review
Systematic review does not make recommendations or
prescribe an integrated course of clinical care for a
given condition.
Some databases of systematic reviews are available
such as Cochraine Database of systematic Review and
Evidence Reports publishes on the Agency for
Healthcare research and Quality ( AHRQ).
Clinical Practice Guidelines
The 2nd step of EBP is development of tools that maybe
used by the practitioner to assist in clinical decisionmaking.
Clinical Practice Guidelines is a systematically
developed statements to assist practitioner and patient
decision about appropriate healthcare or specific
clinical circumstances. ( Institute of Medicine)
It is also known as simple “ practice parameters”
EBP guidelines use the findings of systematic review as
the basis for the guideline recommendations.
Clinical Practice Guidelines
A guideline is composed of multiple recommendations
that links practice to supporting evidence for a specific
intervention.
The strength of the available evidence from various
recommendations is explicitly stated so that clinicians
can judge for themselves.
Guideline Limitations
The use of expert maybe necessary to fill in gaps in the
evidence over reliance on expert opinion raises issues
on credibility.
Patient preferences are often not adequately
addressed.
The absence of cost information. This will weigh the
harm and benefits of different interventions can be
easily compared and contrasted.
Clinical Practice Guidelines
Providers need to assess the quality of a guideline and
evaluate(whether or not it contribute to patient
outcome.
Key Questions to ask:
Who developed the guideline?
Is the guideline developed using an evidence-based
approach? (is evidence prioritized over expert opinion?)
Is the guideline current?
Is it presented in a flexible format? (are patient
preference and individual clinical judgement possible?)
Are the benefits and harms presented for sound
decision making?
Are cost considered?
Implementation
Implementations is defined as applying textual
information to real situations.
It is the active employment of a guideline to promote
effective and efficient care in order to improve patient
outcome.
Computers is a tool to facilitate evidence-Based Practice
and Guideline Implementation.
There has been movement into developing,
implementing, evaluating and determining outcome
from computerizing guideline.
Computers and Guidelines
InterMed collaborators developed a standardized,
common language to represent guidelines. This
language is called
Guideline Interchange Format (GIF)
• The advantage of using this format such as GIF are as
follows:
1. Support multidisciplinary teams developing
guidelines
2. Reduce the duplication efforts in guideline
dvelopment
3. Provide feedback mechanism to update ( guidelines
concurrent with advances iin medical and nursing
knowledge)
Computers and Guidelines
Different Approaches
1. Theory Based-Approach ( Mitman et.al) in
considering tools helps to assure that implementation
decisions are rational and grounded to theory.
2. Multipronged approach – means that several diverse
guideline implementation tool which will be used
simultaneously and supported by leaders and from the
bottom up and top to bottom.
3. Active Approach- it discourage use of only passive
dissemination and implementation methods
Computers and Guidelines
IT community developed SAGE that provides a guideline
model and public domain workbench model knowledge
authoring tools, with standards terminology such as
SNOMED-CT,LOINC and HL7.
This collaboratory has a website and useful tool fro
persons interested in using guideline embedded into
information system.
SAGE has been integrated into clinical information
system called IDX system.
In progress, is a new application on a different clinical
practice guideline. (ADA Diabetes guideline)
4 Categories of Choosing Computerized Tools
1. Knowledge-based tool
2.Attitude based-tool ( e.g.endorsement of the
guidelines)
3. Behavior-based tool (e.g. administrative like
resources related to guidelines)
4. Maintenance-based tool ( computerized reminders,
computerized standing order, audit /feedback can be
integrated)
Nursing Role in Using Automated Tools
There is currently no national professional or academic
group with overall responsibility for assessing Nursing
content within guidelines or for suggesting appropriate
representation of nurses on multidisciplinary panels.
Guideline developers do not readily know where to run
when seeking nurse’s involvement.