09Jones Leadership(F)-ch 09 1/14/07 3:39 PM Page 133 Informatics Dr James Turley suggested the addition of cognitive science to the definition of nursing informatics Understanding the processes employed in structuring knowledge; representing knowledge; and employing knowledge in decision making, recall, and perception are important dimensions in the practice and application of informatics Ongoing research in the cognitive domain provides important understanding to guide the design of information system software, helping to create systems that are increasingly more useful and more effective in supporting decision making by clinicians Turley suggests a model that incorporates the elements of Graves and Corcoran’s model—nursing, information, and computer science—and adds the domain of cognitive science Furthermore, Turley suggests that the nursing science is the foundation on which the other three sciences rest Turley’s model also suggests that it is the intersection of the cognitive, information, and computer sciences that constitutes nursing informatics (Turley, 1996) Nursing science is the raison d’être of nursing informatics, and without the needs and context of nursing science nursing informatics would have no purpose Turley’s model has the further advantage of flexibility: the model can be translated to other health-care science disciplines by changing the foundational domain Nursing informatics has the purpose and the potential to support and improve the care of patients and communities through the collection, management, and communication of information about and for the patient As well, nursing informatics can assist in making the contributions of nursing visible in the medical record and assist the nurse by providing decision support tools Nurses are presented with an increasing array and complexity of information that they are expected to synthesize and incorporate into their patient care decisions More information does not necessarily result in better care unless it is thoughtfully analyzed, organized, and presented in ways that are meaningful to nurses and their practice The timing, content, and format of the information can vary with the recipient; the information needs of clinicians at the point of care are different from the needs of the manager or administrator, and those needs differ from the needs of the policy maker 133 Nursing Cognitive Science Information Science Informatics Computer Science Science FIGURE 9-1 Turley’s suggested model for nursing informatics Consequently, a pivotal role of the informaticist is to collaborate with those individuals and groups to discover their information needs and the decisions that will result and translate those needs into creation of appropriate data collection, analysis, and presentation formats Nursing Informatics Standards of Practice The standards of nursing informatics practice carefully parallel the nursing process (see Table 9-1) The clinical nurse focuses on assessing the needs of a patient and the individuals in the patient’s support system The nurse then develops a plan of care based on careful prioritizing of the nursing diagnoses Then the plan is implemented and assessed and evaluated according to the patient’s responses to the plan Data collected during evaluation are thoughtfully analyzed, and appropriate modifications are made to the plan of care The focus of the nurse informaticist is assessment of systems problems as identified by a group of clinical practitioners; identification of the problems, 09Jones Leadership(F)-ch 09 134 1/14/07 3:39 PM Page 134 Understanding Organizations TABLE 9-1 Comparing the Nursing Process and Nursing Informatics Standards of Practice NURSING PROCESS STANDARDS OF INFORMATICS PRACTICE Assessment: ■ Collect data from physical examination of patient ■ Collect data from listening to patient and family ■ Analyze data ■ Identify patient’s problems related to health status Identify the issue or problem: ■ Prepare a project charter and initial project plan based on assessed problems, opportunities, and directives of the project ■ Define business requirements for a new system ■ Define the desired functional requirements, or activities and services, of the new system Identify alternatives: ■ Analyze requirements in terms of data, processes, interfaces, etc., the system will require ■ Analyze possible solutions in terms of technical, operational, economic, and timeline feasibility ■ Prepare solution recommendation(s) for discussion with the users Choose and develop a solution: ■ Select a solution in collaboration with users ■ Create a project plan, which include timelines, dependencies, evaluation milestones, and evaluation metrics Implement the solution: ■ Implement programming of the solution ■ At defined intervals, evaluate the developing solution in collaboration with users ■ Implement the fully completed solution Evaluate and modify: ■ Evaluate solution with evaluation metrics ■ Implement programming and workflow modifications in response to feedback ■ Evaluate solution after completion of programming modifications to determine further needs or issues (Whitten, Bentley, & Dittman, 2000) Diagnoses Formulate a nursing diagnosis related to each health problem ■ Prioritize the problems and diagnoses in collaboration with patient and/or family ■ Plan: ■ Discuss patient’s expectations ■ Establish outcome goals for patient in collaboration with patient and/or family Implement: ■ Set plan of care in action, delegating responsibilities as appropriate ■ Communicate plan of care to other team members Evaluate: Evaluate plan and implementation as ongoing events ■ Adjust plan as appropriate in context of data collected ■ Return to assessment in context of changing needs and data collected ■ opportunities, and constraints; and description of the outcomes the group desires to achieve Using the information gathered during the assessment phase, the nurse informaticist prioritizes the problems and constraints; carefully explores alternatives in the context of time, fiscal, and resource constraints; and prepares recommendations for the team to consider Working closely with the clinicians, the nurse informaticist facilitates and supports the clinical team in selecting a solution from the options presented, ensuring that the advantages and limitations of each solution are explored carefully Once the clinical team has chosen the most appropriate solution, the nurse informaticist works with the system programmers during design of the software solution, reviewing the progress of the plan with the clinical team at key junctures Upon completion of the programming process, the system is implemented, and the evaluation phase begins Employing evaluation measures defined during the planning phase, the nurse informaticist gathers the evaluation data, analyzes them, and works with the programmers and the clinical team to define the nature of system modifications necessary to resolve identified system issues The evaluation process and subsequent system modification are iterative It is important to recognize that the above summary is just that—a very high-level summary Just as the brief description of the nursing process does not begin to describe the details of interventions and decisions a nurse makes during an episode of patient care, the same can be said for the processes, 09Jones Leadership(F)-ch 09 1/14/07 3:39 PM Page 135 Informatics interventions, and decisions of the nursing informaticist It is also important to point out that the process of identifying and implementing systems solutions necessitates development of detailed workflow information, and the solutions often include changes in workflow that are not related to the software solution Nonetheless, there is value in identifying and comparing the parallels between the nursing processes of patient care and the analysis processes of information system design and informatics Health-Care Data Standards Data standards are intended to minimize confusion and assure that data are collected, stored, transmitted, and retrieved in a manner that ensures that the original meaning is intact and that actions taken in response to the data are consistent with the original meaning of the data (Sensmeier, 2006, p 218) A discussion of data standards should begin with a clear understanding of what constitutes a standard A standard is an agreed-upon reference point, criterion, or value against which something can be measured To be effective, data standards include discrete, precise definitions, adherence to which is not optional (Thede, 2003, p 205) Dr Thede used an apt analogy from the 19th century U.S railroad industry in discussing her vision of standards In the railroad’s early days, standards for track width, or gauge, had not been established, and each railroad company was free to create its own gauge The problems associated with multiple widths quickly became apparent when trains from different railroad companies could not travel beyond their own territory The problems this created for passenger and product movement quickly became apparent and necessitated that the competing companies come to agreement on a standard gauge In the health-care industry, much work is focused on standard development Some standards are widely accepted, and others are evolving The following discussion will briefly describe some of the collaborative work currently being conducted in the United States and globally Interoperability is another term that is frequently used in discussions regarding health-care information systems standards Systems that can effectively exchange data and effectively and effi- 135 ciently use the data that have been exchanged have interoperability Health-care data standards are designed to support and enable interoperability Data standards include “methods, protocols, terminologies, and specifications for the collection, exchange, storage, and retrieval of information associated with health care applications, including medical records, medications, radiological images, payment and reimbursement, medical devices and monitoring systems, and administrative processes” (Washington Publishing Company, 1998) Data standards encompass four primary areas: Definition of data elements Determining data interchange formats to establish how data elements are to be encoded as well as to assure relationships between data elements through defining how documents and information models should be structured Terminologies, which identify and define the terms and concepts used to classify and code data elements and establish relationships between the concepts and terms Knowledge representation, as provided by electronic medical literature, guidelines, evidence-based practice protocols, and clinical decision support (Institute of Medicine, 2004, pp 128-129) Data Elements Data elements are the most basic pieces of information collected, and in order to be able to use the collected data they must be defined clearly, discretely, and unambiguously Definition includes determining how the data are to be collected, by what software application, by what hardware, and when they are to be collected It is also important to establish how the data will be entered into the software system, e.g., as free text or by selection of predefined responses using coded values Without clearly defined, consistently entered, unambiguous data, the ability to recover data with assurance of content is greatly diminished, as is the potential of the use of the data in future research The question of what data should be collected was answered in part through the development of minimum data sets, an example of which is the Nursing Minimum Data Set (NMDS) (Table 9-2) 09Jones Leadership(F)-ch 09 136 1/14/07 3:39 PM Page 136 Understanding Organizations TABLE 9-2 ANA-Approved Terminology Standards (February 24, 2006) DATA SET PURPOSE NMDS (Nursing Minimum Data Set) The NMDS has categories (nursing care, demographics, and service elements) with 16 data elements This seminal work defined the minimum information that should be collected for every patient receiving nursing care and contributed to the foundation necessary for the development of nursing terminologies http://www.nursing.uiowa.edu/NI/collabs_files/Synopsis%20NMDS%20Nov%202003.pdf NMMDS (Nursing Management Minimum Data Set) NMMDA was developed to meet the needs of nursing administrators The NMMDS data set includes 17 data elements across the categories of nursing environment, nursing resources, and financial resources, and it is necessary to inform the strategic decisions of the nurse executive (Huber D., Schumacher L., & Delaney C [1997] Nursing management minimum data set [NMMDS] Journal of Nursing Administration, 27(4), 42–48 TERMINOLOGIES PURPOSE CCC (Clinical Care Classification) CCC emerged from a Medicare-funded nursing research study designed to assess and classify patients to determine the resources required to provide home health services CCC comprises two interrelated taxonomies: ■ 182 nursing diagnoses and outcomes, modified by an expected outcome or actual outcome axis, each of which is modified by three possible conditions: improved, stabilized, or deteriorated ■ 198 nursing interventions modified by four types of action: assess/monitor, care/perform, teach/instruct, and manage/refer http://www.sabacare.com/ ICNP (International Classification for Nursing Practice) International Council of Nurses (ICN) is a federation of national nurse associations representing nursing in more than 128 member nations ICNP is a derivative of the ICN, with the goal of articulating the contribution of nurses around the world to health care and promoting international standardization of nursing ICNP includes nursing diagnoses, nursing interventions, and outcomes http://www.icn.ch/icnp.htm NANDA (North American Nursing Diagnosis Association) NANDA provides nurses at all levels and in all areas of practice with a standardized nursing terminology with which to: ■ Name client responses to actual or potential health problems, life processes, and wellness ■ Document care for reimbursement of nursing services ■ Contribute to the development of informatics and information standards, ensuring the inclusion of nursing terminology in electronic health-care records ■ Facilitate study of the phenomena of concern to nurses for the purpose of improving patient care http://www.nanda.org/ NIC (Nursing Intervention Classification) NIC includes the full range of nursing interventions from general practice to specialty areas Interventions include physiological and psychosocial, illness treatment and prevention, and health promotion for individuals, families, and communities as well as indirect care Both independent and collaborative interventions are included http://www.nursing.uiowa.edu/centers/cncce/nic/index.htm NOC (Nursing Outcome Classification) NOC labels and provides measures for comprehensive patient-focused outcomes that respond to nursing intervention The outcomes are intermediate to the achievement of longer-range outcomes and employ a scale that provides quantifiable information NIC facilitates the identification of risk adjustment factors for population groups http://www.nursing.uiowa.edu/centers/cncce/noc/index.htm 09Jones Leadership(F)-ch 09 1/14/07 3:39 PM Page 137 Informatics 137 DATA SET PURPOSE OMAHA System This is a comprehensive practice and documentation tool for multidisciplinary healthcare practitioners in any setting The three components of the system are problem classification, intervention scheme, and problem rating for outcome http://www.omahasystem.org/ PCDS (Patient Care Data Set) The PCDS was developed as a data dictionary of elements abstracted from clinical information systems The PCDS is multiaxial and combinatorial (a system in which atomic terms are combined to create more complex concepts or problems or structures) http://www.duke.edu/~goodw010/vocab/PCDS.html PNDS (Perioperative Nursing Data Set) Developed by the Association of Perioperative Registered Nurses, the PNDS is a standardized nursing vocabulary that addresses the perioperative patient experience from preadmission through discharge It is the first, and to date the only, nursing language developed by a specialty organization that has been recognized by the ANA as a data set useful for perioperative nursing practice http://www.aorn.org/research/pnds.htm MULTIDISCIPLINARY TERMINOLOGIES PURPOSE ABC (Alternative Billing Codes) ABC defines 5-character alphabetic symbols to represent thousands of integrative healthcare products and services The codes reflect the care delivered by acupuncturists, behavioral health-care workers, chiropractors, medical doctors, massage therapists, mental health–care practitioners, midwives, nurses, nutritionists, etc http://www.abccodes.com/ali/abc_codes/ LOINC (Logical Observation Identifiers Names and Codes) The purpose of the LOINC database is to facilitate the exchange of laboratory and diagnostic results, generated by vendor systems, with other clinical information systems LOINC creates the translation so that other systems can understand and file the data LOINC data are used by practitioners for clinical care, outcomes management, and research http://www.regenstrief.org/loinc/ SNOMED-CT (Systemic Nomenclature of Medicine Clinical Terms) SNOMED-CT consists of health-care concepts, with unique meanings and formal logicbased definitions, that are organized into hierarchies The number of terms and attributes presently enables approximately 1.5 million relationships to be defined in order to support a robust and discrete terminology system SNOMED-CT can also be mapped to other medical terminologies and classification systems already in use http://www.snomed.org/ The NMDS identifies a limited set of data elements that should be collected for every patient These elements are clearly defined and serve as a foundation for further data collection Fortunately, these data elements are generally collected by most electronic medical record systems Data elements are the most basic pieces of information to be collected, and each element must have a unique definition in order to ensure clear and consistent meaning This process is not inconsequential For example, “blood pressure” is a term often assumed to be understood The term, taken alone, can have various meanings relative to the context of the user: a physical therapist may think of blood pressure in terms of pre- or postexercise; a neuronscience practitioner may think in terms of the position of the client at the time of measurement; the nurse clinician may evaluate blood pressure in the context of pre- or postprocedure It becomes obvious just how critical it is to have a clear, discrete, nonambiguous definition of each data element: “Common data standards are essential to simplify and streamline data requirements and allow the information systems that carry the data to function as an integrated whole” (Institute of Medicine, 2004, p 132) ...09Jones Leadership( F)-ch 09 134 1/14/07 3:39 PM Page 134 Understanding Organizations TABLE 9-1 Comparing the Nursing Process and Nursing Informatics Standards of Practice NURSING PROCESS STANDARDS... international standardization of nursing ICNP includes nursing diagnoses, nursing interventions, and outcomes http://www.icn.ch/icnp.htm NANDA (North American Nursing Diagnosis Association) NANDA provides... defining how documents and information models should be structured Terminologies, which identify and define the terms and concepts used to classify and code data elements and establish relationships