Nursing Information Systems

Nursing Information Systems

• Support the use and documentation of nursing processes
• Provide tools for managing nursing care delivery
• Accomplish two main goals

Goals of Nursing Information Systems

• Systems should support nurses' functions and flexibility to access and view data
• Facilitates collecting needed information to provide quality care
• Aids in documenting client conditions and given care
• Supports and enhances nursing practice through improved access to information tools

Advantages of Using Nursing Information Systems

• Increased time spent directly with clients
• Better access to necessary information
• Improved quality of documentation
• Enhanced quality of client care
• Increased nursing productivity
• Better communication among staff
• Fewer errors of omission
• Reduction in medication errors
• Lowered hospital costs
• Increased nurse job satisfaction
• Improved compliance with healthcare regulations
• Development of common clinical databases
• Enhanced client perception of care
• Improved ability to accurately track client records
• Enhanced ability to recruit and maintain nursing staff
• Improved overall hospital image

Clinical Nursing Documentation

• Is essential to the healthcare delivery system
• A wealth of information exists within the documentation
• Information technologies can transform clinical documentation

Clinical Documentation's Role

• Integrating multidisciplinary tools may improve clinical outcomes
• May improve the healthcare environment overall
• Documentation, as evidence, represents: interactions among the healthcare team, administration of assessments, tests, procedures, treatments, education, results of patient responses, and patient interaction outcomes within the care plan

Documentation - Advantages of Automation

• Improved standards compliance
• Increased overall efficiency
• Enhanced timeliness of information
• Expanded information accessibility
• Augmented data archives

Documentation - Approaches

• Document types
• Documentation styles
• Combinations of types and styles

Popular Documentation Approaches

• Charting by exception focuses on documenting deviations from established standards or norms
• Narrative documentation involves writing detailed descriptions of a patient's condition and care
• Flow sheets are used for routine aspects of care like bathing and glucose measurements
• Source of Origination - documentation is categorized by the source, such as laboratory or respiratory therapy
• Problem-oriented documentation organizes information around a patient's specific problems
• Focus charting centers on a specific focus, such as a patient concern or a significant event
• Care plans outline the goals and interventions for a patient's care
• Critical pathways, protocols, and collaborative problems

Guiding Principles for Clinical Documentation Systems

• Building a coherent patient story
• Promoting interdisciplinary collaboration
• Supporting integrated scopes of practice
• Providing evidence-based information at the point of care

Two Approaches to Nursing Care and Documentation Using Automated Systems

• Traditional Nursing Process Approach uses well-established formats like admission assessments and care plans
• Critical Pathways Approach uses guidelines for multidisciplinary care and documentation

Traditional Nursing Process Approach

• This approach is based on paper forms
• Nursing diagnosis often serves as the organizational framework
• Systems following this format document assessment, discharge instructions, generate worklists for scheduled activities, and document discrete data like vital signs and measurements

Critical Pathways Approach

• This approach involves multidisciplinary collaborators
• All healthcare disciplines use this documentation system
• Features include; selecting appropriate care pathways, interaction with physician order and tracking protocol variances

Areas To Address In Health Information Systems

• Source data capture
• Nursing data standards
• Decision support systems

Data Capture: In Context

• Gathering data and information about patients where it originates, with the patient
• Mid-1980's saw the introduction of terminals by the bedside

Nursing-Generated Assessment Data - The Point

• Computer data entry must be able to occur "at Point of Care".
• The concept gains industry acceptance with bedside terminals

Goals for Moving to Point of Care Systems

• The move aims to: minimize documentation time, eliminate redundancies and inaccuracies, improve data timeliness and communication, optimize information access and provide clinicians with required information for care decisions

Point of Care Devices

• Stationary Terminals using standard keyboards and monitors at the bedside
• Special Purpose Terminals - small footprint terminals fixed at the bedside with special function keys for data input, systems used in critical care settings
• There are handheld portable terminals not restricted to any location

Source Data Capture Technologies

• Optical Character Recognition (OCR) converts scanned documents into digital text
• Intelligent Character Recognition (ICR) recognizes handwritten text
• Magnetic Ink Character Recognition (MICR) reads characters on checks and bank documents
• Barcode Scanners reads barcode data on labels
• Data Capture Cards captures data on physical forms
• Point of Care Devices (POC) provides quick diagnostic results

Data Capture Criteria

• Enables nurses to interact with main patient databases and care planning systems at the bedside, home and hospital
• Interacts with existing hospital information systems and regional EHRs
• Compact size that does not interfere with patient care
• Rugged and durable
• Constructed to be disinfected between patients
• Features easy to use, uncomplicated design
• High-resolution screens readable in dark environments
• Provides data entry (e.g., bar code reader, physiological probe)
• Maximizes nurse mobility to enter data at the point of care

Nursing Data Standards: In Context

• Nurses unconsciously use mental processes and systemize information by grouping common features
• The lack of a common system or communication language creates a problem
• Absence of universally accepted methods for defining and collecting nursing data make collection difficult

Nursing Data - Development And Usage

• Integration is a key consideration as developments converge
• The issues that emerge include: promoting use, educating users for data quality, and establishing review and revision mechanisms

Decision Support Systems Considerations

• Decision support system confusion and lack of clarity is prevalent in nursing literature
• Broad Definition - Computerized decision support systems include computer software employing a knowledge base for patient care

Nursing Decision Support Systems (DSS/CDS)

• Direct aids to clinical decision-making
• They are NOT to be confused with Most care planning systems
• Helps nurses maintain and maximize decision-making responsibilities
• Enables prioritization of patient care aspects
• A true decision support system collects assessments at the bedside with source data capture technology and allows computer analysis to recommend nursing diagnoses

Decision Support System - uses:

• Alerting – notifies of a prompt action or decision
• Interpretation – interpret data to assist in decision-making
• Assisting – simplifies computer interactions
• Critiquing – analysis is in the research stage
• Diagnosing – uses data for suggested diagnoses
• Managing – generates a plan of care

Importance of Electronic Patient Records (EPR)

• Documentation must meet requirements, fulfilling a standard of care
• Electronic Patient Records (EPR) are a main communication tool

Application to Community Based Clinical Practice

Community-Based Care

• The fastest-growing healthcare segment
• Involves health promotion and illness prevention
• Requires maintaining surveillance programs
• Informatics plays an integral role

Functions of an Automated System

• Help with patient appointment scheduling to minimize waiting times and smooth clinic load, using carefully defined clinical guidelines
• Maintain the patient registry
• Determine service payment
• Establish billing procedures
• Maintain security
• Guarantee privacy and guarantee confidentiality

The Definition of Telehealth

• Telehealth uses communication and information technology for remote healthcare services

Telehealth

• Born of converged information tech/ telecommunications
• Born of healthcare and medical technology

Factors Influencing Telehealth Growth

• Aging Population needing remote care
• Cost Containment is a driver for efficiency through Telehealth
• Access to healthcare is expanded remotely
• Technology advancements make Telehealth possible
• Increased Demand from patients wanting remote options
• Information Explosion of medical information drives need

Nursing Telepractice

• Nursing specific application of telehealth
• Client centered nursing practices are facilitated remotely using information technology.

Components of Telehealth

• Input component to capture patient data via audio, images, and data
• Throughput component with communication and network technology to deliver content
• Output component using receiving, storing and displaying content on devices like monitors

TeleAssisted Care Services

• Wound management
• Oncology patient monitoring
• Electronic home visits

Challenges for Telehealth

• Obsolescence with how quickly tech changes
• Access to broadband
• Health info infrastructure hurdles
• Provider reimbursement models still evolving
• Interdisciplinary and Interinstitutional collaboration needed
• Collaboration amongst providers/facilities
• Document standards across platforms
• Security standards to protect patient information
• Liability insurance and liability coverage

Application of Technology in Education:

Educational Technology - Computer Usage

• Electronic devices facilitating learning
• Computers provide educational instruction
• Focus on subdivisions of CAI, Including CAI/CMI

Computer-Assisted Instruction (CAI)

• CAI enhances computer literacy
• CAI facilitates in decision making
• CAI reduces anxiety
• CAI positively affects achievement

CAI - Advantages

• Improves reading habits
• Accessibility
• Convenience
• Reduces learning time
• Increased retention
• Around the clock access
• Consistent safe instruction

Effectiveness CAI Variables

• Quality of Software
• Computer Use Environment
• Learner Characteristics

Negative Attitudes Toward CAI

• Poor Design is unattractive and ineffective
• No feedback for incorrect answers

Causes of Negative Attitudes Toward CAI

• Lack of Control for Learners
• Absence of Intellectual Stimulation

Multimedia

• Encompasses varied communication that allows interaction

Multimedia

• Can also combine text, voice, sounds, images, and video
• Implies technologies extend beyond a single computer to connect on a broad scale

Multimedia Goal

• There are two primary goals, including: information gathering and learning activities

Multimedia programs - information gathering

• Provide users with controlled access to the data

Multimedia programs - Learning activities

• Generating learning based on exercise and skill

Information Gathering Program Options

• Hypermedia/hypertext: highlighted text links definitions and multimedia
• Multimedia books: electronic versions of textbooks
• Multimedia Databases: records and fields

Active Learning - Learning Activities Programs

• Classic computer assisted instructions (CAI) are a category
• Simulations give type of same type of experience to provide type of experience of patients
• Practice increases skills by use of repetition
• Problem solving presents the problem and provides resources

Teleconferencing

• Remote communication via devices
• Learners interact remotely

Distance Learning

• Students and Instructors in multiple locations
• Synchronous/Asynchronous

Options for Web Based learning

• Increased popularity
• Shares learning advantages of CAI
• Requires a consideration of institutional infrastructure and course management

Online Instruction Issues

• There a few issues to address: institutional, Tech and course tools for online material

AI

• There are a few AI options: ChatGPT and Deepseek
• Artificial intelligence is a set of technologies that enable computers to perform advanced functions like understanding language and making recommendations

Importance of Computer labs

• A feature used for for instruction in schools

Computer Labs - Types

• Public, Limited and Classrooms are top 3

Considerations with Worldware

• Some software and software may be educative, and used without educational value

Software, Examples of such:

• There are: world processing, E-mail and internet

Nursing: ICNP Definition

• ICNP (International Classification for Nursing Practice) navigation

Multimedia tech, and limitations

• There are some limitations: costs, professional concerns and technology complexities in computing environments

Research application:

Nursing Research

• The nursing research includes: Reviews and literacy assessments

Literature

• It is included as abstracts

Database

• It is found in over 1500 books, journals that is now available for libraries or individual subscriptions

In Data Collecting:

• Using computer technology with patients helps facts that are manageable.

Data Collecting - Web:

• It is very important for management to have direct input

Interviewing:

AI and Methods to collect:

• The system is useable for online collection

Computer assisted

• It should be used with all assessment in study/surveys.

Computer-assisted collection (CATI)

• When CATI is employed. The answer are recorded.

Process, considerations for collection (CAPI)

• Laptop is needed for this process.

How does it impact the collection process? (Interview):

• It makes it effective during data recollection

Advantages of such

• Automated , data results, responses are automated

Data is managed by

• Data is extracted into data sheets

DATA, what and how

• Data has rules that lead to the following, pattern findings and data quantities

DATA is used for

• Used for patients that are risk through data extraction