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Nursing Informatics

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/

Health information and management
http://www.ahima.org

HHS Health Information Technology 
http://healthit.hhs.gov

International Medical Informatics Association


The TIGER Initiative: Technology Informatics Guiding Education Reform