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09Jones Leadership(F)-ch 09 1/14/07 3:39 PM Page 143 Informatics ■ ■ ■ ■ Legibility of handwriting and ready identification of the authors of documentation are fully supported in an EMR system Error reduction is achieved because drug dosages are clearly written and documentation standards, such as the use of leading zeros preceding decimals, are ensured Clinical alerts, such as drug-drug and drugallergy interactions, provided to the physician at the time an order is entered in the EMR save pharmacists and nurses time clarifying orders and enable the appropriate medication intervention to reach the patient more quickly Nurses receive allergy interaction information at the time of medication administration Positive patient identification systems, such as bedside bar-code scanning of patient wristbands, medications, and the medication administration record, can support consistent and clear verification of the five patient rights and can help to avoid medication errors Effective care can be supported by access to evidence-based practice databases and up-to-date protocols, helping to make sure that patients are receiving care based on the most recent scientific information Presenting the most recent evidence to practitioners can be achieved by clinical decision support systems that offer recommendations or that suggest treatment modalities based upon the clinical condition and clinical data of the patient Effectiveness can be further supported through data-mining (retrieval of selected clinical data from the EMR); for example, some systems analyze the response of patients with similar clinical presentations and diagnoses to specific clinical interventions EMR systems can also offer reminders to clinicians regarding best-practice recommendations for laboratory testing, such as monitoring therapeutic blood levels of an antibiotic or anticoagulant Preventive care screening recommendations, such as annual mammograms or initial colonoscopy for patients who have reached the age of 50, are another example of assuring that patients receive timely interventions Patient-centered care is enhanced as documentation by various practice disciplines, such as physicians, nurses, therapists, and pharmacists, is integrated, and practice silos are diminished or eliminated For example, EMR sys- 143 tems support patient-focused problem lists, interdisciplinary communication through integration of documentation entries, and elimination of redundant documentation through presentation of previously documented data when and where they are needed in data screens Computer Hardware Computer technology is changing rapidly, and the half-life of what is considered to be a sophisticated computer has become very short Within that context, this section will briefly discuss the components of a computer Perhaps the place to begin is to clarify that hardware refers to all of the physical Practice to Strive For 9-1 The data collected, stored, and retrieved from the EMR comprise an important key to the future of nursing and the care delivered to patients However, data depend on the value and respect individual practitioners have for what the data represent for the patients for whom they care Nurses need to embrace accurate, complete, and real-time documentation This documentation will enable them and their peers and colleagues to make effective decisions for their patients This documentation will also serve as the database for research and quality improvement efforts that will guide the development of new evidence on which to base practice Nurses need to become involved in the design, development, and feedback of the EMR systems in their hospitals They need to develop an understanding of the design and underlying care philosophies that are used as guideposts in the design of the EMR Nurses need to articulate their workflow needs in order to influence the design of documentation and related policies so that they are realistic Nurses need to advocate for collection of baseline data prior to implementation of major new functionality so that nursing will be able to measure the changes that result from the new documentation processes and workflow Nurses need to support their peers and reinforce the benefits of electronic documentation systems Nurses must become involved; through involvement they participate in shaping their future, rather than respond to what others think the future should be The data nurses choose to collect and the accuracy of those data will significantly influence how nursing is able to articulate the contribution of nursing care to patient outcomes 09Jones Leadership(F)-ch 09 144 1/14/07 3:39 PM Page 144 Understanding Organizations components of the computer This hardware is often classified as processing components, memory, and input and output devices Familiarity with these terms can diminish some of the mystery of computers for those who are not accustomed to using them or their component parts PROCESSING COMPONENTS The central processing unit (CPU) is the brain of the computer Think of the CPU as the control center, directing the flow of information while also interpreting, directing, and monitoring the execution of instructions received from memory The CPU is also responsible for arithmetic logic, the foundation of computer function The motherboard is another key element, providing the connective infrastructure of the computer The CPU, chips, hard drives, and disk drives are mounted on the motherboard, and the motherboard creates the internal organization and is the location for addition of new components An important feature of any computer is the speed at which the computer processes information Speed is usually described as clock speed, or the number of electric pulse cycles that occur in a defined period Hertz is the term used to measure clock speed, and hertz is cycle per second Megahertz (MHz) is million cycles per second, and gigahertz (GHz) is billion cycles per second INPUT AND OUTPUT DEVICES In order to work and accomplish tasks using the computer, input devices are necessary Input devices enable the user to enter data, such as numbers or words, that the computer then uses to perform computations based on commands that are also entered by input devices Another way of perceiving input devices is that they enable two-way communication between the user and the computer Commonly used input devices include the keyboard, mouse, and scanner; some computers support the use of light pens or touch-screens and other devices In most cases, a combination of input devices, such as the keyboard and mouse, is needed for entry of data and commands A means of extracting data from the computer is also necessary; output devices are required for this purpose Output devices include disks, CDs, flash drives, electronic transmission to another computer, and printers, to name the more commonly used devices MEMORY Computer memory consists of read-only memory (ROM), random access memory (RAM), and storage memory ROM is memory used only by the computer and is protected from alteration, including erasure, by the user The information stored in ROM supervises the overall function of the computer and enables certain computer functions, such as starting computer operation, often referred to as booting RAM is usually called the working memory of the computer, and it is RAM that supports the various applications used, such as spreadsheet and word processing Another term associated with RAM is volatile memory, a reference to the temporary nature of RAM storage Instructions needed to operate an application are retrieved from permanent storage, such as the hard drive, CD, or diskette, and used by RAM while the application is in use Because RAM loses the information stored in it each time the computer is turned off, any work completed using applications must be saved to permanent storage so that it can be retrieved later The files created and saved while working on the computer are placed in storage memory, sometimes called permanent memory The term permanent memory should not be misleading; the files stored in permanent memory reside there until such time as they are erased or overwritten by new files Hard disks, CDs, and diskettes are used to store files Another, more recent, innovation for file storage is the flash drive, also known as a thumb drive or memory stick These highly portable devices are available in ever increasing memory capacities (Saba & McCormick, 2006; Thede, 2003) COMPUTER POWER The way in which the computer works with and stores data is based on the binary system A bit is the smallest unit of storage in the computer It has two possible values, zero and one (0 and 1) If you think of the bit as an on-off switch, the “on” position is equal to 1, and the “off ” position is equal to Bits are combined in groups or units of eight bits, 09Jones Leadership(F)-ch 09 1/14/07 3:39 PM Page 145 Informatics TABLE 9-4 Computer Memory in Bytes PREFIX UNITS (# OF BYTES) NUMBER Kilobyte Megabyte Gigabyte Terabyte Petabyte Exabyte Zettabyte Yottabyte Thousand Million Billion Trillion Quadrillion Quintillion Sextillion Septillion 1,000 1,000,000 1,000,000,000 1,000,000,000,000 1,000,000,000,000,000 1,000,000,000,000,000,000 1,000,000,000,000,000,000,000 1,000,000,000,000,000,000,000,000 which are known as a byte A byte represents a single character, such as an M or the number (Saba & McCormick, 2006) The number of possible combinations of and in a byte is 255, and in the early days of computer technology 255 was the limit of the number of characters a computer could represent With the advent of newer technology, computers are able to express increasingly more characters and graphics, greatly expanding the flexibility for image and other visual displays One expression of power today is to indicate the number of bytes the computer can handle: Table 9-4 is a scale of the actual and theoretical storage capacity of computers; for example, at the time this chapter was written, the yottabyte was theoretical storage capacity Privacy and the Protection of Health-Care Data The Health Insurance Portability and Accountability Act (HIPAA) was enacted by Congress in 1996 to protect workers by limiting employer denial of health insurance coverage to employees with preexisting medical conditions Interestingly, because the act also directed the Department of Health and Human Services to develop privacy rules for health data contained in EMRs, HIPAA indirectly promoted significant impetus for development of a number of standards to support data transmission The privacy portion of this act, often referred to as the Privacy Rule, affects all health-care providers and health plans and specifically indicates that pro- 145 tected health information (PHI) may not be disclosed without the permission of the patient (Flores, 2005) HIPAA, although referred to as an act or government regulation, is more appropriately characterized as a process As the years have passed since the law was enacted in 1996, HIPAA has gradually become recognized as a significant source of change in the culture of health care The accountability for protection of PHI has resulted in a changed organizational focus that extends beyond the tenets of the original act For example, quality assurance data designed to monitor and improve patient safety often include PHI information to enhance and strengthen data analysis The need to assure that PHI is appropriately protected and that data are effectively de-identified has resulted from the evolving awareness of the need to respectfully protect information that could be traced back to individual patients The future challenge for the health-care industry will be to balance the need to protect the PHI with the contrasting advantages that could be gained for streamlined patient care as a result of access to medical record information For example, in the event of a widespread health emergency, access to personal medical record information would support creation of aggregate data pools or databases that would greatly speed understanding and insight into the problem and accelerate identification of preventive or treatment solutions Nurses have historically advocated for and protected patient privacy HIPAA supports and increases the accountability of the nurse, as a health-care provider, to protect the privacy of the patient There are personal measures that are deeply embedded in nurses’ daily practice to protect patient privacy For example, nurses can make certain that they protect the privacy of personal security passwords to information systems and refuse to share their passwords Experts advise against writing down passwords due to the risk of discovery by others All practitioners are responsible for all documentation made under their password, even if they did not make the entry This sobering fact offers a compelling rationale for not sharing passwords and assuring that they cannot be discovered by others Another example of protecting the privacy of the patient occurs when using the EMR By ensuring that each session is closed and logged out each time 09Jones Leadership(F)-ch 09 146 1/14/07 3:39 PM Page 146 Understanding Organizations one leaves the computer, the nurse is demonstrating respect for this important patient right Each of these measures is part of the overall strategy present in health-care organizations to honor and respect the trust relationship with patients All Good Things Nursing informatics is a new and important part of the nursing care arsenal Working in partnership with the other members of the team, informaticists help the team define the clinical, administrative, and research outcomes and how those outcomes can be supported with comprehensive clinical data Informaticists assist in creating an infrastructure that supports clear communication through the design of documentation consisting of nonredundant data elements with nonambiguous definitions Nurse informaticists guide nursing leadership through the selection of a terminology system that meets the clinical and strategic goals of nursing practice and supports patient care Nurse informaticists actively participate with clinical and information systems leadership in designing the strategic direction of the EMR system, ensuring the practice needs and imperatives of nursing are incorporated Nursing informaticists also communicate and interpret the role of nursing informatics to the nursing community Effective staff training in effective use of information systems is an ongoing focus of nurse informaticists An important facet of the role is translation of key accountabilities of practicing nurses as they use information systems and assisting the nursing community to perceive and understand the importance of its ongoing engagement and input to the work of nursing informaticists Let’s Talk Describe at least three situations or examples in which clinical decision support benefits patient care Discuss the value that a terminology system provides to nursing practice What are the drawbacks and limitations of terminology systems? How EMR systems that are designed using a terminology system differ from paper medical record documentation? Describe the role of a nursing informaticist Consider the educational preparation for such a role in your response HIPAA was discussed as a motivating factor for patient privacy concerns Discuss the ways in which patient privacy could be jeopardized in the health-care environment NCLEX Questions The Institute of Medicine (IOM) established six major aims for improving the health-care system in the 21st century One major goal is improving patient safety Identify two of the remaining goals A Increase numbers of nurses and increase efficiency B Enhance patient-centered focus and protect privacy C Improve effectiveness and reduce costs D Increase timeliness and enhance patientcentered focus Computers have several types of memory to support their function Which of the following options is not a type of memory? A Flash drive B ROM: read-only memory C RIM: read internal memory D RAM: random access memory Which of the following features is not an example of knowledge representation? A E-mail B Clinical practice guidelines C Systematic reviews of the literature D Clinical decision support Nursing terminology systems support nursing documentation in several important ways Identify the option that is least important in the benefits offered by terminology systems A Ensure the value and visibility of nursing in the medical record B Eliminate lengthy narrative notes C Support nursing research D Support quality assurance and improvement activities 09Jones Leadership(F)-ch 09 1/14/07 3:39 PM Page 147 Informatics Which response is the most accurate regarding the purpose of data standards for information systems? A Data collection and storage B Data retrieval and transmission C Both of the above D Neither of the above Standardized nursing terminology affords nursing a number of benefits The benefits include: A Increased medical record visibility of nursing contributions to patient care B A database that supports clinical research C The ability to implement clinical decision support D A and B E A, B, and C Nursing science serves as the foundation of nursing informatics The domain of informatics exists as the intersection of what other three sciences? A Communication, cognitive, and computer sciences B Information, programming, and communication sciences C Cognitive, computer, and information sciences D Computer, information, and communication sciences Protected health information (PHI) is individually identifiable health information Which of the following data elements is/are considered PHI data? A Name and address B Birth date C Telephone number D Social security number E A, B, and D F A, B, and C G A, B, C, and D Patient safety can be improved through the features of an EMR system by a number of means Which of the following are patient safety outcomes of an EMR? A Legibility of the data entered B Drug-allergy alerts at the time of medication administration C Costing of medications at the time of ordering D A and B E A, B, and C 147 10 Which of the following dimensions of computer hardware and function is/are not correct? A Hertz is the term used to represent the speed of the computer B Data are permanently stored in the hard drive or output device C A byte is eight bits D A byte represents eight characters E A and D F B and C REFERENCES ACS (The Accredited Standards Committee) (2003) ACS X12 Retrieved May 1, 2006, from http://www.x12.org/ x12org/subcommittees/sc_home.cfm?sendToϭPurposeAndSc ope%2Ecfm&doSetϭTRUE&CFIDϭ1748141&CFTOKENϭ 8624906 American Nurses Association (2001) Scope and standards of nursing informatics practice Washington, D.C.: American Nurses Publishing Flores, J.A (2005) HIPAA: Past, present and future implications for nurses Online Journal of Issues in Nursing, 10(2), 131–147 Graves, J.R., & Corcoran, S (1989) The study of nursing informatics Image: Journal of Nursing Scholarship, 21(4), 227–231 Henry, S.B., & Mead, C.N (1997) Nursing classification systems: Necessary but not sufficient for representing “what nurses do” for inclusion in computer-based patient record systems Journal of the American Medical Information Association, 4(3), 222–232 Institute of Medicine (2001) Crossing the quality chasm Washington, D.C.: National Academy Press Institute of Medicine (2004) Keeping patients safe: Transforming the work environment of nurses Washington, D.C.: National Academies Press Mayes, R (2001) Data standards In Saba, V.K., & McCormick, K.A (Eds.) Essentials of computers for nurses: Informatics for the new millennium (3rd ed., pp 167–176) New York: McGraw-Hill NIDSE—Nursing Information and Data Set Evaluation Retrieved May 3, 2006, from http://www.nursingworld.org/ nidsec/ Office of Civil Rights (May 2003) Summary of the HIPAA privacy rule Retrieved May 12, 2006, from http://www.hhs gov/ocr/privacysummary.pdf Royal College of Nursing (UK) (April 15, 2004) Defining nursing Retrieved May 5, 2006, from http://www.rcn.org uk/news/display.php?IDϭ448&areaϭPress Saba, V.K (2001) Historical perspectives of nursing and the computer In Saba, V.K., & McCormick, K.A (Eds.) Essentials of computers for nurses: Informatics for the new millennium (3rd ed., pp 9–45) New York: McGraw-Hill Saba, V.K., & McCormick, K.A (Eds.) (2006) Essentials of nursing informatics (4th ed.) New York: McGraw-Hill Sensmeier, J (2006) Healthcare Data Standards In Saba, V.K., & McCormick, K.A (Eds.) (2006) Essentials of nursing informatics (4th ed., pp 217–228) New York: McGraw-Hill  ... as they use information systems and assisting the nursing community to perceive and understand the importance of its ongoing engagement and input to the work of nursing informaticists Let’s Talk... data standards for information systems? A Data collection and storage B Data retrieval and transmission C Both of the above D Neither of the above Standardized nursing terminology affords nursing. .. with clinical and information systems leadership in designing the strategic direction of the EMR system, ensuring the practice needs and imperatives of nursing are incorporated Nursing informaticists