1 Copyright © 2009, 2006, 2003, 2000, 1997, 1994 by Saunders, an imprint of Elsevier Inc. Chapter 23 Nursing Informatics

2 Copyright © 2009, 2006, 2003, 2000, 1997, 1994 by Saunders, an imprint of Elsevier Inc. Nursing Informatics  Define nursing informatics  Discuss the need for recognized taxonomies and nursing nomenclature in nursing documentation  Discuss trends associated with the computerized electronic record, e-health, PDAs  Describe what a nurse specializing in nursing informatics might do  Review the steps in evaluating a website  Discuss future trends in nursing informatics

3 Copyright © 2009, 2006, 2003, 2000, 1997, 1994 by Saunders, an imprint of Elsevier Inc. What Is Nursing Informatics?  ANA definition of nursing informatics:  “A specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice”  The longitudinal electronic health record (EHR) has become the ultimate goal of health care organizations

4 Copyright © 2009, 2006, 2003, 2000, 1997, 1994 by Saunders, an imprint of Elsevier Inc. Nurse Informaticist (NI)  Nurses  Unique understanding of workflow, hospital and clinical environment, and specific procedures necessary for effective health care information infrastructure  NI critical to translation of standard information into practical models

5 Copyright © 2009, 2006, 2003, 2000, 1997, 1994 by Saunders, an imprint of Elsevier Inc. Information Technology  NI must have basic knowledge of how computer works  NI must be able to converse with technology staff on intellectual level about hardware, software, communications, data representation, and security

6 Copyright © 2009, 2006, 2003, 2000, 1997, 1994 by Saunders, an imprint of Elsevier Inc. What Are Regulatory and Accreditation Requirements?  NI must have clear understanding of regulations to guide organization within boundaries  HIPAA: ensures that health care organizations collect right data in common format  The Joint Commission: inspects and reviews variety of areas within each organization

7 Copyright © 2009, 2006, 2003, 2000, 1997, 1994 by Saunders, an imprint of Elsevier Inc. The Joint Commission  Implemented information management (IM) standards in the mid-1990s  Total of 10 standards  Ensures that facilities are meeting high performance standards through certification  Need for information management regulation

8 Copyright © 2009, 2006, 2003, 2000, 1997, 1994 by Saunders, an imprint of Elsevier Inc. Ethics  Privacy and confidentiality— Health care organization must have good control of its information systems  Security policies must be explicit and well defined  Confidentiality agreements should be reviewed and signed upon hire and yearly thereafter  Breaches of security, confidentiality, or privacy should be dealt with quickly

9 Copyright © 2009, 2006, 2003, 2000, 1997, 1994 by Saunders, an imprint of Elsevier Inc. What Is the Electronic Health Record (EHR)?s  EHR is part of CIS—several types  Electronic medical record (EMR)  Electronic patient record (EPR)  Computerized patient record (CPR)  Office-based/conventional (hospital) system  Web-based system  Handheld or wireless system

10 Copyright © 2009, 2006, 2003, 2000, 1997, 1994 by Saunders, an imprint of Elsevier Inc. What Is e-Health?  e-Health—the current term used to refer to all fields related to computers and medicine  Replaces the older term telehealth  Way of thinking that focuses on improvement of health care through information and communication technology

11 Copyright © 2009, 2006, 2003, 2000, 1997, 1994 by Saunders, an imprint of Elsevier Inc. Trends  Computer literacy required as you advance through nursing  Use of Internet to communicate and provide patient self-care  Evaluation of Internet resources  Use of patient digital assistants (PDAs)

12 Copyright © 2009, 2006, 2003, 2000, 1997, 1994 by Saunders, an imprint of Elsevier Inc. Using the Internet  Next generation of health care delivery  Health information on the Internet can dramatically improve clients’ ability to manage their own health—but users must remember to proceed with caution !  In near future clients will have accessible online medical records

13 Copyright © 2009, 2006, 2003, 2000, 1997, 1994 by Saunders, an imprint of Elsevier Inc.  Few doctors currently communicate with their patients through  Could help to avoid “phone tag” with clients and improve efficiency  Drug-refill requests and educational information could be accessed

14 Copyright © 2009, 2006, 2003, 2000, 1997, 1994 by Saunders, an imprint of Elsevier Inc. Patient Digital Assistant (PDA)  Allows bedside data collection and charting  Conserves time and reduces steps to and from nurses’ station  Offers easier information transmission between workers  Portability and information at your fingertips

15 Copyright © 2009, 2006, 2003, 2000, 1997, 1994 by Saunders, an imprint of Elsevier Inc. How Can a PDA Help Me?  Can use to monitor:  Blood glucose levels  Blood pressure  Diet  Activity  Calculate dosages  Analyze lab results  Access reference materials  Check for drug interactions  Schedule procedures  Order prescriptions  “Beam” assignments

16 Copyright © 2009, 2006, 2003, 2000, 1997, 1994 by Saunders, an imprint of Elsevier Inc. What Do I Need to Know to Evaluate an Internet Resource?  Confine your Internet searches to well-known and reputable sites  Office of the Surgeon General  National Human Genome Research Institute (NHGRI)  Centers for Disease Control and Prevention (CDC)  Agency for Healthcare Research and Quality (AHRQ)  Health Resources and Services Administration (HRSA)