Relevance to Nursing
The first nursing information systems conference was held in the United States in 1977. Nurses have
taken significant strides since then to design and adapt computer processes to enhance client care,
education, administration and management, and nursing research. Advanced practice in nursing
informatics is a growing specialty. Nursing informaticists or nursing informatics specialists are currently
in much demand.Job descriptions for these practitioners often include the important roles of interfacing
between the client care and information technology departments and assisting with the development,
implementation, and evaluation of initiatives in clinical information systems.
The use of computers to systematically solve problems is referred to as information technology (IT). In
nursing,the Technology Informatics Guiding Education Reform (TIGER) Initiative began in 2006 to
identify information and knowledge management best practices and effective technology capabilities for
nurses. TIGER is focused on clinician education through the integration of IT, information
literacy,informatics and technologies, developing and implementing learning innovations, and increasing
faculty and student acceptance and understanding of health IT through education and training.
Management Information Systems
A management information system (MIS) is designed to facilitate the structure and application of data
used to manage an organization or department. The system provides analyses used for strategic
planning, decision making, and evaluation of management activities. All levels of management benefit
from the ability to access accumulated data.
Hospital Information Systems
A hospital information system (HIS) is an MIS that focuses on the types of data needed to manage client
care activities and healthcare organizations. As with any system, the goal is to provide individuals with
the data they need to determine appropriate actions and control them. Typically,an HIS will have
subsystems in the areas of admissions,medical records, clinical laboratory, pharmacy, medical or nursing
order entry, and finance. The personnel in these areas record the data needed to allow management of
billing, quality improvement, scheduling, and inventory both within their own areas and across the
institution.
Computer-Assisted Instruction
Nursing has benefited from the computer revolution in the form of computer-assisted instruction (CAI).
Dozens of software programs help nursing students and nurses learn and demonstrate learning.
Programs cover topics from drug dosage calculations to ethical decision making and are classified
according to format: tutorial, drill and practice,simulation, or testing.
• Tutorials on electrocardiogram (ECG) interpretation,drug interactions, and legal aspects of nursing are
examples of CAI programs. Nurses who become familiar with CAI will also find that they have an easier
time adjusting to the software programs many employers require them to complete for annual
competency testing mandated by accrediting bodies in certain areas. Completion af CAI prgrams may
also be an accoptable means of demonsirating continuing education activities required for registered
nurses license renewal.
• Classroom Technology
In recent years most of educational buildings are now wired to accommedate technologies, smart
classrooms with projectors that display computer screens and document cameras that display objects
and print materials for the entire classroom to view are becoming standard. Other classroom technology
includes the use of individual audience response systems often referred to as "clickers") and class
capture aystems that record and post lectures and visuals to the internet Mobile phones are also used in
class to search for literature, videos, and websites,and to gather data from students using a variety of
survey applications.
• Simulation
Computer technology has significanily enhanced the realism provided in the traditional nursing skills
laboratory. Mannequins, models, task trainers, and other tools can simulate realistic healtheare of
clients.These tools range from systems that use computers and small devices to provide skills practice,
such as learning to insert an IV catheter(referred to as high-fidelity human patient simulators) with the
ability to breathe,speak, and display digital readouts that reflect the impact of nursing interventions.
Case scenarios can be authored in which one or more care providers interact with the simulated client(s)
to role-play a specific situation. Even when all the actors in a scenario are live individuals, such as with
standardized elients, technology is used to record the interactions,mark and categorize events in the
recording that depict specific learning objectives,and allow replay of the scenario during debriefing.
Distance Learning
There are several different models of distance learning educational opportunities delivered under
situations in which the teacher and the learner are not physically in the same place at the same time.
Distance learning may be categorized as asynchronous when the individuals involved are not interacting
at the same "real" time or as synchronous when teachers and students are communicating
simultaneously. In one model of asynchronous distance learning, the student receives course
materials,communicates with the faculty and other students, and submits assignments completely by
mail, phone, fax,email,website,or remote storage service,often referred to as "in the cloud." Another
type of computerized delivery of knowledge is through ebooks. Textbooks are available on a mobile
device and can be annotated and searched.In addition,lectures can be delivered through podcasts Many
schools use a learning management system such as Blackboard,Canvas,eCollege, Sycamore or Moodle to
make course documents and activities available through internet access. Faculty can post syllabi,
handouts, assignments,and examinations in individual course shells,and students can submit papers and
hold discussions online.In general,a course that never requires students to come to a campus is
considered online and one in which no more than 50% of the coursework is on technology and the
remainder is conducted on campus is considered hybrid.
Technology even allows us to create virtual communities. In these interactive web-based
environments,faculty and students create a virtual self, known as an avatar.Using an avatar, you can
navigate through simulated worlds and communicate using audio-video lectures,discussions, and
posters.One example of such interactive virtual communities in healthcare and education is the three-
dimensional simulated world of Second Life.
A model of synchronous distance learning involves groups of students in classrooms at different sites
participating in a class session using two-way videoconferencing.Students who are not at the site where
the faculty member is located can communicate via voice-activated microphones or response pads.
These pads have buttons that permit the students to indicate that they wish to ask a question or even to
respond to multiple-choice test questions.Synchronous distance learning can also be accomplished
through the use of chat,instant messaging, and one-to-one video chat.
Testing
The computer is ideal for conducting certain types of learning evaluations. Surveys can be completed
online,including anonymous questionnaires. Large banks of potential test items can be written that
allow the computer to generate different exams for each student depending on the selection criteria
designated by the faculty. Students'answers can be scored electronically and the overall exam results
analyzed quickly. Some schools subscribe to a service that provides testing and customized
instruction,for example,the National Council Licensure Examination for RNs (NCLEX-RN) in the United
States has been taken on computer for years.The computer determines if the applicant passed the
examination by using a scoring algorithm that ensures all required competencies have been evaluated
fairly.
Student and Course. Record Management
Computers are also very useful for maintaining results of students' grades or attendance. Often student
answer sheets are imported directly into a gradebook on the computer. The program can then calculate
percentages,assign letter grades, and make results available to both students and faculty.
Students are frequently asked to evaluate faculty and courses online or using machine-readable forms.
These data are also stored in the computer,allowing cumulative results to be calculated. This is an
example of what is called data warehousing-the accumulation of large amounts of data that are stored
over time and can be examined for output in different types of reports (charts and tables).
Technology in Nursing Practice
Many activities of the registered nurse involve collecting.recording, and using data. Computers are well
suited to assist the nurse in these functions. Specifically,the nurse records client information in
computer records, accesses other departments' information from centralized computers, uses
computers to manage client scheduling,and uses programs for unique applications such as home health
nursing and case management. Improvement in both clinical and nonclinical processes can occur
through technology in biomedical monitoring,communication,client safety systems, decision support,
and education. As a component of accreditation of nursing institutions as well as health organizations,
nurses are expected to have knowledge about the benefits and limitations of technology skills in using
technology for communication and decision making, and attitudes needed to value technology and use
informatics to both support and protect clients.
Documentation of Client Status and Medical Record Keeping
How do computers assist individual nurses with their activities? In the typical day of a nurse providing
direct care, as much as one-third of the time may be recording in the client's chart. Additional time is
spent trying to access data about the client that may be somewhere in the medical record or eise-where
in the healthcare agency. Nurses access standardized forms, policies, and procedures. Also, nurses
gather broader client information such as length of stay for specific diagnoses. Computers can assist
with each of these tasks.
Bedside Data Entry
There are several different types of computerized bedside data entry systems. These allow safety checks
and recording of medication administration, client assessments, progress notes and care plan updating.
The terminal can be fixed or handheld, and hardwired to the central system or wire-less with the ability
to transmit the data to distant sites,such as from the client's home to the facility.When using bedside
terminals, the nurse must remain sensitive to client concerns related to the technology.Learn how to
navigate and troubleshoot the device before using it at the bedside so the client does not observe any
frustration if you experience difficulties.Always address the client before using the computer. Explain
what the computer is for and how the client's confidentiality is assured.
• Computer-Based Client Records Electronic health records (EHRs) or computer-based patient records
(CPRs) permit electronic client data entry and retrieval by caregivers, administrators, accreditors,and
other individuals who require the data. An EHR can improve healthcare in at least four ways:(1) constant
availability of client health information across the lifespan, (2) ability to monitor quality, (3)access to
ware-housed (stored) data, and (4) ability for clients to share in knowledge and activities influencing
their own health.The Centers for Medicare and Medicaid Services (CMS)Electronic Health Record
Incentive Program provides financial incentives to providers who demonstrate that they have made
"meaningful use" of EHR technology. Because of the way computers provide access to EHRs,providers
can easily retrieve specific data such as trends in vital signs, immunization records, and current
problems. The system can be designed to warn providers about conflicting medications or client
parameters that indicate dangerous conditions. Sophisticated systems allow replay of audio, graphic, or
video data for comparison with current status. Challenges with reading handwriting are eliminated and
all text is searchable.
There are several areas of concern with EHRs.Maintaining the privacy and security of data is a significant
issue. One way in which computers can protect data is by user authentication via passwords or
biometric identifiers (e.g., fingerprint, palm vein, or retinal scans)-only those individuals who have a
legitimate need to access the data receive the password. Additional policies and procedures for
protecting the confidentiality of EHRs are evolving as the use of computer records becomes more
widespread.One role of the nurse informaticist, an expert who combines computer, information, and
nursing sciences, is to develop policies and procedures that promote effective and secure use of
computerized records by nurses and other healthcare professionals. Other concerns involving EHRs
include errors such as wrong-site surgery,medi-cation errors, and delays in treatment that result from
improper data entry.Different from an EHR is a personal health record (PHR), which is an electronic
document that contains the client's medical, personal, and health information but is controlled by the
client, rather than the healthcare provider.The PHR can be stored on a computer database,in an
electronic computer file, or on a portable “smart card”similar to a credit card. A significant advantage of
a PHR stored in a commonly accessible format (e.g., word processor document or portable document
format [pdf]) is that clients can transport and give the information to any care provider they wish,
whenever necessary. A challenge is to keep the information current.
• Data Standardization and Classifications There are many reasons why nursing benefits from the use of
standard classifications and terms to describe and measure clinical,disease,procedure,and outcomes
data.One reason is that, for nursing to be recognized for the value it adds to client well being, research
that shows client improvement must be based on accepted standards This necessitates the use of
common,consistent,clear,and rule-based standards. Nursing classifications like NANDA( North American
Nursing Diagnostic Association), taxonomy, NIC (Nursing Intervention Classification)and NOC( Nursing
Outcome Classification.
• Tracking Client Status
Once an EHR has been established, the nurse can retrieve and display a client's physiological parameters
across time. In addition to the rather straightforward viewing of trends in vital signs, for example, the
nurse can also track more global client progress. Standardized nursing care plans, care maps, critical
pathways,or other prewritten treatment protocols can be stored in the computer and easily placed in
the EHR electronically.Then the nurse and other healthcare personnel can examine progress toward and
variance from the expected plan directly on the computer. EHR vendors often include components for
authoring nursing care plans and tracking care delivery and outcomes.
• Electronic Access to Client Data
Besides computers designed for record keeping, other computers are used extensively in healthcare to
assess and monitor clients' conditions. The data accumulated from various electronic devices can be
part of the EHR and also stored for research purposes.Electronic records take up much less space than
paper records and may be stored more securely.Copies can be made easily on vari-ous types of
electronic media that tend to be more com-pact and durable than paper.Data can also be transmitted
electronically to a consulting specialist in another location.
• Client Monitoring and Computerized Diagnostics
Nursing has benefited greatly from the myriad of client monitors.Medical devices,with their powerful
computer chips,make it possible to extend the nurse's observations and provide valid and reliable data.
In everyday practice,nurses use digital or tympanic thermometers,digital scales, pulse
oximetry,ECG/telemetry/hemodynamic monitoring,apnea monitors,fetal heart monitors, blood glucose
analyzers, ventilators, and IV pumps. Most of these monitors are applied externally,implanted,or even
ingested (swallowed),and are proving to have great value For example,a surgically placed wireless
sensor can measure the pressure inside a bulging weakened blood vessel (aneurysm) and warn of
potential rupture. These instruments can be used in any care setting,from intensive care to the home.
Most keep a record of the most recent values.Some can transmit their data to a more sophisticated
computer or print out a paper record.Some have digital displays that "talk" to the user,giving
instructions or results. Although these devices are extremely useful,they also raise concerns about cost
and privacy.Most devices have error detection or alarms to indicate either that the instrument is
malfunctioning or that the assessed value is outside predetermined parameters.Although alarms are
essential,they also carry the risk of leading to alarm fatigue,when nurses become less sensitive to the
alarms because of their frequency and incidence of false alarms. Nurses must always balance the data
from technologic instruments with their own judgement.
examples of ways in which computers assist nurses in motuloring and diagnosing client conditions.
• Telemedicine or Telehealth
One of the most exciting areas being developed in computer-assisted healthcare is telemedicine.
Telemedicine or telehealth uses technology to transmit electronic data about clients to healthcare
providers at distant locations in one example, two-way audiovisual communication allows an
international expert to examine and consult on a client's case from thousands of kilometres away X-rays,
scans, stored computer data,and almost anything imaginable can be "sent" using computers.Another
example is the ability for a few healthcare providers to provide primary healthcare to clients living in
remote areas using the kinds of monitors described previously plus telephone, fax, and other relatively
simple equipment in the client's home.
• Practice Management
Beyond direct client care, computers also assist nurses in many ways in the management of their work.
In hospitals,data terminals are commonly used to order supplies, tests,meals, and services from other
departments,a process called computerized provider order entry (CPOE). Tracking of these orders allows
the nursing service to determine the most frequent or most costly items used by a particular nursing
unit. This information may lead to decisions to modify a budget,provide different staffing, move supplies
to a different location, or make other changes for more efficient and higher quality care.
Computers are used extensively for scheduling.Client appointments can be easily entered or changed.
Special notes or tags can be applied to the appointment as a reminder to the provider to perform
particular services.The schedule for a single day can be printed so that all personnel have a copy.
Staffing patterns must also be coordinated.Special requests for days off or continuing education classes
can be entered, and the schedule can be viewed for a day, week. month, or year.
Specific Applications of Computers in Nursing Practice
As previously described, numerous systems are in use collecting and classifying the various types of data
usec nursing practice. Some of these systems have been fou particularly useful in specific settings.
• Community and Home Health
Computer networks are being used in innovative ways in home settings. A computer placed in a high-risk
client's family's home allows them to access information on a variety of topics, search the internet, or
email a healthcare provider with questions or concerns. Clients can also record data about their health
status that can be transmitted to the healthcare provider at the central network computer.Examples
that have been successful using this approach include monitoring women at risk for preterm labor,
individuals with AIDS, and clients in very rural settings who are far from their providers. Digital cameras
connected to the computer, often referred to as webcams,permit the healthcare provider to actually
examine the client to some degree. Home alert systems that allow the client to signal the base station in
an emergency are also widely used.
Nurses who visit clients in their homes are using laptop or tablet computer systems to record
assessments and transmit data to the main office.Similar systems have been developed so that nursing
students in community health courses can communicate with their faculty.
• Case Management
Case managers must be able to track a group of clients--the caseload. Software programs allow the case
manager to enter client data and integrate this with predesigned care-tracking templates. In addition,
the case manager must keep abreast of the latest regulations affecting eligibility for healthcare benefits.
Finally, the case manager must document quallty, that is, demonstrate client outcomes related to
money spent
Technology in Nursing Administration
Nursing administrators require data to develop strategic plans for the organization.
• Human Resources
All employers must maintain a database on each employee. In addition to the usual demographic and
salary data, the databose for licensed or certified health-care personnel has unique fields for areas such
as certification, health requirements (e.g., tuberculosis testing, hepatitis immunization,rubella titers
etc),and performance appraisals. Administrators can use this human resources database to
communicate with employees, examine staffing patterns, and create budget projections.
• Medical Records Management
Medical records must be maintained for many years in case the data are needed for client care or
research. Storage of paper documentation can be cumbersome and costly.
Although it is expensive to store records,the cost of human time and energy plus inefficiency in
accessing the contents is even more expensive. Therefore, nurses require computer programs that allow
client records to be searched for data such as the most common diagnoses, number of cases by
diagnosis-related groups, most expensive cases,length of stay or total number of days the case was
open, client outcomes, and so on. Nurse informaticists can assist with the design and implementation of
systems that allow such searches to be generated, analyzed, printed, and distributed. Computerized
records increase the ability to demonstrate the value of nursing care.
• Facilities Management
Many aspects of managing buildings and nonnursing services can be facilitated by computer.Heating, air
conditioning, ventilation, and alarm systems are computer controlled. Security devices such as readers
that scan identification cards, bar codes, or magnetic strips permit only authorized personnel to enter
client or private areas.Computers also manage and report inventory,tracking everything from
pillowcases to syringes.
• Budget and Finance
Advantages of computerized billing are that claims are transmitted much more quickly and have a
greater likelihood of being complete and accurate compared to handwritten documents. If this is the
case, claims will be paid sooner and the agency will have better control over its financial status.
Computers can also affect cost savings by reducing the clerical services time needed for accounts
payable and receivable. In cases where nursing can directly bill and be reimbursed by payers, the same
benefits of computerized accounting apply.
The budget itself is generally a spreadsheet program.This software allows tracking as well as forecasting
and planning. In uncertain times, the ability to perform "what if" calculations is especially valuable.
• Quality Improvement and Utilization Review
Both internal and external stakeholders in healthcare organizations need to know that the services and
activities of the organization have positive results. Once standards,pathways, key indicators, and other
vital data have been identified and described, computers can facilitate the accumulation and analysis of
data for individuals and groups of clients. Quality is considered a process and not an end point. Applying
this perspective, computerized systems are ideal for taking a snapshot view of the institution's quality
indices at any time.
Utilization review consists of examining trends and proposing advantageous use of resources
(specifically,length of stay). For example, might clients who have had a fractured hip repaired have
equivalent outcomes at lesser cost if transferred from hospital to a nursing facility sooner.
• Technology in Nursing Research
Computers are valuable assistants when conducting quantitative and qualitative nursing research. In
each step of the research process, computers facilitate generation, refinement, analysis, and output of
data.Computer resources are an important component of the planning phase of any research project.
The speed and processing power of the computer and its storage capacity must be adequate for the
amount and type of data that will be collected, and the proper software programs must be in place to
manage and analyze the data.Computerized word processing is also an integral component in the
publication and dissemination of research.
