Healthcare Policy & Nursing Informatics

• Informatics professionals who want to practice effectively in today's changing healthcare environment need to be aware of existing and proposed healthcare policy.
• Policy is defined as a course of action that guides present and future decisions.

Healthcare Policy

• Healthcare policy is established on local, state, and national levels to guide the implementation of solutions for the population's health needs.
• Nurses have contributed to the purchased, design, and implementation of IS since the 1970s.
• The American Nurses Association (ANA) recognized NI as a specialty in 1992.
• To be acknowledged as a specialty within nursing, informatics had to demonstrate a differentiated practice base, identify the existence of educational programs in the field, and develop a research agenda.

Definition of Nursing Informatics

• Nursing Informatics was defined as the combination of nursing information and computer sciences to manage and process nursing data into information and knowledge for use in nursing practice.
• Nursing Informatics is now described more broadly as a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice.

Differentiated and Interdisciplinary Practice

• Nursing Informatics brings an added dimension to nursing practice that focuses on knowledge and skill in information management techniques.
• Nursing Informatics practice differentiates itself from other areas of nursing practice but emphasizes its interaction with informatics disciplines such as mathematics, statistics, linguistics, engineering, computer science, and health informatics.

Nursing Shortage and Nursing Informatics

• Nursing has experienced a number of shortages in recent history due to an older nursing workforce, a higher ratio of older associate degree graduates, more attractive career opportunities for women, and decreased interest in nursing as a career due to difficult work environments.
• The nursing shortage is projected to rise from 6% in 2000 to 29% in 2020, potentially leaving more than 800,000 nurses short of the required number if no action is taken.
• As phase 2 of the AAN technology project began with the Bureau of Labor Statistics, staff nurses from three hospitals in Virginia and California were asked to identify or verify the most difficult aspects of their practice and how technology could improve those tasks.
• Systems will be designed, implemented, and tested to determine their effect on nurses' work as the project continues.
• NI specialists are required to help design and implement IT systems that will assist nurses in their practice and to validate the results through research.

National Health Information Infrastructure (NHII)

• The National Health Information Infrastructure (NHII) is a national initiative that will impact NI.
• The NHII is a voluntary initiative involving a three-stage process over 10 years, intended to improve the effectiveness, efficiency, and overall quality of health and healthcare in the United States.

Health Insurance Portability and Accountability Act (HIPAA)

• HIPAA was passed in 1996 and intends to improve public and private health programs by establishing standards to facilitate the efficient transmission of electronic health information.
• HIPAA preempts state law and payer-specific variations of data standards while mandating input from private, standard-setting organizations.
• HIPAA has a significant impact on informatics, IT must be designed to comply with Title II of the act.

Role of Technology in Medication Use Process

• The healthcare industry involves numerous steps, making it an inherently error-prone process where mistakes can occur often.
• This concept was confirmed in the 1999 Institute of Medicine (IOM) report, "To Err is Human: Building a Safer Health".

Computerized Prescriber Order Entry (CPOE)

• Illegible handwriting on medication orders has been shown to be a common cause of prescribing errors, which resulted in patient injury and death.
• The use of a CPOE system can potentially alleviate many problems by defining 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.

Influences on the Adoption of Technology

• Consumers have become increasingly concerned that hospitals are less than safe due to mass media reporting of medical mistakes, which have resulted in patient harm and deaths.
• According to a 1992 AMA report, medication errors related to the misinterpretation of physician's prescriptions were the second most prevalent and expensive claim listed on malpractice cases filed over 7 years on 1992.

Bar Code-Enabled Point-of-Care Technology

• Bar code technology has clearly demonstrated its power to improve productivity and accuracy in the identification of products in various business settings for over 20 years.

New Types of Medication Errors

• Extra dose
• Wrong drug
• Wrong dose
• Omissions
• Unauthorized drug
• Charting errors
• Wrong dosage form

Automated Dispensing Cabinets

• The ADC is a computerized point-of-use medication-management system designed to replace or support the traditional unit-dose drug delivery system.
• Many healthcare facilities have replaced medication carts or open unit-stock systems with ADCs.
• The rationales behind the wide acceptance of ADCs include improving pharmacy productivity, improving nursing productivity, reducing costs, enhancing patient quality and safety, and improving charge capture.

Smart Infusion Pump Delivery System

• Infusion pumps with dose calculation software, sometimes referred to as "smart pumps", reduce medication errors, improve workflow, and provide a new data source for continuous quality improvement by identifying and correcting pump-programming errors.

Healthcare Data Standards

• Standards are critical components in the development and implementation of an electronic health record (HER).
• The effectiveness of healthcare delivery depends on the ability of clinicians to access critical health information when and where needed.
• Data standards as applied to healthcare include terminologies, methods, exchange, protocols, specification for the collection, and storage.

International Statistical Classification of Diseases

• The latest version of a mortality and morbidity classification originated in 1893.
• It is widely accepted, used in the healthcare industry, and has been adopted for various purposes, including data collection, quality of care analysis, resource utilization, and statistical reporting.
• The 10th revision is the most recent revision of the ICD classification system for mortality and morbidity and is used worldwide.

Current Procedural Terminology

• This is a listing of descriptive terms and codes for reporting medical services and procedures.
• In addition to descriptive terms and codes, it contains modifiers, notes, and guidelines to facilitate correct usage.

Systematized Nomenclature of Human Veterinary Medicine International, Clinical Terms (SNOMED)

• A comprehensive multiracial nomenclature and classification system for indexing human and veterinary medical vocabulary, including signs and symptoms, diagnoses, and procedures.

LOINC (Logical Observation Identifiers Names and Codes)

• Provide a set of universal names and numeric identifier codes for laboratory and clinical observations and measurements in a database structure.
• Represents laboratory data in terms of names for tests and clinical observations.
• Consistency in terminology is important for patient safety.

RxNorm

• Is a clinical drug nomenclature produced by NLM in consultation with the FDA and VA.
• RxNorm provides standard names for clinical drugs (active ingredient+strength+dose form) and for those forms as administered.
• It provides links from clinical drugs to their active ingredients, drug components (active ingredients+strength), and some related brand names.

Unified Medical Language System (UMLS)

• Consists of a metathesaurus of terms and concepts from dozens of vocabularies.
• It contains a semantic network of relationships among the concepts recognized in the metathesaurus and an information source map of the various biomedical databases referenced.

National Uniform Claim Committee Recommended Data Set for Noninstitutional Claim

• Promotes and maintains a standard data set for the use of noninstitutional claims and encounter information.

Integrating the Healthcare Enterprise (IHE)

• This is an initiative that provides a detailed framework for implementing standards and their implementation.
• Combining the strength of these initiatives and their approaches tends to minimize their weaknesses and can lead to significant gains for the healthcare sector as a whole.

International Organization of Standardization (ISO)

• This organization develops and publishes standards internationally.
• This standard includes the development of reference terminology models for nursing diagnoses, nursing actions, and relevant terminology and definitions for its implementation.

American National Standard Institute (ANSI)

• ANSI serves as the coordinator for voluntary standards activity in the U.S.
• OMG is representative of different approaches to standard development.
• OMG is an international consortium of over 800 organizations, primarily for-profit vendors of information system technology, interested in the development of standards based on object-oriented technologies.

National Committee on Vital and Health Statistics Subcommittees on Standards and Security

• This workgroup develops recommendations based on public hearings and input from input stake holders and domain experts.

Electronic Health Record (EHR) Federal Initiatives

• In April 2004, the president of the United States issued an executive order for action to put EHRs in place for most Americans in 10 years.
• There is a growing consensus that EHR systems can meet clinical needs in healthcare by capturing, storing, and displaying clinical information to improve treatment and provide aggregate cross-patient data analysis.

Electronic Health Record Systems

• Are the set of components that form the mechanism by which patient records are created, used, stored, and retrieved, and include people, data, rules, and procedures, processing, and storage devices.
• Consists of a longitudinal collection of electronic health information for and about persons, where healthcare is provided to an individual.

Department of Veterans Affairs

• The Veterans Health Information Systems and Technology Architecture support day-to-day clinical and administrative operations at local VA healthcare facilities.
• The Computerized Patient Record System is a new interface that provides healthcare providers a single place to review and update a patient's health record and order medications, special procedures, x-rays, nursing orders, diets, and laboratory tests.

Department of Defense

• Providers have had a computerized physician order entry capability to order lab tests, radiology examinations, and issue prescriptions electronically for over 10 years.
• The DoD Pharmacy Data Transaction Service links military treatment facilities, mail-order pharmacies, and network pharmacies, enabling providers at all military and civilian pharmacies to track medication transactions and to check for drug allergies and drug interactions.

Indian Health Service

• The IHS has been a pioneer in using computer technology to capture clinical and public health data.
• Its Resource and Patient Management Systems was developed in the 1970s, and many facilities have access to decades of personal health information and epidemiologic data on local populations.

Office of the National Coordinator for Health Information Technology

• Created by the executive order of April 2004 to coordinate HIT efforts in the federal sector and to collaborate with the private sector in driving HIT adoption across the healthcare system.

The National Committee on Vital and Health Statistics

• Held a series of national hearings to develop a consensus vision of the National Health Information Infrastructure (NHII).
• In the resulting report, "Information for Health," the concept of an infrastructure that emphasizes health-oriented interactions and information-sharing among individuals and institutions, rather than simply physical, technical, and data systems that make those interaction possible.

Agency for Healthcare Research and Quality

• AHRQ funded demonstration grants to establish and implement interoperable health information systems and data sharing to improve the quality, safety, efficiency, and effectiveness of healthcare for patients and populations on a specific state or regional level.

Centers for Medicare and Medicaid Services

• CMS has initiated several pilot projects to promote health IT.

Public-Private Partnership

• Is focused on the use of EHR-Ss and HIT to improve care.
• Includes private sector organizations specifically formed to address issues of connectivity, HIT, and standards development.

Connecting for Health

• This is a large private collaborative with federal participants supported by the Markle and the Robert Wood Johnson Foundations that is addressing the barriers to developing an interconnected health information infrastructure.
• It brings together healthcare providers, payer organizations, HIT vendors, and representatives of federal and state agencies.

Health Initiative

• This is an independent, nonprofit affiliated organization that fosters improvement in healthcare quality, safety, and efficiency through information and IT.
• Its membership includes hospitals, other providers, practicing clinicians, community organizations, payers, employers, community-based organizations, HIT suppliers, manufacturers, and academic organizations.

Institute of Medicine

• Serves as an independent advisor to the nation with the goal of improving health, as the Institute of Medicine has championed the advantages of using IT to improve healthcare.

Certification Commission for Health Information Technology

• The Health Information and Management Systems (HIMSS), American Health Information Management Association (AHIMA), and National Alliance for Health Information Technology (NAHIT) have joined together to establish the (CCHIT).
• The goal of this group is to reduce the risk of EHR investment.

Health Level Seven

• This is an international, non-for-profit, volunteer standards organization known for its large body of work in producing technical specifications for the transfer of healthcare data.
• It is considered essential by informaticists and technical staff.

Dependable Systems for Quality Healthcare

• Healthcare is undergoing a transformation from an inefficient and costly care delivery model to a more efficient, consumer-centric, science-based model that proactively focuses on health management.
• Dependability includes system reliability, service availability, confidentiality, data integrity, responsiveness, and safety.

Attributes of Dependability

• System reliability: The system consistently behaves in the same way.
• Service availability: Required services are present and usable when they are needed.
• Confidentiality: Sensitive information is disclosed only to those authorized to see it.
• Data integrity: Data are not corrupted or destroyed.
• Responsiveness: The system responds to user input within an expected and acceptable time period.
• Safety: The system does not cause harm.
• All computer systems are vulnerable to human-created threats (malicious code attacks, software bugs) and natural threats (hardware aging, earthquakes).

Guidelines for Dependable Systems

• Guideline 1: Architect for dependability.
• Guideline 2: Anticipate failures.
• Guideline 3: Anticipate success.
• Guideline 4: Hire meticulous managers.
• Guideline 5: Don't be adventurous.

Nursing Minimum Data Set Systems

• Clinical nursing visibility is present from national to international contexts by implementing Nursing Minimum Data Set Systems.
• The identification of NMDS visionary work began in the united states in the 1980s by Werly and Lang (1988), which spurred activity extending to national efforts to develop similar data sets around the world and support an initiative to develop an international i-NMDS.
• The NMDS is a standardized approach that facilitates the abstraction of minimum, common, essential core data elements to describe nursing practice from both paper and electronic records.

Elements of NMDS

• Nursing care
• Patient demographics
• Service elements

Nursing Care Elements

• Nursing diagnosis
• Nursing intervention
• Nursing outcome
• Intensity of nursing care

Patient Demographic Elements

• Personal identification
• Date of birth
• Sex
• Race and ethnicity
• Residence

Eight Benefits of the NMDS

• Access to comparable, minimum nursing care, and resources data on local, regional, national, and international levels.
• Enhanced documentation of nursing care provided.
• Identification of trends related to patient or client problems and nursing care provided.
• Impetus to improved costing of nursing services.
• Improved data for quality assurance evaluation.
• Impetus to further development and refinement of NISs.
• Comparative research on nursing diagnoses, nursing interventions, nursing outcomes, intensity of nursing care, and referral for further nursing services.
• Contribution toward advancing nursing as a research-based discipline.

Standard Nursing Terminologies Recognized by ANA in 2004

• ABC codes
• Clinical Care Classification (CCC)
• Health Care Classification
• International Classification for Nursing Practice (ICNP)
• Logical Observation Identifiers Names and Codes (LOINC)
• NANDA-Nursing Diagnoses: Definitions & Classification
• Nursing Outcomes Classification (NOC)
• Nursing Interventions Classification (NIC)
• Omaha System
• Patient Care Data Set (PCDS)
• Perioperative Nursing Data Set (PNDS)
• The ANA has recognized 11 languages and two data sets as standard nursing terminologies.
• A list of 11 languages have been recognized by ANA 2004 and two data sets

Data Sets

• Nursing Minimum Data Set (NMDS)
• Nursing Management Minimum Data Set (NMMDS)
• The NMDS serves as a key component of the standards developed by the nursing information & data set evaluation center(NIDSEC).
• The NIDSEC develops and disseminates standards related to nomenclature, clinical associations, clinical data repositories, and system characteristics/decision support/contextual variables pertaining to data sets in information systems that support the documentation of nursing practice.

NMDS and Data Elements

• Environment:
  • Unit/cost center identifier
  • Type
  • Patient/client population
  • Volume
  • Accreditation
  • Organizational decision making power
  • Environmental complexity
  • Patient/client accessibility
• Method of care delivery
• Clinical decision-making complexity
• Nursing care:
  • Management demographic profile
  • Staffing
  • Staff demographic profile staff satisfaction
• Financial resources:
  • Payer type reimbursement
  • Budget
  • Expense

NMDS Relationship to International Nursing Minimum Data Set (i-NMDS)

• The i-NMDS includes core internationally relevant, essential, and minimum data elements to be collected for providing nursing care.
• These data can provide information to describe, compare, and examine nursing practice around the globe.
• The i-NMDS is intended to build on the efforts already underway in individual countries, and it is imperative that the national healthcare infrastructure supports the collection and reuse of nursing data.

Purposes of Nursing Care

• Describing the human phenomena, nursing interventions, 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
• Testing evidence-based practice improvements
• Addressing the nursing shortage, inadequate working conditions, poor distribution and inappropriate utilization of nursing personnel, and the challenges as well as opportunities of global technological innovations.
• Empowering the public internationally.