Nursing Informatics
Introduction
This page is to assist the student nurse to become more
familiar with the array of technological advances that assist nursing to
provide high quality, evidence based care. This is to serve only as an
introduction, and the student is expected to utilize the suggested resources to
further their knowledge base. Healthcare facilities vary in the amount of
technology, and the type of technology that is utilized. You must become
familiar with the policies, procedures, and protocols that are being utilized
at the facility in which you are practicing.
Computer Systems
in Healthcare
Nurses utilize computers in various aspects of patient care.
Patient data will be input into computer systems, and this data will be
retrieved by various disciplines at various times to provide patient care.
Computer systems interface between various departments and systems so that
patient care will be provided in a transparent, seamless manner. In most
healthcare facilities, digital imaging will be available at the point of care
in an expeditious manner. Paper records and printing of data will continue to
be minimized in all aspects of healthcare.
Nursing
Informatics
Defined by the American Nurses Association (ANA, 2008) as a
specialty that “integrates nursing science, computer science, and information
science, to manage, communicate, and expand data, information, knowledge, and
wisdom of nursing practice. Nursing informatics facilitates the integration of
data, information and knowledge to support patients, nurses, and other
providers in their decision-making in all roles and settings. This support is
accompanied through the use of information structures, information processes,
and information electronic technology.” Most healthcare facilities have nursing
informatics departments, and nursing informatics is an up and growing specialty
that nurses should consider when they are pursuing furthering their education
Electronic
Documentation and Patient Education:
Many hospitals have either implemented, are in the process
of implementing, or are planning to implement electronic documentation. This
documentation has many different facets, which include but is not limited to:
electronic ordering, electronic assessments, electronic retrieval of results,
electronic progress notes and the electronic documentation of patient/family
education. Many hospitals have electronic patient/family education systems,
whereby handouts can be printed to assist in the teaching. This provides the
patients and their families with evidence based, up to date education, as well
as medication information. These electronically generated forms allow for more
seamless, legible documentation of multidisciplinary care. Most systems also
have reminders, as well as hard stops to assist in ascertaining complete and
thorough documentation.
Computerized
Physician Order Entry (CPOE)
Many hospitals have already or will be implementing
Computerized Physician Order Entry (CPOE). This system allows physicians and/or
healthcare providers to directly enter orders for patient care into the
hospital’s information system. This information system interfaces with other
departments (ie. pharmacy, laboratory, radiology, rehabilitation, nutrition,
etc…). These orders are transmitted efficiently and reduces errors related to
handwriting, or delays in transcription. Depending upon the system being
utilized, these orders might be entered remotely. Most systems have features
that allow for allergy checking, interaction checking, duplication checks, as well
as helping to avoid adverse drug reactions. The major incentive for the
implementation of these systems is the enhanced patient safety that they offer,
with the reduction of adverse events.
Computerized
Medication Administration, Bar Coded Medication Administration:
There are multiple ways that computers are utilized for
medication administration. In their simplest form, they are used to ascertain
information about a medication prior to administering it. Medication orders
might be handwritten and/or faxed to the pharmacy or they might be generated
via a computer system. In some institutions, computers are utilized for the
documentation of administered medications. In other institutions, computers are
utilized in conjunction with bar code scanners to ensure the five rights of the
medication administration process. Barcode scanning allows for “real time”
documentation, as well as assisting in the prevention of adverse drug
reactions. Prescriptions for outpatients might be computer generated, or they
might be e-scribed directly to the patient’s pharmacy if the services are
available.
Simulation Use in
Nursing
Some of your clinical experience will be completed with the
use of simulation. This might occur in the nursing lab, or at a more
sophisticated, simulation lab which utilizes higher levels of technology. The
simulation experience’s goal is to create a realistic environment, where you as
the student can perform techniques and plan care without live human
interaction. For the simulation experience to be successful, you must come
prepared, and interact with the simulator as if it were a real patient. This
simulation experience will help to prepare you to provide high quality, safe
care to your patients, while allowing you to learn evidence based care within a
non-threatening environment. Because of the sophistication of the system, as
well as the expense of such systems, there are many rules that need to be
followed, when using a simulation lab. Please know these rules and adhere to
them
Legal and Ethical Issues:
Whether the medical record is on paper or electronic,
extreme measures must be taken to secure all patient information. This includes
security access sign-on’s, and passwords. Passwords are required to be changed
on a regular schedule. Some institutions will give students individualized
sign-on’s, whereas others will only allow access to the instructor. Sign-on’s
and passwords are never shared, and computers are never left unattended while a
system is accessed. The reading of a patient’s medical record must only be done
by those that have a clear, distinct, reason to do so. Hospitals randomly
monitor the accessing of patient’s medical records. If any patient information
is printed, it also must be secured. Discussions about patients must be limited
to clinical reasons and never for personal reasons. These discussions never
should occur in public places. This includes discussions via social media.
Every effort must be made to protect the privacy of patients, and any violation
of this has legal and ethical implications that would result in disciplinary
actions. Computers and the programs on them are the property of the
institution, and tampering with them, or changing them in any way is not
allowed.
Additional
resources
Alliance for Nursing Informatics
http://www.allianceni.org
American College of Medical Informatics
www.amia.org
American Nurses Association
American Nursing Informatics Association
https://www.ania.org/
Alliance for Nursing Informatics
http://www.allianceni.org
American College of Medical Informatics
www.amia.org
American Nurses Association
American Nursing Informatics Association
https://www.ania.org/
Health information and management
http://www.ahima.org
http://www.ahima.org
HHS Health Information Technology
http://healthit.hhs.gov
International Medical Informatics Association
http://healthit.hhs.gov
International Medical Informatics Association
The TIGER Initiative: Technology Informatics Guiding Education Reform