Nursing Informatics Lecture2010

NURSING INFORMATICSNURSING INFORMATICS

COMPUTER AND NURSINGCOMPUTER AND NURSING

Nurses are becoming computer Nurses are becoming computer literate and the nursing profession is literate and the nursing profession is implementing practice standards for implementing practice standards for its clinical care and data standards its clinical care and data standards for its nursing information technology for its nursing information technology systems.systems.

NI represents the transition of data NI represents the transition of data and data information and knowledge and data information and knowledge into action. NI represents the into action. NI represents the practice, administration, community practice, administration, community health, nursing education, and health, nursing education, and nursing research applications. nursing research applications.

It also addresses other new It also addresses other new applications such as international applications such as international aspects or peripheral to the field aspects or peripheral to the field such as legal, consumer issues, or such as legal, consumer issues, or theoretical issues. This new edition theoretical issues. This new edition also includes new content to also includes new content to demonstrate how IT supports nurses demonstrate how IT supports nurses to improve quality, ensure safety, to improve quality, ensure safety, measure outcomes, and determine measure outcomes, and determine costs.costs.

Nursing informatics is a defined by the Nursing informatics is a defined by the American Nurses Association (ANA, 2001) American Nurses Association (ANA, 2001)

A specialty that integrates nursing A specialty that integrates nursing science, computer science, and science, computer science, and information science to manage and information science to manage and communicate data, information, and communicate data, information, and knowledge in nursing practice. knowledge in nursing practice.

Nursing Informatics facilitates the Nursing Informatics facilitates the integration of data, information, and integration of data, information, and knowledge to support patients, knowledge to support patients, nurses, and other providers in their nurses, and other providers in their decision making in all roles and decision making in all roles and settings.settings.

This support is accomplished through This support is accomplished through the use information structures, the use information structures, information processes, and information processes, and information technology.information technology.

ISSUES IN INFORMATICSISSUES IN INFORMATICS

The issues involved in patient safety The issues involved in patient safety are described by experts form the are described by experts form the perspective of the role of the perspective of the role of the technology in the medication use technology in the medication use process. process.

This new chapter contributes to the This new chapter contributes to the growing interest of the nursing growing interest of the nursing profession in computerized patient profession in computerized patient order entry (CPOE) and bar coding.order entry (CPOE) and bar coding.

An important framework to An important framework to understand the issues in medication understand the issues in medication delivery is presented by these delivery is presented by these experts in the field. experts in the field.

INFORMATICS THEORYINFORMATICS THEORY The chapter of nursing informatics theory The chapter of nursing informatics theory

provides an update on theoretical overview of the provides an update on theoretical overview of the new nursing specialty. This chapter also provides new nursing specialty. This chapter also provides a brief description of all 13 terminologies for a brief description of all 13 terminologies for documenting nursing practice, recognized by the documenting nursing practice, recognized by the ANA. The chapter on concept-oriented nursing ANA. The chapter on concept-oriented nursing terminologies provides an excellent update and terminologies provides an excellent update and overview of the reference terminology model overview of the reference terminology model approved by the International Standard approved by the International Standard Organization (ISO) as one of the first standards Organization (ISO) as one of the first standards for a profession. This chapter also covers the for a profession. This chapter also covers the different definitions, models, and core concepts of different definitions, models, and core concepts of NI. In this chapter the authors describe the key NI. In this chapter the authors describe the key aspects of NI as it relates to the EHR.aspects of NI as it relates to the EHR.

ADMINISTRATIVE ADMINISTRATIVE APPLICATIONS APPLICATIONS

The chapter on administrative The chapter on administrative applications reinforces the applications reinforces the theoretical foundations of theoretical foundations of administrative applications in the administrative applications in the past decade, but updates the chapter past decade, but updates the chapter related to important workflow and related to important workflow and challenges, chances and choices challenges, chances and choices being made by nurse administrators. being made by nurse administrators.

CONSUMER USE OF CONSUMER USE OF INFORMATICSINFORMATICS

The new chapter provides an The new chapter provides an overview on the innovative use of the overview on the innovative use of the Internet by consumers and patients. Internet by consumers and patients. The communication between The communication between patients/consumers and healthcare patients/consumers and healthcare providers is discussed as a providers is discussed as a mechanism for facilitating consumer mechanism for facilitating consumer satisfaction. Issues related to satisfaction. Issues related to consumer use on the Internet are consumer use on the Internet are discussed.discussed.

An excellent theoretical framework An excellent theoretical framework and description of consumers making and description of consumers making decisions has been updated. New decisions has been updated. New references have been added to this references have been added to this chapter.chapter.

EDUCATIONAL APPLICATIONEDUCATIONAL APPLICATION

The chapter on nursing curriculum in The chapter on nursing curriculum in the information age provides an the information age provides an update of the educational update of the educational applications including curriculum applications including curriculum design. It provides an overview of design. It provides an overview of technology applications in nursing technology applications in nursing education and how they are education and how they are reshaping higher nursing education. reshaping higher nursing education.

The chapter describes the resources The chapter describes the resources needed to move the nursing needed to move the nursing curriculum and nursing education curriculum and nursing education into the information age. The author into the information age. The author describes the strategies used to describes the strategies used to integrate information and computer integrate information and computer technology into the nursing technology into the nursing curriculum. curriculum.

She indicates that information technology She indicates that information technology in education will cut across departments in education will cut across departments and disciplines and will facilitate and disciplines and will facilitate interactions and connectivity. Curriculum interactions and connectivity. Curriculum implications including faculty implications including faculty development, interactive learning, development, interactive learning, cognition, electronic communication, cognition, electronic communication, multimedia, and informatics are multimedia, and informatics are summarized and described as they relate summarized and described as they relate to the NI curriculum.to the NI curriculum.

RESEARCH APPLICATIONRESEARCH APPLICATION

The chapter on computer use in The chapter on computer use in nursing research provides an update nursing research provides an update and a new approach to research and a new approach to research applications. The authors focus on applications. The authors focus on the differences between quantitative the differences between quantitative and qualitative research. and qualitative research.

They provide an overview of They provide an overview of computer-based applications that computer-based applications that facilitate and support the steps of the facilitate and support the steps of the research process including data research process including data collection, data management and collection, data management and coding, data analysis, and results coding, data analysis, and results reporting. reporting.

They compare and contrast selected They compare and contrast selected computer software applications that computer software applications that are used including examples of are used including examples of specific applications that have been specific applications that have been used in quantitative and qualitative used in quantitative and qualitative research studies.research studies.

Historical Perspectives of Nursing Historical Perspectives of Nursing and Computer and Computer

INTERNATIONAL PERSPECTIVEINTERNATIONAL PERSPECTIVE

There is also much developing There is also much developing internationally in standards and internationally in standards and EHRs, this section of the book allows EHRs, this section of the book allows the students and scholars of NI to the students and scholars of NI to gain an understanding of the gain an understanding of the leadership of nurses internationally leadership of nurses internationally in advancing the NI agenda.in advancing the NI agenda.

HISTORICAL PERSPECTIVE OF HISTORICAL PERSPECTIVE OF NURSING AND COMPUTER NURSING AND COMPUTER

The computer is the most powerful The computer is the most powerful technological tool to transform the nursing technological tool to transform the nursing profession prior to the new century. The profession prior to the new century. The computer has transformed the nursing computer has transformed the nursing paper-based record to computer-based paper-based record to computer-based records. Today and tomorrow, the records. Today and tomorrow, the computer and the Internet are essential computer and the Internet are essential for settings where nurses function- for settings where nurses function- hospitals, ambulatory care centers, health hospitals, ambulatory care centers, health maintenance organizations, community maintenance organizations, community health agencies, academic institutions health agencies, academic institutions research centers, and schools of nursing.research centers, and schools of nursing.

““Computer”Computer” is an all encompassing term is an all encompassing term referring to information technology (IT), referring to information technology (IT), computer systems, and when they are computer systems, and when they are used in nursing, refer to nursing used in nursing, refer to nursing information systems (NIs), nursing information systems (NIs), nursing applications, and/or nursing informatics applications, and/or nursing informatics (NI). “NI” has emerged as a new term (NI). “NI” has emerged as a new term encompassing these technologies enabling encompassing these technologies enabling nurses to manage health care and patient nurses to manage health care and patient care more efficiently and effectively and, care more efficiently and effectively and, at the same time, make nurses more at the same time, make nurses more accountable.accountable.

Computers in nursing are used to manage Computers in nursing are used to manage information in patient care, monitor the quality of information in patient care, monitor the quality of care, evaluate the outcomes of care. Computer care, evaluate the outcomes of care. Computer sand networks are now used for communicating sand networks are now used for communicating (sending/receiving) data and messages via the (sending/receiving) data and messages via the Internet, accessing resources, and interacting Internet, accessing resources, and interacting with patients on the World Wide Web (WWW). with patients on the World Wide Web (WWW). Nurses are increasingly involved with systems Nurses are increasingly involved with systems used for planning, budgeting, and policy-making used for planning, budgeting, and policy-making for patient care services as well as enhancing for patient care services as well as enhancing nursing education and distance learning with new nursing education and distance learning with new media modalities. Computers also used to media modalities. Computers also used to support nursing research, test new systems, support nursing research, test new systems, design new knowledge databases, and advance design new knowledge databases, and advance the role of nursing in the health care industry.the role of nursing in the health care industry.

MAJOR HISTORICAL PERPSECTIVES OF MAJOR HISTORICAL PERPSECTIVES OF NURSING AND COMPUTERSNURSING AND COMPUTERS

Computer technology emerged in nursing in response to Computer technology emerged in nursing in response to the changing and developing technologies in the health the changing and developing technologies in the health care industry and in nursing practice. It is analyzed care industry and in nursing practice. It is analyzed according to: according to:

1. six time periods – prior to the 1960’s, the 1960’s, 1970’s, 1. six time periods – prior to the 1960’s, the 1960’s, 1970’s, the 1980’s, the 1990’s and post 2000the 1980’s, the 1990’s and post 2000

2. Four major nursing areas; nursing practice, administration, 2. Four major nursing areas; nursing practice, administration, education, researcheducation, research

3. Standards initiatives – nursing practice, nursing data, and 3. Standards initiatives – nursing practice, nursing data, and health care data standardshealth care data standards

4. significant landmark events4. significant landmark events5. Major landmark milestone chart listing the events that 5. Major landmark milestone chart listing the events that

influenced the introduction of computers into the nursing influenced the introduction of computers into the nursing profession including the key “computer/informatics” nurse profession including the key “computer/informatics” nurse that directed the activity.that directed the activity.

SIX TIME PERIODSIX TIME PERIODSix historical perspectives of nursing and Six historical perspectives of nursing and

computers follow:computers follow: Prior to the 1960s – starting in the Prior to the 1960s – starting in the

1950s, and as the computer industry 1950s, and as the computer industry grew, the use of computers in the grew, the use of computers in the health care industry also grew. During health care industry also grew. During this time, there were only a few experts this time, there were only a few experts who formed a cadre of pioneers that who formed a cadre of pioneers that attempted to adapt computers to health attempted to adapt computers to health care and nursing. During this time the care and nursing. During this time the nursing profession was also undergoing nursing profession was also undergoing changes. The images of nursing was changes. The images of nursing was improving, nursing practices and improving, nursing practices and services were expanding in scope and services were expanding in scope and complexity. complexity.

And the number of nurses was increasing. These And the number of nurses was increasing. These events provided the impetus for the profession to events provided the impetus for the profession to embrace computers. Computers were initially embrace computers. Computers were initially used in health care facilities for basic business used in health care facilities for basic business office functions. These early computers used office functions. These early computers used punch cards to store data and card readers to punch cards to store data and card readers to read computer programs, sort and prepare data read computer programs, sort and prepare data for processing. They were linked together and for processing. They were linked together and operated by a paper tape and used operated by a paper tape and used teletypewriters to print their output. As computer teletypewriters to print their output. As computer technology advanced, the healthcare technology advanced, the healthcare technologies improved.technologies improved.

1960s – During the 1960s the use of computer 1960s – During the 1960s the use of computer technology in health care setting s began to be technology in health care setting s began to be questioned. Questions such as “Why computers?” and questioned. Questions such as “Why computers?” and what should be computerized?” were discussed. Nursing what should be computerized?” were discussed. Nursing practice standards were reviewed, and nursing practice standards were reviewed, and nursing resources were analyzed. Studies were conducted to resources were analyzed. Studies were conducted to determine how computer technology could be utilized determine how computer technology could be utilized effectively in the health care industry and what areas of effectively in the health care industry and what areas of nursing should be automated. The nurses’ station in the nursing should be automated. The nurses’ station in the hospital was viewed as the hub of information hospital was viewed as the hub of information exchange, the most appropriate center for the exchange, the most appropriate center for the development of the computer application. During this development of the computer application. During this period, computer technology advanced, while the period, computer technology advanced, while the number of health care facilities increased. number of health care facilities increased.

The introduction of cathode ray tube (CRT) terminals, online The introduction of cathode ray tube (CRT) terminals, online data communication, and real-time processing added data communication, and real-time processing added important dimensions to the computer systems, providing important dimensions to the computer systems, providing more accessible and “user-friendly” machines. Hospital more accessible and “user-friendly” machines. Hospital information systems (HISs) were developed primarily to information systems (HISs) were developed primarily to process financial transactions and serve as billing and process financial transactions and serve as billing and accounting systems. However, a few HISs emerged that accounting systems. However, a few HISs emerged that documented and processed a limited number of medical documented and processed a limited number of medical orders and nursing care activities. Vendors of computer orders and nursing care activities. Vendors of computer systems were beginning to enter a health care field and systems were beginning to enter a health care field and market software applications for various hospital functions; market software applications for various hospital functions; however, because of technology limitations, lack of however, because of technology limitations, lack of standardization, and diversity of paper-based patient care standardization, and diversity of paper-based patient care records, progress was slow.records, progress was slow.

1970s – In the 1970s the inevitable continued 1970s – In the 1970s the inevitable continued integration of computers into nursing. Nurses integration of computers into nursing. Nurses began to recognize the value of the computer began to recognize the value of the computer for their profession. During this decade, giant for their profession. During this decade, giant steps were taken in both dimensions: nursing steps were taken in both dimensions: nursing and computer technology. Nurses recognized and computer technology. Nurses recognized the computer’s potential for improving the the computer’s potential for improving the documentation of nursing practice, the quality documentation of nursing practice, the quality of patient care, and the repetitive aspects of of patient care, and the repetitive aspects of managing patient care. They assisted in the managing patient care. They assisted in the design and development of nursing design and development of nursing applications for the HISs and other applications for the HISs and other environments where nurses functioned. environments where nurses functioned.

Interestingly, computer applications for Interestingly, computer applications for the financial and management functions of the financial and management functions of patient care systems were perceived as patient care systems were perceived as cost-saving technologies. Further, several cost-saving technologies. Further, several mainframe HISs were designed and mainframe HISs were designed and developed, a few of which eventually developed, a few of which eventually became forerunners of a number of became forerunners of a number of today’s systems. May of the early systems today’s systems. May of the early systems were funded by contracts or grants form were funded by contracts or grants form federal agencies.federal agencies.

FOUR MAJOR NURSING AREASFOUR MAJOR NURSING AREAS

This second section addresses the historical This second section addresses the historical perspectives’ of nursing that shaped the need for perspectives’ of nursing that shaped the need for computers, information technologies, and computers, information technologies, and informatics. The focus is on these four major informatics. The focus is on these four major nursing areas:nursing areas:

Nursing PracticeNursing Practice – Nursing has practice evolved – Nursing has practice evolved and changed radically. It has become an integral and changed radically. It has become an integral part of the HER. Computer systems with nursing part of the HER. Computer systems with nursing and patient care data, nursing care plans are no and patient care data, nursing care plans are no longer separate subsystems of the computerized longer separate subsystems of the computerized HISs, but rather integrated into one HISs, but rather integrated into one interdisciplinary patient health record in the HER. interdisciplinary patient health record in the HER.

Nursing AdministrationNursing Administration – Nursing administration – Nursing administration in the hospitals has also changed with the in the hospitals has also changed with the introduction of the computer that links nursing introduction of the computer that links nursing departments together.departments together.

Nursing EducationNursing Education – The computer has – The computer has radically changed nursing education. Most radically changed nursing education. Most universities and schools of nursing offer universities and schools of nursing offer computer enhanced courses, online computer enhanced courses, online courses, and/or distance education. They courses, and/or distance education. They are becoming universities without walls are becoming universities without walls where students can attend a university where students can attend a university anywhere in the world without being anywhere in the world without being present. Campus-wide computer systems present. Campus-wide computer systems are available for students to communicate are available for students to communicate via e-mail, transfer data files, access the via e-mail, transfer data files, access the digital libraries, and retrieve online digital libraries, and retrieve online resources of millions of Internet WWW resources of millions of Internet WWW sites.sites.

Nursing ResearchNursing Research – Nursing research – Nursing research provides the impetus to use the computer provides the impetus to use the computer for analyzing nursing data. Software for analyzing nursing data. Software programs are available for processing both programs are available for processing both quantitative and qualitative research data. quantitative and qualitative research data. With the advancement of computer With the advancement of computer technology databases supporting nursing technology databases supporting nursing research emerged, principally for online research emerged, principally for online searching and retrieving information from searching and retrieving information from the electronic bibliographic literature the electronic bibliographic literature systems or other databases that contain systems or other databases that contain relevant health care content such as drug relevant health care content such as drug data.data.

STANDARDS INITIATIVESSTANDARDS INITIATIVES The third significant historical perspective The third significant historical perspective

concerns standards initiatives focusing on concerns standards initiatives focusing on nursing practice standards, nursing data nursing practice standards, nursing data standards, and health care data standards standards, and health care data standards as well as federal legislation that impact as well as federal legislation that impact on the use of the computer into nursing. on the use of the computer into nursing. These standards have influenced the These standards have influenced the nursing profession and its need for nursing profession and its need for computer systems, information computer systems, information technology, and terminologies to gain technology, and terminologies to gain acceptance among the health care policy acceptance among the health care policy makers.makers.

NURSING PRACTICE NURSING PRACTICE STANDARDSSTANDARDS

Nursing practice standards have Nursing practice standards have been developed and recommended been developed and recommended by the ANA, the official professional by the ANA, the official professional nursing organization. The ANA nursing organization. The ANA published the Standards of Clinical published the Standards of Clinical Nursing Practice (ANA, 1998) which Nursing Practice (ANA, 1998) which focused not only on the organizing focused not only on the organizing principles of clinical nursing practice principles of clinical nursing practice but also the standards of professional but also the standards of professional performance.performance.

NURSING DATA STANDARDSNURSING DATA STANDARDS Nursing data standards have emerged as a new Nursing data standards have emerged as a new

requirement for the HER. The original elements requirement for the HER. The original elements and historical details are described in the third and historical details are described in the third edition; however, for this fourth edition it is edition; however, for this fourth edition it is important to understand that currently there are important to understand that currently there are 13 nursing terminologies that have been 13 nursing terminologies that have been recognized by the ANA. Several of these recognized by the ANA. Several of these terminologies are in the public domain and usable terminologies are in the public domain and usable by the general public such as the Critical Care by the general public such as the Critical Care Classification (CCC) system by Saba and Classification (CCC) system by Saba and colleagues.colleagues.

The ANA is responsible for the recognition of the The ANA is responsible for the recognition of the terminologies and for determining if they have terminologies and for determining if they have met the criteria to be included in the National met the criteria to be included in the National Library of Medicine (NLM) Unified Medical Library of Medicine (NLM) Unified Medical Language Systems (UMLS).Language Systems (UMLS).

HEALTH CARE DATA STANDARDS HEALTH CARE DATA STANDARDS

ORGANIZATIONORGANIZATION It is critical to review the standards organizations It is critical to review the standards organizations

that have emerged to either develop or that have emerged to either develop or recommend health care data standards that recommend health care data standards that should be recommended to the federal should be recommended to the federal government as required health care data government as required health care data standards. The major ones are listed below:standards. The major ones are listed below:

1.1. American National Standards Institute (ANSI) is a American National Standards Institute (ANSI) is a private non-profit membership organizationprivate non-profit membership organization

2.2. American Society for Testing and Materials American Society for Testing and Materials (ASTM)(ASTM)

3.3. Health Level Seven (HL7)Health Level Seven (HL7)4.4. SNOMED InternationalSNOMED International5.5. National Committee on Vital and Health Statistics National Committee on Vital and Health Statistics

(NCVHS)(NCVHS)

EARLY COMPUTER-BASED NURSING EARLY COMPUTER-BASED NURSING APPLICATIONSAPPLICATIONS

Several computer-based nursing applications, developed Several computer-based nursing applications, developed before the mid-1970s as part of larger HISs, still exist. Each before the mid-1970s as part of larger HISs, still exist. Each in its own way developed different nursing applications in its own way developed different nursing applications focused in documentation of nursing practice and focused in documentation of nursing practice and management of patient care. These applications were management of patient care. These applications were designed for hospitals, ambulatory care settings, and designed for hospitals, ambulatory care settings, and community health agencies. Additionally, several community health agencies. Additionally, several significant nursing projects were conducted to improve significant nursing projects were conducted to improve nursing care documentation methodologies, which in turn nursing care documentation methodologies, which in turn could be computerized. These major nursing applications, could be computerized. These major nursing applications, which influenced the industry, were subsystems, or which influenced the industry, were subsystems, or components of early HISs focused on: components of early HISs focused on:

(a) early HISs (a) early HISs (b) early ambulatory care information systems (b) early ambulatory care information systems (c) early community health nursing information management (c) early community health nursing information management

systems, systems, (d) early computer-focused nursing projects, and (d) early computer-focused nursing projects, and (e) early educational applications.(e) early educational applications.

LANDMARK EVENTS IN NURSING AND LANDMARK EVENTS IN NURSING AND COMPUTERSCOMPUTERS

Computers were introduced into the nursing profession Computers were introduced into the nursing profession over 35 years ago. Major milestones of nursing are over 35 years ago. Major milestones of nursing are interwoven with the advancement of computer and interwoven with the advancement of computer and information technologies, the increased need for nursing information technologies, the increased need for nursing data, development of nursing applications, and changes data, development of nursing applications, and changes making the nursing profession an autonomous discipline. making the nursing profession an autonomous discipline. The major developments in the use of information The major developments in the use of information technologies and nursing, and in the introduction of NI, technologies and nursing, and in the introduction of NI, were chronologically described by program effort, or by were chronologically described by program effort, or by organizational initiative. The landmark events were organizational initiative. The landmark events were described by the following categories:described by the following categories:– Early conferences, meetingsEarly conferences, meetings– Early academic initiativesEarly academic initiatives– Initial ANA initiativesInitial ANA initiatives– Initial National League for Nursing (NLN) initiativesInitial National League for Nursing (NLN) initiatives– Early international initiativesEarly international initiatives– Initial educational resources andInitial educational resources and– Significant collaborative eventsSignificant collaborative events

ELECTRONIC HEALTH RECORD FROM A ELECTRONIC HEALTH RECORD FROM A HISTORICAL PERSPECTIVEHISTORICAL PERSPECTIVE

OBJECTIVESOBJECTIVES1.Describe the Nicholas E. Davies Program1.Describe the Nicholas E. Davies Program2.Name the four key criteria sections of the Davies 2.Name the four key criteria sections of the Davies

applicationapplication3.Name and describe one feature of an electronic 3.Name and describe one feature of an electronic

health record (EHR) implementation that has not health record (EHR) implementation that has not changed over time.changed over time.

4.Describe an external factor that has impacted 4.Describe an external factor that has impacted HER implementationHER implementation

5.Describe several of the commonalities found in all 5.Describe several of the commonalities found in all Davies winnersDavies winners

INTRODUCTION TO DAVIESINTRODUCTION TO DAVIES

The Computer-based Patient Record The Computer-based Patient Record Institute (CPRI), a nonprofit membership Institute (CPRI), a nonprofit membership organization founded in 1992, was a organization founded in 1992, was a unique organization representing all unique organization representing all stakeholders in healthcare, focusing on stakeholders in healthcare, focusing on clinical applications of information clinical applications of information technology. CPRI was among the first technology. CPRI was among the first nationally based organizations to initiate nationally based organizations to initiate and coordinate activities to facilitate and and coordinate activities to facilitate and promote the routine use of computer-promote the routine use of computer-based patient records (CPRs) throughout based patient records (CPRs) throughout healthcare.healthcare.

WHAT’S THE SAME?WHAT’S THE SAME? How they define the EffortHow they define the EffortThe 19 Organizational Davies winners located throughout the The 19 Organizational Davies winners located throughout the

country started and completed their implementations at country started and completed their implementations at different times and in different departments of their facility, different times and in different departments of their facility, under different types of leadership. On the surface it would under different types of leadership. On the surface it would appear they have little in common. A closer look, however, appear they have little in common. A closer look, however, reveals that these organizations have much in common. reveals that these organizations have much in common. Prior to the onset of effort, the winning organizations have Prior to the onset of effort, the winning organizations have clearly made the HER a key component of the strategic clearly made the HER a key component of the strategic vision. Recognized organizations know and understand the vision. Recognized organizations know and understand the healthcare is an information business. A first year winner, healthcare is an information business. A first year winner, the Veteran’s Health Administration (VHA), whose mission the Veteran’s Health Administration (VHA), whose mission is to provide high-quality healthcare for America’s veterans, is to provide high-quality healthcare for America’s veterans, made the development of an HER a major long term goal.made the development of an HER a major long term goal.

How is the Effort Organized?How is the Effort Organized? The implementation of HER is a daunting effort. A The implementation of HER is a daunting effort. A

common element to all Davies winners is the common element to all Davies winners is the shared belief that information management is a shared belief that information management is a key tool to the clinical and business processes of key tool to the clinical and business processes of the hospital. Without exception, one or more of the hospital. Without exception, one or more of the senior executives realizes the importance of the senior executives realizes the importance of the HER initiative and champions the effort.the HER initiative and champions the effort.

The champion is absolutely necessary to ensure The champion is absolutely necessary to ensure continued funding and appropriate resources continued funding and appropriate resources needed for the project to realize success. needed for the project to realize success.

Impact to ValueImpact to ValueDocumenting the impact of an HER is Documenting the impact of an HER is

very difficult at best and impossible very difficult at best and impossible for some organizations. The system for some organizations. The system impacts an organization in subtle impacts an organization in subtle ways, such as avoidance of a ways, such as avoidance of a medication error, and directly medication error, and directly through non-duplication of an through non-duplication of an ordered test.ordered test.

Still ExpensiveStill ExpensiveA commonalty shared by all Davies A commonalty shared by all Davies

Organizational winners is the cost of their Organizational winners is the cost of their HER implementation; expensive. The trait HER implementation; expensive. The trait continues even today. Over the years of continues even today. Over the years of the Davies program, organization after the Davies program, organization after organization has set aside multiple organization has set aside multiple millions from their capital budgets to millions from their capital budgets to finance the cost of the infrastructure, finance the cost of the infrastructure, hardware. And software all needed for an hardware. And software all needed for an HER implementation.HER implementation.

What’s Different?What’s Different? Where Winners Obtained Systems?Where Winners Obtained Systems?In the first years of the Davies, winning In the first years of the Davies, winning

organizations had spent years in the development organizations had spent years in the development of their award winning systems. The three of their award winning systems. The three organizations honored in the first year of the organizations honored in the first year of the program all developed their own systems. IHC in program all developed their own systems. IHC in Utah was the practice site for a visionary group of Utah was the practice site for a visionary group of clinicians and scientists. Around 1965 they began clinicians and scientists. Around 1965 they began experimenting with the process of applying experimenting with the process of applying computer technology to the provision of care. computer technology to the provision of care. From these early experiments came the creation From these early experiments came the creation of an integrated. of an integrated.

Time to Get ThereTime to Get ThereAs more healthcare organizations purchase As more healthcare organizations purchase

commercially available EMRs the timeline form commercially available EMRs the timeline form initial planning, through purchase, training, and initial planning, through purchase, training, and successful implementation shortens. For early successful implementation shortens. For early Davies winners like the VHA, Brigham & Davies winners like the VHA, Brigham & Women’s, and Regenstrief Institute for Health Women’s, and Regenstrief Institute for Health Care, the EMR was part of a strategic plan that Care, the EMR was part of a strategic plan that took more than a decade to realize. The took more than a decade to realize. The Regenstrief institute was founded in 1969 in Regenstrief institute was founded in 1969 in Indianapolis, Indiana, on the belief that industrial Indianapolis, Indiana, on the belief that industrial engineering principles could be applied to engineering principles could be applied to healthcare. healthcare.

External AgendaExternal Agenda

Factors external to healthcare organizations Factors external to healthcare organizations helped to accelerate the timeline for helped to accelerate the timeline for adoption of EMRs. In 1993, the driving adoption of EMRs. In 1993, the driving force for developing an advanced CIS at force for developing an advanced CIS at Queen’s Medical Center in Honolulu, Queen’s Medical Center in Honolulu, Hawaii, was the onset of healthcare reform Hawaii, was the onset of healthcare reform and managed care. Survival of Queens and managed care. Survival of Queens necessitated a seamless integrated necessitated a seamless integrated healthcare system.healthcare system.

TechnologyTechnology

The technology behind each EMR affects the The technology behind each EMR affects the ability to meet user demands for rapid, ability to meet user demands for rapid, response, system reliability, future growth, response, system reliability, future growth, and customization. Throughout the decade and customization. Throughout the decade of Davies, new technologies have emerged of Davies, new technologies have emerged and are being incorporated into the and are being incorporated into the systems being deployed today.systems being deployed today.

Davies Pool of ApplicantsDavies Pool of Applicants

In the early years of the Davies program, In the early years of the Davies program, only a few healthcare organizations had only a few healthcare organizations had successful EMR implementations of successful EMR implementations of sufficient scope and implementation to sufficient scope and implementation to apply for the award. Despite “raising the apply for the award. Despite “raising the bar” through three criteria revisions since bar” through three criteria revisions since the debut of the award, applications have the debut of the award, applications have steadily increased as more organizations steadily increased as more organizations realize the value of EMR.realize the value of EMR.

COMPUTER SYSTEMCOMPUTER SYSTEM

Computer hardwareComputer hardware

INPUT DEVICESINPUT DEVICES KEYBOARD – has alphabetic, numeric and function keys KEYBOARD – has alphabetic, numeric and function keys

for the entry of information.for the entry of information. TERMINAL – consists of a monitor, keyboard and TERMINAL – consists of a monitor, keyboard and

communication lines attached to a computer system. It communication lines attached to a computer system. It accepts customer inputs for processing.accepts customer inputs for processing.

TOUCH TONE DEVICE – accepts data when telephone TOUCH TONE DEVICE – accepts data when telephone buttons are pushed. This trigger the telephone, which in buttons are pushed. This trigger the telephone, which in turn send signals to the computer.turn send signals to the computer.

SET-UP BOXES – Sometimes called information appliance, SET-UP BOXES – Sometimes called information appliance, enable the user to request for a specific program to be enable the user to request for a specific program to be aired through a cable box triggered by a remote control.aired through a cable box triggered by a remote control.

MOUSE – A handheld pointing device, used to move a MOUSE – A handheld pointing device, used to move a pointer on the screen. Underneath is a ball that is rolled pointer on the screen. Underneath is a ball that is rolled on a flat surface to control the movement of the pointer. on a flat surface to control the movement of the pointer. This device is commonly used for personal computers.This device is commonly used for personal computers.

TRACKBALL – Is similar to a mouse but TRACKBALL – Is similar to a mouse but the ball is the one directly moved to the ball is the one directly moved to control the movement of the pointer.control the movement of the pointer.

JOYSTICK – is a pointing device with a JOYSTICK – is a pointing device with a base and a vertical handle that pivots in base and a vertical handle that pivots in all directions. This is usually used in all directions. This is usually used in playing computer games.playing computer games.

TOUCH SCREEN – Is a display screen that TOUCH SCREEN – Is a display screen that allows user to interact with the system allows user to interact with the system by touching specific areas on the screen.by touching specific areas on the screen.

LIGHT PEN – Is a sensitive stylus or pen device LIGHT PEN – Is a sensitive stylus or pen device that is used by engineers, illustrators and that is used by engineers, illustrators and graphics designers. It serves as a virtual pen that graphics designers. It serves as a virtual pen that allows freehand drawing.allows freehand drawing.

GRAPHIC TABLET – This is connected by a wire to GRAPHIC TABLET – This is connected by a wire to a light pen through which the user can sketch a light pen through which the user can sketch image.image.

SCANNING DEVICE – translates images of text, SCANNING DEVICE – translates images of text, photo and other graphics into digital form. The photo and other graphics into digital form. The digitized image can then be manipulated or digitized image can then be manipulated or reproduced using a computer.reproduced using a computer.

SCANNER – Translates bar code symbols into digital form SCANNER – Translates bar code symbols into digital form and is usually used in malls and supermarkets.and is usually used in malls and supermarkets.

MARK INTERFACE CHARACTER RECOGNITION – device is MARK INTERFACE CHARACTER RECOGNITION – device is able to read the numbers printed (using magnetic ink) at able to read the numbers printed (using magnetic ink) at the bottom of checks. It can only read a limited number the bottom of checks. It can only read a limited number of characters and is usually used by banks.of characters and is usually used by banks.

OPTICAL MARK RECOGNITION – device uses a device that OPTICAL MARK RECOGNITION – device uses a device that reads pencil and ink marks and converts them into data reads pencil and ink marks and converts them into data that can be read and manipulated by the computer.that can be read and manipulated by the computer.

WAND READER – Is a commons canning device used in WAND READER – Is a commons canning device used in price tags. It uses a device that reads preprinted price tags. It uses a device that reads preprinted characters and converts them into digital code.characters and converts them into digital code.

FAX MACHINES OR FACSIMILE TRANSMISSION FAX MACHINES OR FACSIMILE TRANSMISSION MACHINES – scan hardcopy and transmit data to MACHINES – scan hardcopy and transmit data to another fax machine using telephone linesanother fax machine using telephone lines

IMAGE SCANNER OR GRAPHICS SCANNER – It IMAGE SCANNER OR GRAPHICS SCANNER – It converts text, drawings and photographs into converts text, drawings and photographs into electronic files stored in a computer system.electronic files stored in a computer system.

MAGNETIC STRIP CARD – contains data encoded MAGNETIC STRIP CARD – contains data encoded and stored on magnetic strips. It is usually used and stored on magnetic strips. It is usually used in credit cards, ATM cards and identification in credit cards, ATM cards and identification cards. It usually holds half a page of data.cards. It usually holds half a page of data.

PHONE CARD – Is a smart card that contains a PHONE CARD – Is a smart card that contains a microprocessor and a memory chip. It usually microprocessor and a memory chip. It usually holds 30 pages of data.holds 30 pages of data.

PLASTIC LASER RECORDABLE WALLET PLASTIC LASER RECORDABLE WALLET TYPECARD – holds about 200 pages of data and TYPECARD – holds about 200 pages of data and is used with an optical card reader.is used with an optical card reader.

SPEECH SYNTHESIZER – convert human speech SPEECH SYNTHESIZER – convert human speech into digital form. The data can then be into digital form. The data can then be transformed back into human speech.transformed back into human speech.

MULTIMEDIA DEVICES – record music and other MULTIMEDIA DEVICES – record music and other sound signals and transform them into digital sound signals and transform them into digital format to be used as input for PCs.format to be used as input for PCs.

DIGITAL CAMERAS – capture images in DIGITAL CAMERAS – capture images in electronic form for immediate viewing on electronic form for immediate viewing on computer screen or tv. These images can be computer screen or tv. These images can be stored and manipulated using computers.stored and manipulated using computers.

VIDEO CONVERTERS - Transform video or films VIDEO CONVERTERS - Transform video or films into digital format. Signals coming form into digital format. Signals coming form videocassette recorders, laser disk or videocassette recorders, laser disk or camcorder are converted into digital form camcorder are converted into digital form through a video card installed in the computer.through a video card installed in the computer.

SENSOR – Collects specific kinds of data from SENSOR – Collects specific kinds of data from the environment and convert these into the environment and convert these into computer readable data. Examples, include computer readable data. Examples, include sensor that measure the temperature, humidity, sensor that measure the temperature, humidity, smoke, gas and light.smoke, gas and light.

OUTPUT DEVICESOUTPUT DEVICES

Output hardware consists of devices which Output hardware consists of devices which communicate the result of processing back to the communicate the result of processing back to the user by converting electrical signals from the user by converting electrical signals from the arithmetic/Logic Unit into a form recognizable by arithmetic/Logic Unit into a form recognizable by a human operator. The most common output a human operator. The most common output devices include video displays, high-speed devices include video displays, high-speed printers and console typewriters. A recent printers and console typewriters. A recent development in output equipment is an audio development in output equipment is an audio response unit that can construct sentences with response unit that can construct sentences with human speakers’ words that have been human speakers’ words that have been digitalized and stored in memory device. Others digitalized and stored in memory device. Others synthesize human speech, providing the synthesize human speech, providing the appropriate response by generating signals appropriate response by generating signals similar to those produced in regular speech.similar to those produced in regular speech.

MONITORS – display images using grids of dots MONITORS – display images using grids of dots called pixels. It is the most common output called pixels. It is the most common output device that shows information on the screen device that shows information on the screen when you type. Monitors come in many types when you type. Monitors come in many types and sizes – from the simple monochrome (one and sizes – from the simple monochrome (one color) screen to full color screens.color) screen to full color screens.

PRINTER – Is another common equipment used PRINTER – Is another common equipment used to output information fomr the computer. The to output information fomr the computer. The digital equivalent of the information shown on digital equivalent of the information shown on the screen are transferred or printed on paper. the screen are transferred or printed on paper. There are many different types of printers with There are many different types of printers with various levels of quality. The three basic types various levels of quality. The three basic types of printers are: dot matrix, inkjet and of printers are: dot matrix, inkjet and laserprinters.laserprinters.

PLOTTER – Is an output device used to produce high PLOTTER – Is an output device used to produce high quality drawings. Text is drawn as images. Plotters can quality drawings. Text is drawn as images. Plotters can draw in black and white or in color. Plotters have built-in draw in black and white or in color. Plotters have built-in microprocessors that converts the characters and microprocessors that converts the characters and instructions from the computer into a series of instructions from the computer into a series of coordinates which the plotter then draws. It can draw coordinates which the plotter then draws. It can draw curved lines just like a pen or paper. It requires lots of curved lines just like a pen or paper. It requires lots of memory to store highly accurate images. Plotters usually memory to store highly accurate images. Plotters usually come in two designs: flat bed and drum.come in two designs: flat bed and drum.

COMPUTER OUTPUT MICROFILM – (COM) produces output COMPUTER OUTPUT MICROFILM – (COM) produces output in the form of tiny images on a 3.5 mm roll of film in the form of tiny images on a 3.5 mm roll of film (microfilm) or in 4 x 6 inch film called microfiche. This (microfilm) or in 4 x 6 inch film called microfiche. This enables compact storage of a large number of images.enables compact storage of a large number of images.

SPEAKERS – produce sound output from the SPEAKERS – produce sound output from the computer. One form of speaker is the computer. One form of speaker is the headphone, which may be used individually. headphone, which may be used individually. Speakers allow the user to listen to high quality Speakers allow the user to listen to high quality music through their computer.music through their computer.

PICTURE PHONE – Is the newer version of a PICTURE PHONE – Is the newer version of a telephone with a TV-like screen and a built in telephone with a TV-like screen and a built in camera that allows you to see the person you camera that allows you to see the person you are exchanging messages with directly on are exchanging messages with directly on screen. This device is used in video screen. This device is used in video conferencing or teleconferencing, where conferencing or teleconferencing, where television, sound and computer technology are television, sound and computer technology are used to allow people in different sites to see used to allow people in different sites to see each other and talk with one another.each other and talk with one another.

CENTRAL PROCESSING UNIT CENTRAL PROCESSING UNIT

The processing and conversion of data The processing and conversion of data form input to output is done in the central form input to output is done in the central processing unit (CPU). Its main function is processing unit (CPU). Its main function is to perform arithmetic and logical to perform arithmetic and logical operations on data taken from the primary operations on data taken from the primary storage or on information entered through storage or on information entered through any input device.any input device.

The CPU is composed of five basic The CPU is composed of five basic components: main storage, registers, components: main storage, registers, buses, ALU and the control unit.buses, ALU and the control unit.

BASIC CPU COMPONENTS BASIC CPU COMPONENTS

1.1. MAIN STORAGE – the main storage (also MAIN STORAGE – the main storage (also called memory or primary storage) is called memory or primary storage) is where instructions and data are stored where instructions and data are stored while processing is done. The data are while processing is done. The data are stored while processing is done. The data stored while processing is done. The data stored are usually given unique stored are usually given unique addresses or memory locations to addresses or memory locations to facilitate storage and retrieval. The CPU facilitate storage and retrieval. The CPU usually accesses the data through its usually accesses the data through its address. The Two types of memory inside address. The Two types of memory inside the main storage are the RAM and the the main storage are the RAM and the ROM.ROM.

2. RAM – Random Access Memory (RAM) are 2. RAM – Random Access Memory (RAM) are a part of the memory of the computer a part of the memory of the computer uses to store given instructions which uses to store given instructions which can later be changed or erased. When can later be changed or erased. When data are loaded or put in the RAM, it data are loaded or put in the RAM, it means writing data. When data are means writing data. When data are accessed from the RAM, it means reading accessed from the RAM, it means reading data. RAM requires electric current to data. RAM requires electric current to retain information on it. Hence, all retain information on it. Hence, all information stored in it are lost erased information stored in it are lost erased when the computer power is turned off or when the computer power is turned off or interrupted. This kind of memory is interrupted. This kind of memory is volatile.volatile.

3. ROM – Read Only Memory (ROM) 3. ROM – Read Only Memory (ROM) contains stored instructions that a contains stored instructions that a computer requires to be able to do computer requires to be able to do its basic routine operations. This its basic routine operations. This part is non-volatile; the instructions part is non-volatile; the instructions still hold even when there is power still hold even when there is power interruption or shut-off. From the interruption or shut-off. From the name, we can only read the name, we can only read the information or instructions stored.information or instructions stored.

4. REGISTERS – Are parts of CPU that 4. REGISTERS – Are parts of CPU that function as fast-accessed temporary function as fast-accessed temporary memory locations. The bits of memory locations. The bits of information taken form the main information taken form the main memory and those that will be memory and those that will be placed in the main memory are placed in the main memory are temporarily held in the registers temporarily held in the registers while computations are being while computations are being performed.performed.

5. BUSES – Are bundles of tiny wires that serve as the 5. BUSES – Are bundles of tiny wires that serve as the communication path between components of the CPU. communication path between components of the CPU. The three most important buses are the address, data The three most important buses are the address, data and control buses.and control buses.

6. ALU – Arithmetic Logic Unit performs all the arithmetic and 6. ALU – Arithmetic Logic Unit performs all the arithmetic and logical calculations of the CPU. The arithmetic operations logical calculations of the CPU. The arithmetic operations consist of addition, subtraction, division and consist of addition, subtraction, division and multiplication. Logical calculations involve comparisons of multiplication. Logical calculations involve comparisons of two or more numbers.two or more numbers.

7. CONTROL UNIT – Is responsible for directing the flow of 7. CONTROL UNIT – Is responsible for directing the flow of instruction and data within the CPU. It fetches the instruction and data within the CPU. It fetches the instructions form the main memory for execution in the instructions form the main memory for execution in the CPU. Aside from controlling the input and output devices, CPU. Aside from controlling the input and output devices, it also passes data to the ALU for computation.it also passes data to the ALU for computation.

SECONDARY STORAGESECONDARY STORAGE

the secondary storage is where data are stored the secondary storage is where data are stored permanently. It is outside the primary storage and serves permanently. It is outside the primary storage and serves just like a filing cabinet.just like a filing cabinet.

There are two reasons why we need to store data in an There are two reasons why we need to store data in an auxiliary or secondary storage device. First, the primary auxiliary or secondary storage device. First, the primary storage can only store a limited amount of data. Second, storage can only store a limited amount of data. Second, the data stored in the primary storage are volatile and the data stored in the primary storage are volatile and temporary. If we used a secondary storage area, then a temporary. If we used a secondary storage area, then a limitless amount of data can be stored permanently. IN limitless amount of data can be stored permanently. IN short, secondary storage provides cheap, non-volatile high short, secondary storage provides cheap, non-volatile high capacity storage.capacity storage.

The two classes of secondary storage media are direct The two classes of secondary storage media are direct access media and sequential access storage media. Direct access media and sequential access storage media. Direct Access Media (e.g. floppy disk) support sequential or Access Media (e.g. floppy disk) support sequential or random access where data can be accessed directly, unlike random access where data can be accessed directly, unlike sequential access media (eg. Magnetic tape) where data sequential access media (eg. Magnetic tape) where data are accessed in a specific orderare accessed in a specific order

SECONDARY SECONDARY STORAGE MEDIASTORAGE MEDIA

MAGNETIC TAPEMAGNETIC TAPE

A sequential access storage media where A sequential access storage media where blocks of data are stored serially along blocks of data are stored serially along the length of the tape and can only be the length of the tape and can only be accessed in a serial manner. This is the accessed in a serial manner. This is the old traditional medium which is sound, old traditional medium which is sound, robust, with high capacity and the robust, with high capacity and the cheapest storage medium. It is still cheapest storage medium. It is still popular for long-term/high. Volume popular for long-term/high. Volume storage even though it is the slowest in storage even though it is the slowest in terms of retrieval of data.terms of retrieval of data.

MAGNETIC DISKMAGNETIC DISK

The magnetic disk is a direct access storage The magnetic disk is a direct access storage media which, lie a phonograph record, is media which, lie a phonograph record, is divided into tracks and sectors. Common types divided into tracks and sectors. Common types are the hard disks and floppy disks. The hard are the hard disks and floppy disks. The hard disks are stacks of rigid magnetic disks that disks are stacks of rigid magnetic disks that are permanently mounted in a unit that may are permanently mounted in a unit that may be internal or external to the computer and are be internal or external to the computer and are often used as a virtual memory or extension of often used as a virtual memory or extension of RAM. They have relatively high capacity and RAM. They have relatively high capacity and fast retrieval speed but very fragile. fast retrieval speed but very fragile.

Floppy disksFloppy disks

are much slower than the hard disks are much slower than the hard disks and have less capacity ranging from and have less capacity ranging from 1.44 Mb to 200 Mb. A newcomer to 1.44 Mb to 200 Mb. A newcomer to the scene is the super floppy disk the scene is the super floppy disk which has a capacity of 120 Mb.which has a capacity of 120 Mb.

OPTICAL DISKS OPTICAL DISKS

– A rigid disk of plastic onto which data A rigid disk of plastic onto which data are recorded by special lasers that are recorded by special lasers that physically burn pits into the disk. An physically burn pits into the disk. An optical disk has the same technology optical disk has the same technology as the music CD. They can usually as the music CD. They can usually contain about 650 Mb of data. Some contain about 650 Mb of data. Some common forms of optical disks are CD-common forms of optical disks are CD-ROM, CD-R, CD-RW, DVD, DVD-R, DVD-ROM, CD-R, CD-RW, DVD, DVD-R, DVD-RW and Magneto-Optical Disk.RW and Magneto-Optical Disk.

Compact Disk-Read Only MemoryCompact Disk-Read Only Memory

– – (CD-ROM) Is a non-erasable disk (CD-ROM) Is a non-erasable disk that stores computer data, usually in that stores computer data, usually in standard system uses – 12 cm standard system uses – 12 cm diameter with CD Recordable (CD diameter with CD Recordable (CD Writer), can write data on the disk Writer), can write data on the disk only once, but with CD-Rewritable only once, but with CD-Rewritable (CD Co-Writer), that can erase and (CD Co-Writer), that can erase and rewrite data on the disk up to 1,000 rewrite data on the disk up to 1,000 times.times.

..

A Digital Versatile Disk (DVD)-A Digital Versatile Disk (DVD)-

contains digitized and compressed contains digitized and compressed video information, as well as large video information, as well as large volumes of other digital data in both volumes of other digital data in both 8 volumes of other digital data in 8 volumes of other digital data in both 8 and 12 cm. diameter disks. It both 8 and 12 cm. diameter disks. It also has its own Read-Only (DVD), also has its own Read-Only (DVD), Recordable (DVD-R) and Rewritable Recordable (DVD-R) and Rewritable (DVD-RW) versions. Some have (DVD-RW) versions. Some have double-sided capacity of up to 15.9 double-sided capacity of up to 15.9 GbGb

MAGNETO-OPTICAL DISK MAGNETO-OPTICAL DISK

(MO), a hybrid between magnetic disk (MO), a hybrid between magnetic disk and optical disk, uses optical and optical disk, uses optical technology for read and magnetic technology for read and magnetic recording technique assisted by optical recording technique assisted by optical focusing. It comes in 3.2 inch and 5.25-focusing. It comes in 3.2 inch and 5.25-inch disks with capacities of 5 Gb and inch disks with capacities of 5 Gb and above. The principal advantage of the above. The principal advantage of the MO media over a purely optical CD MO media over a purely optical CD media is its longevity and cheaper cost media is its longevity and cheaper cost per megabyte.per megabyte.

SOFTWARESOFTWARE

The set of instructions or programs The set of instructions or programs that tells the computer how to do a that tells the computer how to do a specific task is called a software specific task is called a software (there is no such word as softwares, (there is no such word as softwares, because the plural form of software because the plural form of software is also software). A software may be is also software). A software may be categorized as System software or categorized as System software or Application software.Application software.

System software performs tasks necessary System software performs tasks necessary to the efficient management of the to the efficient management of the hardware. It refers to computer programs hardware. It refers to computer programs or library files whose purpose is to help or library files whose purpose is to help run the computer system. These programs run the computer system. These programs are usually made available to the user by are usually made available to the user by the manufacturers of the computer the manufacturers of the computer system. It includes operating systems, system. It includes operating systems, utility programs, compilers and utility programs, compilers and interpreters.interpreters.

System software performs tasks necessary System software performs tasks necessary to the efficient management of the to the efficient management of the hardware. It refers to computer programs hardware. It refers to computer programs or library files whose purpose is to help or library files whose purpose is to help run the computer system. These programs run the computer system. These programs are usually made available to the user by are usually made available to the user by the manufacturers of the computer the manufacturers of the computer system. It includes operating systems, system. It includes operating systems, utility programs, compilers and utility programs, compilers and interpreters.interpreters.

SYSTEM SOFTWARESYSTEM SOFTWARE

OPERATING SYSTEM OPERATING SYSTEM

– The operating system is a set of The operating system is a set of programs which controls and programs which controls and coordinates the whole operation of the coordinates the whole operation of the computer system. It acts as the computer system. It acts as the computer’s internal government, computer’s internal government, controller and resource manager.controller and resource manager.

Examples: OS/2, UNIX, LINUX, DOS/MVS. Examples: OS/2, UNIX, LINUX, DOS/MVS. MacOS, JAvaOS, Windows NT, Windows MacOS, JAvaOS, Windows NT, Windows XP, Windows CE, Windows 2000XP, Windows CE, Windows 2000

It is the first program loaded in It is the first program loaded in memory to ensure the convenience memory to ensure the convenience of the user and the efficiency of the of the user and the efficiency of the whole computer system. The whole computer system. The operating system provides the operating system provides the interface among the hardware, interface among the hardware, application programs, files and users. application programs, files and users. Examples: Windows 98, windows 95, Examples: Windows 98, windows 95, windows 3.1, Novel, Netware.windows 3.1, Novel, Netware.

UTILITY PROGRAMS UTILITY PROGRAMS

are system software service programs are system software service programs that help the operating system that help the operating system efficiently manage files and do efficiently manage files and do housekeeping functions. These include housekeeping functions. These include programs for data backup, data programs for data backup, data recovery, virus protection, data recovery, virus protection, data compression, data security and file compression, data security and file fragmentation.fragmentation.

COMPILERS AND COMPILERS AND INTERPRETERS INTERPRETERS

Are programs that translate high-level Are programs that translate high-level language programs into object code. language programs into object code. Compilers translate the whole program Compilers translate the whole program as an object code at once while as an object code at once while interpreters translate it one statement interpreters translate it one statement at a time. Examples: COBOL compiler, at a time. Examples: COBOL compiler, Fortran compiler, C Compiler, BASIC Fortran compiler, C Compiler, BASIC Interpreter, Prolog Interpreter, Java Interpreter, Prolog Interpreter, Java InterpreterInterpreter

APPLICATION APPLICATION SOFTWARESOFTWARE

Are programs that help solve and meet Are programs that help solve and meet user problems and needs directly. They user problems and needs directly. They are designed to perform specific functions, are designed to perform specific functions, which make daily activities easier and which make daily activities easier and facilitate the performance of work facilitate the performance of work efficiently and effectively. Application efficiently and effectively. Application software can serve as productivity tools; software can serve as productivity tools; assist in graphics and multimedia projects; assist in graphics and multimedia projects; support home personal and educational support home personal and educational use, and facilitate communication.use, and facilitate communication.

Productivity SoftwareProductivity Software

Word Processing Software – allows users to Word Processing Software – allows users to create and manipulate documents that contain create and manipulate documents that contain text and graphics. Example: Microsoft Word; text and graphics. Example: Microsoft Word; Word Perfect, WordstarWord Perfect, Wordstar

Spreadsheet software – allows users to enter Spreadsheet software – allows users to enter data into rows and columns and perform data into rows and columns and perform computations or make graphs based on the computations or make graphs based on the data given. Examples: Microsoft excel, Corel data given. Examples: Microsoft excel, Corel Quattro Pro, Lotus 123.Quattro Pro, Lotus 123.

Database Software – allows users to manage Database Software – allows users to manage data by organizing these in database tables. data by organizing these in database tables. Examples: Microsoft access; visual foxpro; Examples: Microsoft access; visual foxpro; filemaker pro; Dbase; Oracle: MS SQLfilemaker pro; Dbase; Oracle: MS SQL

Presentation Graphics Software – Allows users to Presentation Graphics Software – Allows users to create presentations that communicate ideas, create presentations that communicate ideas, messages and other information through a slide messages and other information through a slide how. Examples: Powerpoint; Photoshop; adobe how. Examples: Powerpoint; Photoshop; adobe illustrator; free hand; corel drawillustrator; free hand; corel draw

Personal Information Manager Software – Allows Personal Information Manager Software – Allows users to maintain an address book and users to maintain an address book and appointment calendar and make use of a notepad appointment calendar and make use of a notepad to record ideas and reminders. Examples: Outlookto record ideas and reminders. Examples: Outlook

Project Management Software – Allows users to Project Management Software – Allows users to plan, schedule, track and analyze the progress of plan, schedule, track and analyze the progress of a project. Examples: Harvard project manager, a project. Examples: Harvard project manager, Microsoft project.Microsoft project.

GRAPHICS AND MULTIMEDIAGRAPHICS AND MULTIMEDIA Computer-Aided Design (CAD) softwareComputer-Aided Design (CAD) software – –

allows users to create engineering, architectural allows users to create engineering, architectural and scientific designs. Examples: Autovis, and scientific designs. Examples: Autovis, AutocadAutocad

Desktop Publishing softwareDesktop Publishing software – allows users – allows users to design and produce page layout and to design and produce page layout and sophisticated documents. Examples: Adobe sophisticated documents. Examples: Adobe Pagemaker, QuarkXPress, Microsoft PublisherPagemaker, QuarkXPress, Microsoft Publisher

Web Page Design SoftwareWeb Page Design Software – Allows users to – Allows users to design and produce web pages. Examples: design and produce web pages. Examples: Dreamweaver, FrontPage, HyperstudioDreamweaver, FrontPage, Hyperstudio

Image Editing SoftwareImage Editing Software – Gives users – Gives users the capability to modify existing images. the capability to modify existing images. Examples: Photodraw, Director, PhotoshopExamples: Photodraw, Director, Photoshop

Video/Audio Editing softwareVideo/Audio Editing software – allows – allows users to modify video/audio segment. users to modify video/audio segment. Example: AuthowareExample: Authoware

Multimedia Authoring softwareMultimedia Authoring software – – allows users to create electronic allows users to create electronic interactive presentations that can include interactive presentations that can include text, images, video, audio and animation. text, images, video, audio and animation. Examples: Illustrator, Hyperstudio, Flash, Examples: Illustrator, Hyperstudio, Flash, ToolBook.ToolBook.

CATEGORY OF CATEGORY OF APPLICATION APPLICATION SOFTWARESOFTWARE

Home, Personal and Educational Home, Personal and Educational UseUse

Integrated softwareIntegrated software – combines – combines several productivity software several productivity software applications that share a similar interface applications that share a similar interface and common features into a single and common features into a single package. Examples: Lotus Suite, package. Examples: Lotus Suite, Microsoft Office, Microsoft works, Claris Microsoft Office, Microsoft works, Claris works.works.

Personal Finance softwarePersonal Finance software – Is an – Is an accounting program that helps pay bills, accounting program that helps pay bills, balance a checkbook, track income and balance a checkbook, track income and expenses, follow investments and expenses, follow investments and evaluate financial plans. Examples: evaluate financial plans. Examples: Quicken, QuickBooks, PeachTree.Quicken, QuickBooks, PeachTree.

Legal SoftwareLegal Software – Assists in the – Assists in the creation of legal documents and creation of legal documents and provides legal advice.provides legal advice.

Photo-editing softwarePhoto-editing software – Is used – Is used to edit digital photographs. to edit digital photographs. Examples: PhotoDrawExamples: PhotoDraw

Clip Art/ Image GalleryClip Art/ Image Gallery – Is a – Is a collection of clip art and collection of clip art and photographs that can be used in all photographs that can be used in all types of documents.types of documents.

Home Design/ Landscaping Home Design/ Landscaping softwaresoftware – Assists users in – Assists users in planning and remodeling.planning and remodeling.

Educational SoftwareEducational Software – Teaches users a – Teaches users a particular skill and gives lessons about any particular skill and gives lessons about any subject. Examples: MATLAB, Medical subject. Examples: MATLAB, Medical Insurance & Coding, Activity Software, Insurance & Coding, Activity Software, Agri-science, Activity SoftwareAgri-science, Activity Software

Entertainment softwareEntertainment software – Includes – Includes interactive games, videos and other interactive games, videos and other programs designed to support a hobby or programs designed to support a hobby or provide amusement. Examples: Final provide amusement. Examples: Final fantasy, starcraft, counterstrike, Redalert, fantasy, starcraft, counterstrike, Redalert, Battlerealm.Battlerealm.

COMMUNICATIONSCOMMUNICATIONS E-mail softwareE-mail software – Is used to create, send, – Is used to create, send,

receive, forward, store, print, and delete receive, forward, store, print, and delete electronic mail. Examples: Eudora, Outlook, electronic mail. Examples: Eudora, Outlook, NetscapeNetscape

Web BrowserWeb Browser – Is a software application used – Is a software application used to acces and view web pages. Examples: to acces and view web pages. Examples: Internet Explorer, Netscape NavigatorInternet Explorer, Netscape Navigator

Chat client softwareChat client software – allows a user to – allows a user to connect to a chat room and chat via the connect to a chat room and chat via the computer. Examples: Internet Relay Chat (IRC), computer. Examples: Internet Relay Chat (IRC), Microsoft Internet Relay Chat (MIRC), ICQMicrosoft Internet Relay Chat (MIRC), ICQ

CATEGORY OF APPLICATION CATEGORY OF APPLICATION SOFTWARESOFTWARE

Groupware software-Groupware software- Helps groups of Helps groups of people on a network to work together people on a network to work together and share information.and share information.

Videoconference softwareVideoconference software – allows a – allows a meeting between two or more meeting between two or more geographically-separated users to use a geographically-separated users to use a network or the internet to transmit audio network or the internet to transmit audio and video data. and video data.

Examples: Net MeetingExamples: Net Meeting There are three basic types of application There are three basic types of application

software: commercial shareware and open software: commercial shareware and open source. Commercial software come source. Commercial software come prepackaged and is available form software prepackaged and is available form software vendors, commercial software must be vendors, commercial software must be purchased. Shareware are software developed purchased. Shareware are software developed and released as demonstration versions of their and released as demonstration versions of their commercial product. Each demonstration copy commercial product. Each demonstration copy has an expiration date which gives the user has an expiration date which gives the user ample time to evaluate and decide whether to ample time to evaluate and decide whether to purchase the product or not. Open Source purchase the product or not. Open Source software is created by generous programmers software is created by generous programmers and released to the public domain for free and and released to the public domain for free and for public use.for public use.

PEOPLEWAREPEOPLEWARE

The skilled workers in the Information The skilled workers in the Information Technology field are considered are Technology field are considered are considered as the peopleware. The major considered as the peopleware. The major compositions of these IT professionals are compositions of these IT professionals are the management group, systems, and the management group, systems, and procedures group, programming group procedures group, programming group and the computer’s operations group.and the computer’s operations group.

Because of the pervasiveness of Because of the pervasiveness of computers, the need for trained workers in computers, the need for trained workers in the Information Technology field has the Information Technology field has increased exponentially. There are increased exponentially. There are different titles used to describe the major different titles used to describe the major composition of the peopleware.composition of the peopleware.

MAJOR IT GROUPS AND MAJOR IT GROUPS AND DESCRIPTIONDESCRIPTION

Management GroupManagement Group– Computer Systems Manager – Directs and Computer Systems Manager – Directs and

plans programming, computer operations and plans programming, computer operations and data processing. Also coordinates the data processing. Also coordinates the development of computer hardware systems development of computer hardware systems design and software. Like all managers, he/she design and software. Like all managers, he/she performs the functions of planning, organizing, performs the functions of planning, organizing, staffing and controlling the project. He/She staffing and controlling the project. He/She should possess technical competence, should possess technical competence, managerial skills, knowledge of the business managerial skills, knowledge of the business process and the ability to communicate and process and the ability to communicate and motivate people.motivate people.

Systems and Procedures GroupSystems and Procedures GroupComputer Scientist/Computer Engineer/System Computer Scientist/Computer Engineer/System

Analyst- With expertise in hardware or software Analyst- With expertise in hardware or software design, they analyze, develop and apply design, they analyze, develop and apply principles to produce computer applications and principles to produce computer applications and gadgets. They also design, programming tools, gadgets. They also design, programming tools, knowledge-based systems and computer games. knowledge-based systems and computer games. Basically, they must be able to think logically; Basically, they must be able to think logically; must have good communication skills; and must must have good communication skills; and must be able to work under pressure, concentrate and be able to work under pressure, concentrate and pay close attention to details; and must be pay close attention to details; and must be lifelong learners to upgrade their technical lifelong learners to upgrade their technical expertise.expertise.

Programming GroupProgramming Group– Computer Programmer – Responsible for writing, testing Computer Programmer – Responsible for writing, testing

and maintaining detailed instruction or programs, a and maintaining detailed instruction or programs, a computer programmer is often referred to by the computer programmer is often referred to by the language he/she knows or the type of environment language he/she knows or the type of environment he/she generally works in like the Java, Cobol, web-he/she generally works in like the Java, Cobol, web-based programmers, etc. He/She must be a critical based programmers, etc. He/She must be a critical thinker; able to pay close attention to minute details; thinker; able to pay close attention to minute details; must have the drive and motivation to work with must have the drive and motivation to work with minimum supervision; must have the patience, minimum supervision; must have the patience, persistence and perseverance to make and debug persistence and perseverance to make and debug programs; can work under pressure; must have the programs; can work under pressure; must have the ingenuity, creativeness and imagination to develop new ingenuity, creativeness and imagination to develop new problem-solving techniques; with good communication problem-solving techniques; with good communication and interpersonal skills; and must be a lifelong learner to and interpersonal skills; and must be a lifelong learner to hone expertise.hone expertise.

COMPUTER OPERATIONS COMPUTER OPERATIONS GROUPGROUP

1. Computer Operator – the computer sets up the 1. Computer Operator – the computer sets up the processor and related equipment, loads and processor and related equipment, loads and unloads programs, and ensures proper and unloads programs, and ensures proper and correct operations of the computer.correct operations of the computer.

2. Data Encoder/Data Entry Operator – A data 2. Data Encoder/Data Entry Operator – A data encoder prepares and encodes documents to encoder prepares and encodes documents to transform source document into machine transform source document into machine readable and acceptable inputs.readable and acceptable inputs.

3. Computer Librarian – A computer Librarian is 3. Computer Librarian – A computer Librarian is responsible for cataloguing, storing and responsible for cataloguing, storing and securing processed storage media like disks and securing processed storage media like disks and tapes.tapes.

CLASSIFICATION OF CLASSIFICATION OF COMPUTERSCOMPUTERS

Today computers come in different sizes and Today computers come in different sizes and shapes, and with unlimited computing shapes, and with unlimited computing capabilities. Because of the rapid development in capabilities. Because of the rapid development in hardware and software, and the changing needs hardware and software, and the changing needs of the users, we find big and bulky mainframe of the users, we find big and bulky mainframe computers and cute handheld palmtops.computers and cute handheld palmtops.

Computers may be classified into the following: Computers may be classified into the following: according to capacity, with their ability to perform according to capacity, with their ability to perform task, as well as their maximum number of task, as well as their maximum number of programs they can run; according to purpose, programs they can run; according to purpose, their goals and aims for a variety of tasks; and their goals and aims for a variety of tasks; and according to the type of processing, which are according to the type of processing, which are their special uses in different fields of work.their special uses in different fields of work.

CLASSIFICATION OF COMPUTERS CLASSIFICATION OF COMPUTERS ACCORDING TO PURPOSEACCORDING TO PURPOSE

CLASSIFICATION OF COMPUTERS ACCORDING TO CLASSIFICATION OF COMPUTERS ACCORDING TO CAPACITYCAPACITY

CAPABILITIES AND LIMITATIONS OF COMPUTERSCAPABILITIES AND LIMITATIONS OF COMPUTERS Some of the things computers can do:Some of the things computers can do: They can do repetitive and routine workThey can do repetitive and routine work They have the speed to process They have the speed to process

voluminous data in a flash, resulting in voluminous data in a flash, resulting in greater productivity and less manpower greater productivity and less manpower needs.needs.

Computers are reliable and accurateComputers are reliable and accurate They can store and recall tremendous They can store and recall tremendous

amount of information.amount of information.

Computers have a self-checking capabilityComputers have a self-checking capability Computers can be self-operatingComputers can be self-operating They can do remote processingThey can do remote processing With all the capabilities mentioned above, With all the capabilities mentioned above,

computers still have limitations. They are always computers still have limitations. They are always dependent on instructions and data given through dependent on instructions and data given through the program made by the programmer. They can the program made by the programmer. They can never generate information on their own, can never generate information on their own, can never correct wrong instructions, cannot decide if never correct wrong instructions, cannot decide if they were not programmed for certain specific they were not programmed for certain specific tasks and are vulnerable to a virus attack.tasks and are vulnerable to a virus attack.

Computer software and systemsComputer software and systems

Software is the general term applied to the Software is the general term applied to the instructions that direct the computer’s instructions that direct the computer’s hardware to perform work. It is distinguished hardware to perform work. It is distinguished form hardware by its conceptual rather than form hardware by its conceptual rather than physical nature. Hardware consists of physical physical nature. Hardware consists of physical components, whereas software consists of components, whereas software consists of instructions communicated electronically to the instructions communicated electronically to the hardware. Software is needed for two purposes. hardware. Software is needed for two purposes. First, computers do not directly understand First, computers do not directly understand human language, and software is needed to human language, and software is needed to translate instructions created in human translate instructions created in human language into machine language. At the language into machine language. At the machine level, computers can understand only machine level, computers can understand only binary numbers, not English or any other binary numbers, not English or any other human language.human language.

Second, packaged or stored software is needed to Second, packaged or stored software is needed to make the computer an economical work tool. make the computer an economical work tool. Users create their own software every time they Users create their own software every time they needed to use the computer. However, writing needed to use the computer. However, writing software instructions (programming) is extremely software instructions (programming) is extremely difficult, time-consuming, and, for most people, difficult, time-consuming, and, for most people, tedious. It is much more practical and economical tedious. It is much more practical and economical for one highly skilled person or programming for one highly skilled person or programming team to develop programs that many other team to develop programs that many other people can buy and use to do common tasks. people can buy and use to do common tasks. Software is supplied as organized instruction sets Software is supplied as organized instruction sets called “programs,” or more typically as a set of called “programs,” or more typically as a set of related programs called a “package.”related programs called a “package.”

For example, several prominent software For example, several prominent software companies sell their own version of a companies sell their own version of a package of programs that are typically package of programs that are typically needed to support an office computer, needed to support an office computer, including a word processor, a spread including a word processor, a spread sheet, a graphics program, and sometimes sheet, a graphics program, and sometimes a database manager. Programs translate a database manager. Programs translate operations the user needs into language operations the user needs into language and instructions that the computer can and instructions that the computer can understand. By itself, computer hardware understand. By itself, computer hardware is merely a collection of printed circuits, is merely a collection of printed circuits, plastic, metal and wires. Without software, plastic, metal and wires. Without software, hardware is malfunctional.hardware is malfunctional.

Open source and Free softwareOpen source and Free software

Most nurses use OSS/FS on a daily basis, but Most nurses use OSS/FS on a daily basis, but without even realizing it. Everybody who sends e-without even realizing it. Everybody who sends e-mail or uses the Web uses OSS/FS most of the mail or uses the Web uses OSS/FS most of the time, as the majority of the hardware and time, as the majority of the hardware and software that allows the Internet to function (Wen software that allows the Internet to function (Wen servers, file transmission protocol [FTP] servers, servers, file transmission protocol [FTP] servers, and mail systems) are OSS/FS. Many popular Web and mail systems) are OSS/FS. Many popular Web sites are hosted on Apache (OSS/FS) servers, for sites are hosted on Apache (OSS/FS) servers, for example, Amazom, Google, and Yahoo. While free example, Amazom, Google, and Yahoo. While free software ( as defined by the Free Software software ( as defined by the Free Software Foundation [FSF]; has existed since the mid-Foundation [FSF]; has existed since the mid-1980s, the GNU is Not Unix Project (GNU)/Linux 1980s, the GNU is Not Unix Project (GNU)/Linux Operating system has been developing since the Operating system has been developing since the early 1990s, and the open source initiative (OSI).early 1990s, and the open source initiative (OSI).

A number of acronyms are used to denote a A number of acronyms are used to denote a combination of free software and open source combination of free software and open source software.software.– OSS – open source software/free softwareOSS – open source software/free software– FOSS – free and open source softwareFOSS – free and open source software– FLOSS – free/libre/open source softwareFLOSS – free/libre/open source software– GNU – GNU is Not Unix Project ( a recursive acronym)- a GNU – GNU is Not Unix Project ( a recursive acronym)- a

project started by Richard Stallman that has turned into project started by Richard Stallman that has turned into the FSF to develop and promote alternatives to the FSF to develop and promote alternatives to proprietary Unix implementation.proprietary Unix implementation.

– GNU.Linux or Linux – the complete operating system GNU.Linux or Linux – the complete operating system including the Linux kernel, the GNU components, and including the Linux kernel, the GNU components, and many other programs.many other programs.

OSS/FS –The TheoryOSS/FS –The Theory

BackgroundBackground While we use the term “open source” (and While we use the term “open source” (and

the acronym OSS/FS) in this chapter, we the acronym OSS/FS) in this chapter, we do so loosely (and some would argue, do so loosely (and some would argue, incorrectly) to cover several concepts, incorrectly) to cover several concepts, including open source software, free including open source software, free software, and GNU/Linux. Each of these software, and GNU/Linux. Each of these concepts and applications has their own concepts and applications has their own definitions and attributes.definitions and attributes.

Free Software DefinitionFree Software Definition Is defined by the FSF in terms of four freedoms for the Is defined by the FSF in terms of four freedoms for the

software user, i.e. to have the freedom to use, study, software user, i.e. to have the freedom to use, study, redistribute, and improve the software in any way they redistribute, and improve the software in any way they wish. A program is only free software if users have all of wish. A program is only free software if users have all of these freedoms. Confusion around the use and meaning of these freedoms. Confusion around the use and meaning of the term “free software” arises from the multiple meanings the term “free software” arises from the multiple meanings of the word “free” in the English language. In other of the word “free” in the English language. In other languages there is less of problem, with different words languages there is less of problem, with different words being used for the “freedom” versus “no cost” meanings of being used for the “freedom” versus “no cost” meanings of “free”- most notably the French word “libre” the free of free “free”- most notably the French word “libre” the free of free software is defined in terms of :liberty, not price” and to software is defined in terms of :liberty, not price” and to understand the concepts, one needs to think of “free” as in understand the concepts, one needs to think of “free” as in “free speech,” not as in free beer.“free speech,” not as in free beer.

Open Source Software DefinitionOpen Source Software Definition Is any software that satisfies the open Is any software that satisfies the open

software initiative’s definition. The open software initiative’s definition. The open source concept is said to promote software source concept is said to promote software reliability and quality by supporting reliability and quality by supporting independent peer review and rapid independent peer review and rapid evolution of source code, as well s making evolution of source code, as well s making the source code of software freely the source code of software freely available.available.

OSS/FS Development OSS/FS Development Models/SystemsModels/Systems

The development models of OSS/Fs are The development models of OSS/Fs are said to contribute to its distinctions form said to contribute to its distinctions form proprietary software. Shaw et al. (2002) proprietary software. Shaw et al. (2002) state that OSS/FS has been “developed” state that OSS/FS has been “developed” and disseminated in an open forum, then and disseminated in an open forum, then it “revolutionizes the way in which it “revolutionizes the way in which software has historically been developed software has historically been developed and distributed”. A similar description, in a and distributed”. A similar description, in a United Kingdom government report, United Kingdom government report, emphasizes the open publishing of source emphasizes the open publishing of source doe and that development os often largely doe and that development os often largely through voluntary efforts.through voluntary efforts.

Choosing OSS/FS or NotChoosing OSS/FS or Not Proposed Benefits of OSS/FSProposed Benefits of OSS/FS OSS/FS has been described as the OSS/FS has been described as the

electroonic equivalent of generic drugs. In electroonic equivalent of generic drugs. In the same way as the formulas for generic the same way as the formulas for generic drugs are made public, so OSS/Fs source drugs are made public, so OSS/Fs source code is accessible to the user.code is accessible to the user.

As OSS/FS can be obtained royalty free, it As OSS/FS can be obtained royalty free, it is less expensive to acquire than is less expensive to acquire than proprietary alternatives. This means proprietary alternatives. This means OSS/FS can transform healthcare in OSS/FS can transform healthcare in developing countries just as the developing countries just as the availability of generic drugs have.availability of generic drugs have.

Data ProcessingData Processing

Defining Data, Databases, Information, and Defining Data, Databases, Information, and Information SystemsInformation Systems

Data are raw uninterrupted facts that are without Data are raw uninterrupted facts that are without meaning. For example, a patient’s weight is meaning. For example, a patient’s weight is recorded as 140 lb, without additional information recorded as 140 lb, without additional information this fact or datum cannot be interrupted. The this fact or datum cannot be interrupted. The patient could be a young child who is overweight patient could be a young child who is overweight or an adult who is several pounds underweight. or an adult who is several pounds underweight. When data are interpreted, information is When data are interpreted, information is produced. While data are meaningless, produced. While data are meaningless, information by definition is meaningful. For data information by definition is meaningful. For data to be interpreted and information produced, the to be interpreted and information produced, the data must be processed. This means that the data must be processed. This means that the data are organized so that patterns and data are organized so that patterns and relationships between the data can be identified. relationships between the data can be identified. There are several approaches to organizing data.There are several approaches to organizing data.

Types of DataTypes of Data When developing automated When developing automated

database systems, each data database systems, each data element is defined. As part of this element is defined. As part of this process, the data classified. There process, the data classified. There are two primary approaches to are two primary approaches to classifying data in a database classifying data in a database system. First, they are classified in system. First, they are classified in terms of how these data will be used terms of how these data will be used by the user. by the user.

Computer-Based Data typesComputer-Based Data types Alphanumeric data include letters and Alphanumeric data include letters and

numbers in any combination; however, the numbers in any combination; however, the numbers in an alphanumeric filed cannot numbers in an alphanumeric filed cannot perform numeric function. For example, an perform numeric function. For example, an address is alphanumeric data that may address is alphanumeric data that may include both numbers and letters. A social include both numbers and letters. A social security number is an example of security number is an example of alphanumeric data made up of numbers. It alphanumeric data made up of numbers. It makes no logical sense to add or perform makes no logical sense to add or perform any other numerical functions on either any other numerical functions on either addresses or social security numbers.addresses or social security numbers.

Conceptual Data TypesConceptual Data Types Conceptual data types reflect how Conceptual data types reflect how

users view the data. These can be users view the data. These can be based on the source of the data, For based on the source of the data, For example, the lab produces lab data, example, the lab produces lab data, and the x-ray department produces and the x-ray department produces image data.image data.

Database management SystemsDatabase management Systems DBMS are computer programs used DBMS are computer programs used

to input, store, modify, process and to input, store, modify, process and access data in a database. Before a access data in a database. Before a DBMS can be used, the DBM software DBMS can be used, the DBM software must first be configured to manage must first be configured to manage the data specific to the project.the data specific to the project.

This process of configuring the This process of configuring the database software is called database database software is called database system design. Once the software is system design. Once the software is configured for the project, the configured for the project, the database software is used to enter database software is used to enter the project data into the computer. the project data into the computer.

Advantages of Automated Database ManagementAdvantages of Automated Database Management Automated DBMS decrease data redundancy, Automated DBMS decrease data redundancy,

increase data consistency, and improve access to increase data consistency, and improve access to all data. These advantages result form the fact all data. These advantages result form the fact that in a well-designed automated system all data that in a well-designed automated system all data exist on only one place. The datum is never exist on only one place. The datum is never repeated. Data redundancy occurs when the repeated. Data redundancy occurs when the same data are stored in the database more than same data are stored in the database more than once. Making a copy of class notes to store the once. Making a copy of class notes to store the same notes in two different folders is an example same notes in two different folders is an example of data redundancy.of data redundancy.

ID F-Name L-Name Address-1 Address-2 City St

01 Betty Smith SRU, School of

nursing

20 North St. Pgh PA

02 Leslie Brown DBMS Institute

408 Same st. NY NY

03 Dori Jones Party Place 5093 Butter St.

Any VA

04 Glenn Clark Univ of Study

987 Carriag

e Rd

Types of FilesTypes of Files Within a DBMS, there are two basic types Within a DBMS, there are two basic types

of files. These are the data files, as of files. These are the data files, as described in the previous section, and the described in the previous section, and the processing files that direct the computer processing files that direct the computer activities. On a personal computer, it is activities. On a personal computer, it is easy to see a list of the files that are easy to see a list of the files that are stored on the computer. For example, on a stored on the computer. For example, on a computer using one of the Windows computer using one of the Windows Operating Systems, drives. At this point, a Operating Systems, drives. At this point, a list if files and folders will usually be list if files and folders will usually be displayed. If folders are displayed, simply displayed. If folders are displayed, simply open the folders by clicking on them. The open the folders by clicking on them. The name for each file will be displayed.name for each file will be displayed.

Processing FilesProcessing Files Executable files consist of a computer Executable files consist of a computer

program or set of instructions that, when program or set of instructions that, when executed, causes the computer to open or executed, causes the computer to open or start a specific computer program or start a specific computer program or function. These are the files that tell a function. These are the files that tell a computer what actions the computer computer what actions the computer should perform when running a program. should perform when running a program. For example, running a SET-UP.EXE file will For example, running a SET-UP.EXE file will tell the computer to begin installing the tell the computer to begin installing the related computer program on the related computer program on the computer. On a personal computer, most computer. On a personal computer, most executable files end with the extension executable files end with the extension EXE.EXE.

Data FilesData Files Data files contain data that have been captured Data files contain data that have been captured

and stored on a computer using a software and stored on a computer using a software program. Many times the extension for the file program. Many times the extension for the file identifies the software program used to create identifies the software program used to create the file. For example, a document created in the file. For example, a document created in Microsoft Word will have the extension DOC. Microsoft Word will have the extension DOC. Sometimes the extension indicates the format, Sometimes the extension indicates the format, especially if it is a standard format used across especially if it is a standard format used across several computer programs. For example, a word several computer programs. For example, a word processing document can be saved as “text processing document can be saved as “text only”. This means that formatting specific to the only”. This means that formatting specific to the software program is stripped off. In this case, the software program is stripped off. In this case, the standard extension is TXT.standard extension is TXT.

Database ModelDatabase Model

A database system provides access to A database system provides access to both the data in the database and to the both the data in the database and to the interrelationship within and between the interrelationship within and between the various data elements. Building a various data elements. Building a database begins by identifying these data database begins by identifying these data elements and the relationship that exist elements and the relationship that exist between the data elements. The American between the data elements. The American National Standards Institute (ANSI) National Standards Institute (ANSI) Standards Planning and Requirements Standards Planning and Requirements Committee SPARC.Committee SPARC.

Conceptual ModelsConceptual Models A conceptual model includes a diagram and A conceptual model includes a diagram and

narrative description of data elements, their narrative description of data elements, their attributes and the relationship between the data. attributes and the relationship between the data. It defines the structure of the whole database in It defines the structure of the whole database in terms of the attributes of the entities (data terms of the attributes of the entities (data elements) relationships, constraints, and elements) relationships, constraints, and operation. For example, there may be a database operation. For example, there may be a database system to manage patient medication orders. system to manage patient medication orders. With each individual order, there will be several With each individual order, there will be several data elements. The data elements include the data elements. The data elements include the specific medication, the dose, the time and specific medication, the dose, the time and frequency of administration, the route of frequency of administration, the route of administration, and any specific directions for administration, and any specific directions for administering the medication.administering the medication.

Structural or Physical Data ModelsStructural or Physical Data Models

The physical data model includes The physical data model includes each of the data elements and the each of the data elements and the relationship between the data relationship between the data elements, as they will be physically elements, as they will be physically stored on the computer. There are stored on the computer. There are four primary approaches to the four primary approaches to the development of a physical data development of a physical data model. model.

1.1. Heirarchical – have been compared to Heirarchical – have been compared to inverted trees. All access to data starts inverted trees. All access to data starts at the top of the hierarchy or at the root. at the top of the hierarchy or at the root. The table at the root will have pointers The table at the root will have pointers called branches that will point to tables called branches that will point to tables with data that relate hierarchically to the with data that relate hierarchically to the root. Each table is referred to as a node. root. Each table is referred to as a node. For example, a master index might For example, a master index might include pointers to each patient’s record include pointers to each patient’s record node. Each of the patient record nodes node. Each of the patient record nodes could include pointers to lab data, could include pointers to lab data, radiology data, and medication data for radiology data, and medication data for that patient.that patient.

2. Network Model – developed from hierarchical models. In a 2. Network Model – developed from hierarchical models. In a network model, the child node is not limited to one network model, the child node is not limited to one parent. This makes it possible for a network model to parent. This makes it possible for a network model to represent many-to-many relationships; however, the represent many-to-many relationships; however, the presence of multiple links between data does make it presence of multiple links between data does make it more difficult if data relationship changes and redesign is more difficult if data relationship changes and redesign is needed.needed.

3. Relational Database Models – Relational database models 3. Relational Database Models – Relational database models consist of a series of files set up as tables. Each column consist of a series of files set up as tables. Each column represents an attribute and each row is a record. Another represents an attribute and each row is a record. Another name for a row is “tuple”. The intersection is the row and name for a row is “tuple”. The intersection is the row and the column is cell. The datum in the cell is the the column is cell. The datum in the cell is the manifestation of the attribute for that record.manifestation of the attribute for that record.

4. Object-Oriented Model – An object-4. Object-Oriented Model – An object-oriented database was developed oriented database was developed because the rational model has a because the rational model has a limited ability to deal with binary limited ability to deal with binary large objects or BLOBs. BLOBs are large objects or BLOBs. BLOBs are complex data types such as images, complex data types such as images, sounds, spreadsheets, or text sounds, spreadsheets, or text messages messages

Database Life CycleDatabase Life Cycle

The development and use of a DBMS The development and use of a DBMS follow a systematic process called follow a systematic process called the life cycle of a database system. the life cycle of a database system. The number of steps used to The number of steps used to describe this process can vary from describe this process can vary from one author to another.one author to another.

InitiationInitiation

Occurs when a need or problem is Occurs when a need or problem is identified and the development of a identified and the development of a DBMS is seen as a potential solution. DBMS is seen as a potential solution. This initial assessment looks at what This initial assessment looks at what is the need, what are the current is the need, what are the current approaches, and what are the approaches, and what are the potential options for dealing with the potential options for dealing with the need.need.

Planning and AnalysisPlanning and Analysis This step begins with an assessment of the users This step begins with an assessment of the users

view and the development of the conceptual view and the development of the conceptual model. What are all the information needs of the model. What are all the information needs of the department and how is the information used? department and how is the information used? This includes the internal and external uses of This includes the internal and external uses of information. External needs for information come information. External needs for information come from outside the department. What are all the from outside the department. What are all the reports that the department has been unable to reports that the department has been unable to fill? What information would the department like fill? What information would the department like to report but has not reported because it is too to report but has not reported because it is too difficult or time-consuming to collect the data?difficult or time-consuming to collect the data?

Detailed Systems DesignDetailed Systems Design

Begins with the selection of the Begins with the selection of the physical model; hierarchical, physical model; hierarchical, network, relational, or object-network, relational, or object-oriented. Using the physical model, oriented. Using the physical model, each table and the relationship each table and the relationship between the tables are developed.between the tables are developed.

ImplementationImplementation

Includes training the users, testing Includes training the users, testing the system, developing a procedure the system, developing a procedure a manual for use of the system, a manual for use of the system, piloting the BMS, and finally “going piloting the BMS, and finally “going live”. The procedure manual outlines live”. The procedure manual outlines the “rules” for how the system is the “rules” for how the system is used in day-to-day operations.used in day-to-day operations.

Evaluation and MaintenanceEvaluation and Maintenance

When a new database system has been When a new database system has been installed, the developers and users can be installed, the developers and users can be very anxious to immediately evaluate the very anxious to immediately evaluate the system. Initial or early evaluations may system. Initial or early evaluations may have limited value. It will take a few weeks have limited value. It will take a few weeks or even months for users to adjust their or even months for users to adjust their work routines to this new approach to work routines to this new approach to information management. The first information management. The first evaluation should be informal and focus evaluation should be informal and focus more on troubleshooting specific more on troubleshooting specific problems.problems.

Common Database OperationsCommon Database Operations

DBMSs vary form small program DBMSs vary form small program running on a personal computer to running on a personal computer to massive programs that manage the massive programs that manage the data for large international data for large international enterprises. No matter what size or enterprises. No matter what size or how a DBMS is used, there are how a DBMS is used, there are common operations that are common operations that are performed by all DBMSs.performed by all DBMSs.

Data Input OperationsData Input Operations

Are used to enter new data, update data in Are used to enter new data, update data in the system, or change/modify data in the the system, or change/modify data in the DBMS. Data are usually entered through a DBMS. Data are usually entered through a set of screens that have been designed for set of screens that have been designed for data entry. A well-designed screen will data entry. A well-designed screen will discourage data entry errors. In addition, discourage data entry errors. In addition, the program can be designed to alert the the program can be designed to alert the user to potential errors or to prevent user to potential errors or to prevent obvious data errors. obvious data errors.

Data Processing ProcessesData Processing Processes

Are DBMS directed actions that the Are DBMS directed actions that the computer performs on the data once computer performs on the data once entered into the system. It is these entered into the system. It is these processes that are used convert raw processes that are used convert raw data into meaningful information. data into meaningful information. These include common database These include common database functions discussed previously in this functions discussed previously in this chapter.chapter.

Data Output OperationsData Output Operations

This section includes online and This section includes online and written reports. The approach to written reports. The approach to designing these reports will have a designing these reports will have a major impact on what information major impact on what information the reader actually gains form the the reader actually gains form the report. Reports that are clear and report. Reports that are clear and concise help the reader see the concise help the reader see the information in the data. On the other information in the data. On the other hand, poorly designed reports can hand, poorly designed reports can mislead and confuse the reader.mislead and confuse the reader.

The Development of Data The Development of Data WarehousesWarehouses

Healthcare Institutions have been automating Healthcare Institutions have been automating their processes and developing databases since their processes and developing databases since the mid-1960s. In most institutions, the process the mid-1960s. In most institutions, the process began in two areas, the financial department and began in two areas, the financial department and in department systems.in department systems.

Some of the oldest and most developed Some of the oldest and most developed departmentals systems are in the labs, radiology, departmentals systems are in the labs, radiology, medical records, and cardiac departments. medical records, and cardiac departments. Initially, these systems developed as islands of Initially, these systems developed as islands of automation that were focused on the operational automation that were focused on the operational needs of the individual department. The needs of the individual department. The development of these systems and the interfaces development of these systems and the interfaces between these systems were strongly influenced between these systems were strongly influenced by the free-for-service approach to financing by the free-for-service approach to financing healthcare.healthcare.

Purposes of Data WarehousePurposes of Data Warehouse The development of a dat warehouse The development of a dat warehouse

requires a great deal of time, energy and requires a great deal of time, energy and money. An organization’s decision to money. An organization’s decision to develop a data warehouse is based on develop a data warehouse is based on several goals and purposes. Because of its several goals and purposes. Because of its integrated nature a data warehouse integrated nature a data warehouse spares users form the need to learn spares users form the need to learn several different applications. For several different applications. For example, a warehouse no longer requires example, a warehouse no longer requires healthcare providers to acces the lab healthcare providers to acces the lab reporting system to see lab work and use reporting system to see lab work and use a different result.a different result.

The Internet: A Nursing ResourceThe Internet: A Nursing Resource

In the years since its inception, the Internet has In the years since its inception, the Internet has had a tremendous impact on society, changing had a tremendous impact on society, changing the way we communicate, conduct business, the way we communicate, conduct business, obtain information, and manage our lives. While obtain information, and manage our lives. While Internet use is still concentrated in the more Internet use is still concentrated in the more developed areas of the world, it has served to developed areas of the world, it has served to globalize our thinking. From the comfort of one’s globalize our thinking. From the comfort of one’s home or office, a person can quickly and easily home or office, a person can quickly and easily access information from around the world. Often, access information from around the world. Often, the user is not even aware of the location of the the user is not even aware of the location of the information source. In a sense, the world has information source. In a sense, the world has become smaller, as we communicate in real time become smaller, as we communicate in real time with people on the other side of the globe.with people on the other side of the globe.

The History Of the InternetThe History Of the Internet The internet might never have come about, or at The internet might never have come about, or at

least would have been much longer in appearing, least would have been much longer in appearing, if in 1957 the Russians had not jolted the United if in 1957 the Russians had not jolted the United Sates out of its complacency by launching Sates out of its complacency by launching Sputnik. The result was the creation of the Sputnik. The result was the creation of the Advanced Research Project Agency (ARPA) by Advanced Research Project Agency (ARPA) by President Eisenhower. Housed in the Pentagon President Eisenhower. Housed in the Pentagon with the Department of Defense, ARPA worked with the Department of Defense, ARPA worked with the RAND Corporation’s think tank to solve with the RAND Corporation’s think tank to solve the problem of how U.S. authorities could the problem of how U.S. authorities could communicate after a nuclear war. These communicate after a nuclear war. These individuals realized that no matter how individuals realized that no matter how thoroughly a conventional system such as the thoroughly a conventional system such as the telephone network was protected, the switching telephone network was protected, the switching and wiring would be vulnerable to attack.and wiring would be vulnerable to attack.

Who Controls the Internet?Who Controls the Internet?

Today, the connection of all major Today, the connection of all major networks to the Internet represents networks to the Internet represents the pinnacle of computer the pinnacle of computer communication. The Internet itself communication. The Internet itself has no owners, censors, bosses, has no owners, censors, bosses, board of director, or stock holders. In board of director, or stock holders. In principle, any computer or network principle, any computer or network that obeys the protocols, which are that obeys the protocols, which are technical, not social or political, can technical, not social or political, can be equal player.be equal player.

The Technology Behind the The Technology Behind the InternetInternet

We have mentioned earlier that it was We have mentioned earlier that it was standardized communication protocols standardized communication protocols that enabled that Internet to function. A that enabled that Internet to function. A protocol, in plain English, is just an agreed protocol, in plain English, is just an agreed on format for doing something. On the on format for doing something. On the Internet, protocols determine how data will Internet, protocols determine how data will be transmitted between two devices, the be transmitted between two devices, the type of error checking that will be formed, type of error checking that will be formed, how data compression, if any, is how data compression, if any, is accomplished, how the sending computer accomplished, how the sending computer will signal that it has finished sending a will signal that it has finished sending a message, and how the receiving computer message, and how the receiving computer will signal that it has received a message.will signal that it has received a message.

The Domain Name System (DNS)The Domain Name System (DNS)

IN order for the computers on the Internet IN order for the computers on the Internet to perform the tasks required, they have to perform the tasks required, they have to have a way of identifying each other. to have a way of identifying each other. The Internet’s DNS permit us to give The Internet’s DNS permit us to give globally unique “names” to networks and globally unique “names” to networks and computers. There are several benefits to computers. There are several benefits to this system, First a name is easier to this system, First a name is easier to remember than the long string of numbers remember than the long string of numbers that makes up an IP address, which is that makes up an IP address, which is assigned to each computer on the assigned to each computer on the network.network.

Another benefit is that a name allows Another benefit is that a name allows for a change of physical location that for a change of physical location that is transparent to the user. For is transparent to the user. For instance, a computer could be instance, a computer could be moved from one city to another moved from one city to another without changing names, and without changing names, and someone using the Internet would someone using the Internet would not notice the move.not notice the move.

Top Level Domain (TLDs)Top Level Domain (TLDs)

Each country as of 2003, has a two-Each country as of 2003, has a two-letter TLD. Example, Canada os .CA, letter TLD. Example, Canada os .CA, Great Britain is .UK, Germany is .DE Great Britain is .UK, Germany is .DE and Switzerland .CH.and Switzerland .CH.

Current Top Level Domain NamesCurrent Top Level Domain Names .AERO - for the air transport industry.AERO - for the air transport industry .BIZ – for businesses.BIZ – for businesses .COM – Commercial/business organizations.COM – Commercial/business organizations .COOP – for cooperatives.COOP – for cooperatives .EDU – Restricted to 4-year degree granting institutions in .EDU – Restricted to 4-year degree granting institutions in

North AmericaNorth America .GOV – Restricted to the U.S. federal government.GOV – Restricted to the U.S. federal government .INFO – for all users.INFO – for all users .INT – Restricted to organizations that were established by .INT – Restricted to organizations that were established by

international treatyinternational treaty .NET – For network resources.NET – For network resources .ORG – For non-profit organizations’.ORG – For non-profit organizations’ .PRO – for professions.PRO – for professions

How Large is the Internet?How Large is the Internet?

Results from the domain survey, Results from the domain survey, which sought to discover every host which sought to discover every host on the Internet , were released by on the Internet , were released by the Internet Software Consortium on the Internet Software Consortium on March 15, 2001, from data collected March 15, 2001, from data collected during January of the same year. The during January of the same year. The survey indicated that at that time, survey indicated that at that time, the Internet had over 109 million the Internet had over 109 million host in 230 countries.host in 230 countries.

Use of the Internet – Then and NowUse of the Internet – Then and Now

Even though the original purpose for creating Even though the original purpose for creating networks was intended to be computer sharing, it networks was intended to be computer sharing, it did not take long for users to realize that they did not take long for users to realize that they could also send message to one another. Indeed, could also send message to one another. Indeed, they become far more enthusiastic about this they become far more enthusiastic about this function than the original. The e-mail software function than the original. The e-mail software was made freely available to anyone who wanted was made freely available to anyone who wanted it, which was typical of the atmosphere of the it, which was typical of the atmosphere of the Internet in its first two decades. The people Internet in its first two decades. The people involved developed applications that they freely involved developed applications that they freely shared with others. These applications could be shared with others. These applications could be software for any purpose, files of information, or software for any purpose, files of information, or pictures.pictures.

File Transfer ProtocolFile Transfer Protocol

The FTP was mentioned above as the The FTP was mentioned above as the method used by early internauts (a method used by early internauts (a moniker for users of the Internet) to moniker for users of the Internet) to upload files to and download files from upload files to and download files from distant computers. FTP used the Internet’s distant computers. FTP used the Internet’s TCP/IP protocols for the transfer data. TCP/IP protocols for the transfer data. Uploading a file refers to the process of Uploading a file refers to the process of moving a file form the user’s computer to moving a file form the user’s computer to another computer.another computer.

TelnetTelnet

Mentioned earlier as one of the Mentioned earlier as one of the protocols used on the Internet, a protocols used on the Internet, a terminal emulation that is part of the terminal emulation that is part of the TCP/IP protocols. Telnet allows a TCP/IP protocols. Telnet allows a connecting computer to behave like connecting computer to behave like a terminal for a distant computer a terminal for a distant computer regardless of the type of computer regardless of the type of computer that is either the target or originator that is either the target or originator of the Telnet session.of the Telnet session.

Usenet News and Online ForumsUsenet News and Online Forums

There are several types of discussion groups on There are several types of discussion groups on the Internet: newsgroups, online forums, and the Internet: newsgroups, online forums, and mailing list. Newsgroups are a sort of worldwide mailing list. Newsgroups are a sort of worldwide bulletin board system that is accessed using bulletin board system that is accessed using software called a news-reader. WWW browser software called a news-reader. WWW browser contains a news-reader that tracks the messages contains a news-reader that tracks the messages that you have read and can be set up to allow that you have read and can be set up to allow you to easily access new messages. It also allows you to easily access new messages. It also allows you to post a message to the group. There are you to post a message to the group. There are newsgroups on almost every topic. They were newsgroups on almost every topic. They were originally organized hierarchically under seven originally organized hierarchically under seven main headings, but with the explosion of the main headings, but with the explosion of the Internet there are now more upper level Internet there are now more upper level headings.headings.

E-mailE-mail

One of the most popular uses for the One of the most popular uses for the Internet remains the ability to send Internet remains the ability to send and receive electronic mail or e-mail. and receive electronic mail or e-mail. The number of email users is growing The number of email users is growing rapidly. Many individuals have more rapidly. Many individuals have more than one email address, using each than one email address, using each for different purposes.for different purposes.

The Anatomy of an E-mail AddressThe Anatomy of an E-mail Address

Recall that the Internet works because all Recall that the Internet works because all computers that are connected use the computers that are connected use the same protocol. Therefore, all e-mail same protocol. Therefore, all e-mail addresses follow the same format. An e-addresses follow the same format. An e-mail address has two parts, separated by mail address has two parts, separated by the “@” sign. The first part is what may be the “@” sign. The first part is what may be called the user name, user ID, or login called the user name, user ID, or login name. Some organizations let users select name. Some organizations let users select their user name, while other assign them their user name, while other assign them based on a system such as first name. You based on a system such as first name. You may find such symbols as an underline(_), may find such symbols as an underline(_), a hyphen (-), or even a percent sign (%) or a hyphen (-), or even a percent sign (%) or pound sign(#) in the user name. pound sign(#) in the user name.

[email protected] | | |

User ID Name of Domain Name Computer

Using E-mailUsing E-mail

To send and receive e-mail, besides To send and receive e-mail, besides having an account on the Internet that having an account on the Internet that provides an e-mail address and having a provides an e-mail address and having a computer, you need communication computer, you need communication software. The function that e-mail software software. The function that e-mail software provide vary with the package, but all provide vary with the package, but all permit a user to receive and read a permit a user to receive and read a message, send a reply, initiate a new message, send a reply, initiate a new message, forward a received message to message, forward a received message to someone else, and organize received someone else, and organize received messages in a folder.messages in a folder.

Use of Emoticons and Use of Emoticons and AbbreviationsAbbreviations

To make up for the inability of message To make up for the inability of message recipients to accurately judge the mood of recipients to accurately judge the mood of the sender, the practice of typing the sender, the practice of typing characters available on a standard characters available on a standard keyboard to form a “picture” was begun. keyboard to form a “picture” was begun. These small icons called emoticons or These small icons called emoticons or smileys are often used to denote a mood. smileys are often used to denote a mood. They were originally intended to be viewed They were originally intended to be viewed by tilting your head to the left.by tilting your head to the left.

E-mail EtiquetteE-mail Etiquette

When sending e-mail, you should When sending e-mail, you should show the same consideration that show the same consideration that you would show when writing ti you would show when writing ti anyone. Given the nature of e-mail, anyone. Given the nature of e-mail, there are a few additional things that there are a few additional things that should be considered. Using all should be considered. Using all capital letters is considered capital letters is considered “shouting”; additionally it is about “shouting”; additionally it is about 50% harder to read than the 50% harder to read than the traditional upper and lowercase text.traditional upper and lowercase text.

Organizing Received FilesOrganizing Received Files

Once you start using e-mail, you will find Once you start using e-mail, you will find that you want to keep some of the that you want to keep some of the messages that you receive. E-mail messages that you receive. E-mail packages provide a way to create folders packages provide a way to create folders and transfer a received message to them. and transfer a received message to them. This allows you to keep your “inbox” or This allows you to keep your “inbox” or mailbox area clear for messages that you mailbox area clear for messages that you still have to attend to and allows you to still have to attend to and allows you to keep messages you may want in the keep messages you may want in the future in an organized manner.future in an organized manner.

File AttachmentsFile Attachments

All e-mails used to be plain text files. All e-mails used to be plain text files. A plain text file, often referred to as A plain text file, often referred to as an ASCII file, can be read by all e-an ASCII file, can be read by all e-mail software and all word mail software and all word processors. Text files, however, have processors. Text files, however, have no formatting; that is, text placement no formatting; that is, text placement cannot be determined by the cannot be determined by the individual who created the file, nor individual who created the file, nor can this individual add any attributes can this individual add any attributes such as boldface or italics.such as boldface or italics.

PDA and wireless devicesPDA and wireless devices

An information technology evolves, the An information technology evolves, the trend is to provide greater functionality trend is to provide greater functionality using smaller computers. Individual use of using smaller computers. Individual use of information technology depends on a information technology depends on a continuum along several dimensions: the continuum along several dimensions: the desired physical size and characteristics of desired physical size and characteristics of the hardware, the length of time a mobile the hardware, the length of time a mobile device (computer that does not have to be device (computer that does not have to be plugged into an electrical outlet in order to plugged into an electrical outlet in order to use it).use it).

Continuum of Information Technology for Personal Continuum of Information Technology for Personal ComputingComputing

Desktop computer versus Smartphone Physical Desktop computer versus Smartphone Physical CharacteristicsCharacteristics

The distinction between different forms of The distinction between different forms of computers re relative according to characteristics computers re relative according to characteristics such as weight, display size, processing power, such as weight, display size, processing power, memory, storage capacity, and battery life. In memory, storage capacity, and battery life. In general, a desktop computer is too heavy to hand general, a desktop computer is too heavy to hand carry, has a larger display, processing power carry, has a larger display, processing power measured in gigahertz(GHz), memory capacity up measured in gigahertz(GHz), memory capacity up to gigabytes (GB), storage capacity up to GB, and to gigabytes (GB), storage capacity up to GB, and is not designed to run on internal battery power. is not designed to run on internal battery power. In contrast, a smartphone (a hybrid device In contrast, a smartphone (a hybrid device combining wireless telehpone, e-mail, Internet combining wireless telehpone, e-mail, Internet access and PDA organizer functions) is at the access and PDA organizer functions) is at the opposite end of the continuum. A smartphone opposite end of the continuum. A smartphone represents a convergence between computing represents a convergence between computing and communicating.and communicating.

Notebook/Laptop versus Tablet versus PDA Notebook/Laptop versus Tablet versus PDA Physical CharacteristicsPhysical Characteristics

A notebook/laptop computer is light A notebook/laptop computer is light enough to hand carry, has a slightly enough to hand carry, has a slightly smaller display, and slightly less smaller display, and slightly less processing power and storage capacity processing power and storage capacity than a desktop computer. However, like a than a desktop computer. However, like a desktop, it is possible to add external desktop, it is possible to add external devices to a notebook/laptop to enhance devices to a notebook/laptop to enhance any shortcoming. The trade-off is that any shortcoming. The trade-off is that adding external devices increases the adding external devices increases the weight of the system. weight of the system.

Battery LifeBattery Life

Mobile devices depend on batteries. The Mobile devices depend on batteries. The length of time a battery supports use of length of time a battery supports use of the device and the length of time it takes the device and the length of time it takes for the battery to recharge determine the for the battery to recharge determine the usefulness of the device. Users are usefulness of the device. Users are frustrated by limited battery life that does frustrated by limited battery life that does not support their workflow. There are not support their workflow. There are different types of batteries, and depending different types of batteries, and depending the individual battery characteristics.the individual battery characteristics.

PDA Operating SystemsPDA Operating Systems This type of operating system determines This type of operating system determines

in part the strategies for conserving in part the strategies for conserving energy in order to prolong battery life. The energy in order to prolong battery life. The operating system for a computer operating system for a computer determines many of the characteristics of determines many of the characteristics of the computer because the operating the computer because the operating system controls how the hardware and the system controls how the hardware and the software work together. The two most software work together. The two most commonly use operating systems for PDAs commonly use operating systems for PDAs are Palm OS or Windows Mobile. Other less are Palm OS or Windows Mobile. Other less frequently used operating systems include frequently used operating systems include Blackberry, Hiptop, Linux and Symbian.Blackberry, Hiptop, Linux and Symbian.

Mobile DevicesMobile Devices Size and weight determine to what extent a Size and weight determine to what extent a

computer is considered portable. Any computer computer is considered portable. Any computer system that can be hand carried or rolled around system that can be hand carried or rolled around is a portable device. A desktop computer is a portable device. A desktop computer mounted on a wheeled cart or stand and plugged mounted on a wheeled cart or stand and plugged into a battery so it can be rolled from room to into a battery so it can be rolled from room to room is considered portable. Computers that are room is considered portable. Computers that are small and light weight enough to be hand carried small and light weight enough to be hand carried are mobile devices. A laptop is considered mobile. are mobile devices. A laptop is considered mobile. The key to a mobile device is the non-bulky The key to a mobile device is the non-bulky display. A computer that can be held in the palm display. A computer that can be held in the palm of one hand is used with the other hand is a of one hand is used with the other hand is a handheld device. A PDA is considered a handheld. handheld device. A PDA is considered a handheld. The key to a handheld device is the miniature The key to a handheld device is the miniature keyboard.keyboard.

Wireless DevicesWireless Devices

For a computer to connect wirelessly there For a computer to connect wirelessly there must be a physical component added to must be a physical component added to the device to enable wireless the device to enable wireless communication. Depending on what communication. Depending on what standard device follows, there is also a standard device follows, there is also a requirement for a wireless access point to requirement for a wireless access point to the network. It is possible to set up a the network. It is possible to set up a desktop computer to connect wirelessly to desktop computer to connect wirelessly to a network, but that involves special a network, but that involves special hardware meeting specific standards for hardware meeting specific standards for wireless communication.wireless communication.

Why Use a PDA?Why Use a PDA?

In the clinical practice setting, time is a In the clinical practice setting, time is a precious commodity. Practices that allow a precious commodity. Practices that allow a nurse to manage and organize time nurse to manage and organize time effectively and efficiently are valuable. effectively and efficiently are valuable. One strategy for better use of time is to One strategy for better use of time is to organize data and information so that it is organize data and information so that it is readily available when needed. Most readily available when needed. Most nurses would like to eliminate post-it notes nurses would like to eliminate post-it notes and other small paper reminders and the and other small paper reminders and the multiple small reference books that fill multiple small reference books that fill (and fall out of) lab coat pockets.(and fall out of) lab coat pockets.

PDA Generic Functions and Their PDA Generic Functions and Their Application to Clinical PracticeApplication to Clinical Practice

The PDA evolved as an information The PDA evolved as an information technology to support personal technology to support personal information management. A PDA is a information management. A PDA is a handheld computer that allows the user to handheld computer that allows the user to organize and manage personal organize and manage personal information. A PDA provides an address information. A PDA provides an address book, a calculator, date book, memo book, a calculator, date book, memo pad(for typed inputs), notepad (for hand-pad(for typed inputs), notepad (for hand-written input), to do lists, and a way to written input), to do lists, and a way to synchronize part or all of this information synchronize part or all of this information with another computer, to help the user with another computer, to help the user organize their time and tasks.organize their time and tasks.

1. Address book – is an always-alphabetical list that has 1. Address book – is an always-alphabetical list that has fields for name, address, phone number, fields for name, address, phone number, organization, e-mail, and other data.organization, e-mail, and other data.

2. Calculator – Is a basic function calculator, capable of 2. Calculator – Is a basic function calculator, capable of basic mathematical operations. basic mathematical operations.

3. Date book – allows the nurse to keep track of his or 3. Date book – allows the nurse to keep track of his or her schedule, from a daily, weekly, or monthly her schedule, from a daily, weekly, or monthly respective.respective.

4. Memo pad – provides a place to compose memos, 4. Memo pad – provides a place to compose memos, which can be synchronized with another computer.which can be synchronized with another computer.

5. Note pad – (the only function that responds to 5. Note pad – (the only function that responds to handwriting) is useful in jotting quick notes.handwriting) is useful in jotting quick notes.

6. To do list – allows the nurse to create multiple lists 6. To do list – allows the nurse to create multiple lists and keep track of tasks to be done daily, weekly, or and keep track of tasks to be done daily, weekly, or monthly.monthly.

Add-on SoftwareAdd-on Software

Stand-alone and SynchronizedStand-alone and Synchronized Several very useful applications that Several very useful applications that

facilitate professional time management facilitate professional time management are available for the PDA. These are available for the PDA. These applications may work as stand-alone applications may work as stand-alone programs with no need to connect to programs with no need to connect to anything once they are loaded onto the anything once they are loaded onto the PDA. e.g., a viewer for reading an e-book. PDA. e.g., a viewer for reading an e-book. Some applications require periodic Some applications require periodic asynchronous updating e.g., a subscription asynchronous updating e.g., a subscription with quarterly updates.with quarterly updates.

General Freeware, Shareware, and General Freeware, Shareware, and Commercial ApplicationsCommercial Applications

A PDA may be used for viewing A PDA may be used for viewing information, or to perform office information, or to perform office automation tasks (e.g., to create, automation tasks (e.g., to create, view, and edit documents, view, and edit documents, spreadsheets, and databases), or to spreadsheets, and databases), or to browse the Internet.browse the Internet.

Incorporating Evidence: Use of Computer-Based Clinical Incorporating Evidence: Use of Computer-Based Clinical Decision Support System for Health ProfessionalsDecision Support System for Health Professionals

DefinitionDefinition A CDSS may be defined as any computer A CDSS may be defined as any computer

program that helps health professionals program that helps health professionals make clinical decisions. CDSS software has make clinical decisions. CDSS software has a knowledge base designed for the a knowledge base designed for the clinician involved in patient care to aid in clinician involved in patient care to aid in clinical decision-making. Computer clinical decision-making. Computer software employing a knowledge base software employing a knowledge base designed for use by a clinician involved in designed for use by a clinician involved in patient care, as a direct aid to clinical patient care, as a direct aid to clinical decision making.decision making.

Types of DSSTypes of DSS

Administrative and Organizational Administrative and Organizational SystemsSystems

Integrated systemsIntegrated systems

Responsibility of User: Ethical and Responsibility of User: Ethical and Legal IssuesLegal Issues

CDSS are considered similar to CDSS are considered similar to medical devices but the legal medical devices but the legal responsibility for treatment and responsibility for treatment and advice given to a patient rests with advice given to a patient rests with the clinician regardless of whether a the clinician regardless of whether a CDSS is used. Still unknown are the CDSS is used. Still unknown are the legal ramification of not following legal ramification of not following CDSS advice.CDSS advice.

ISSUES IN INFORMATICSISSUES IN INFORMATICS

Nursing Informatics and Healthcare Policy Nursing Informatics and Healthcare Policy Nurses have contributed to the purchase, design Nurses have contributed to the purchase, design

and implementation of IS since the 1970s. In and implementation of IS since the 1970s. In 1992, the American Nurses Association (ANA) 1992, the American Nurses Association (ANA) recognized NI as a specialty. Attempts in 1989 to recognized NI as a specialty. Attempts in 1989 to be recognized as a specialty failed, but political be recognized as a specialty failed, but political forces within ANA supported the request hen it forces within ANA supported the request hen it was repeated in 1992. To be acknowledged as a was repeated in 1992. To be acknowledged as a specialty within nursing, informatics had to specialty within nursing, informatics had to demonstrate a differentiated practice base, demonstrate a differentiated practice base, identify the existence of educational programs in identify the existence of educational programs in the field, show support form nationally recognized the field, show support form nationally recognized organizations, and develop a research agenda.organizations, and develop a research agenda.

Differentiated and Interdisciplinary Differentiated and Interdisciplinary PracticePractice

A description of NI as a differentiated A description of NI as a differentiated practice is given in the scope of practice is given in the scope of practice and standards (ANA, 2001). practice and standards (ANA, 2001). As the document emphasizes, NI As the document emphasizes, NI brings an added dimension to brings an added dimension to nursing practice that focuses on nursing practice that focuses on knowledge and skill in information knowledge and skill in information and information management and information management techniques.techniques.

Preparation for Specialty PracticePreparation for Specialty Practice

To become a specialty, it was necessary To become a specialty, it was necessary for NI to show that educational programs for NI to show that educational programs are available to prepare nurses to practice are available to prepare nurses to practice in the field. Between 1988 and 1992, the in the field. Between 1988 and 1992, the Division of Nursing (DN), Health and Division of Nursing (DN), Health and Human Services Administration (HRSA), Human Services Administration (HRSA), funded two Master’s NI programs, funded two Master’s NI programs, University of Utah. And one doctoral University of Utah. And one doctoral program in NI at the University of program in NI at the University of Maryland.Maryland.

The Role of Technology in the The Role of Technology in the Medication-Use ProcessMedication-Use Process

Until recently, the majority of Until recently, the majority of technology acquisitions have technology acquisitions have consisted of basic stand-alone consisted of basic stand-alone computer systems, which were computer systems, which were primarily used for data input to primarily used for data input to increase each department’s increase each department’s efficiency with financial efficiency with financial accountability measures.accountability measures.

Influences on the Adoption of Influences on the Adoption of TechnologyTechnology

Consumers have become increasingly concerned Consumers have become increasingly concerned that hospitals are less than safe following the that hospitals are less than safe following the numerous mass media reporting of medical numerous mass media reporting of medical mistakes, which have resulted in patient harm mistakes, which have resulted in patient harm and deaths. In 1995, there were television and and deaths. In 1995, there were television and newspaper accounts that reported the tragic newspaper accounts that reported the tragic death of a patient from a preventable adverse death of a patient from a preventable adverse drug event (ADE) due to an inadvertent drug event (ADE) due to an inadvertent administration of a massive overdose of a administration of a massive overdose of a chemotherapy agent over 4 days. This particular chemotherapy agent over 4 days. This particular error became a watershed event for patients, error became a watershed event for patients, practitioners, and healthcare organizations alike, practitioners, and healthcare organizations alike, not only because it occurred at the world not only because it occurred at the world renowned Dana Farber Cancer Institute, but also renowned Dana Farber Cancer Institute, but also because it happened to the prestigious Boston because it happened to the prestigious Boston Globe healthcare reporter Betsy Lehman.Globe healthcare reporter Betsy Lehman.

Healthcare Data StandardsHealthcare Data Standards

Standards are critical components in Standards are critical components in the development and the development and implementation of an electronic implementation of an electronic health record (EHR). The health record (EHR). The effectiveness of healthcare delivery effectiveness of healthcare delivery is dependent on the ability of is dependent on the ability of clinicians to access critical health clinicians to access critical health information when and where it is information when and where it is needed.needed.

Need for Healthcare Data Need for Healthcare Data StandardsStandards

Data standards as applied to healthcare Data standards as applied to healthcare include the “methods, protocols, include the “methods, protocols, terminologies, and specifications for the terminologies, and specifications for the collection, exchange, storage, and collection, exchange, storage, and retrieval of information associated with retrieval of information associated with healthcare applications, including medical healthcare applications, including medical records, medications, radiological images, records, medications, radiological images, payment and reimbursement, medical payment and reimbursement, medical devices and monitoring systems, and devices and monitoring systems, and administrative processes”.administrative processes”.

Healthcare Data Interchange Healthcare Data Interchange StandardsStandards

Data interchange standards address, Data interchange standards address, primarily, the format of messages primarily, the format of messages that are exchanged between that are exchanged between computer systems, document computer systems, document architecture, clinical templates, user architecture, clinical templates, user interface, and patient data linkage.interface, and patient data linkage.

Message Format StandardsMessage Format Standards

Four broad classes of message format Four broad classes of message format standards have emerged in the healthcare standards have emerged in the healthcare sector: medical device communications, sector: medical device communications, digital imaging communications, digital imaging communications, administrative data exchange, and clinical administrative data exchange, and clinical data exchange. It should be noted that data exchange. It should be noted that there is considerable overlap among there is considerable overlap among standards development activities, and standards development activities, and there may be more than one standard there may be more than one standard available for each of these classes.available for each of these classes.

Electronic Health Record Systems: U.S. Electronic Health Record Systems: U.S. Federal Initiatives and Public/Private Federal Initiatives and Public/Private

PartnershipsPartnerships

Defining Electronic Health Record SystemsDefining Electronic Health Record Systems The term HER-S is often used interchangeably The term HER-S is often used interchangeably

with computerized patient record, clinical with computerized patient record, clinical information system, electronic medical record, information system, electronic medical record, and many others. Yet the choice of the words in and many others. Yet the choice of the words in the term HER-D reflects the broader focus on the the term HER-D reflects the broader focus on the health of the consumer or patient and indicates health of the consumer or patient and indicates that the EHR-S may be used by all participants in that the EHR-S may be used by all participants in the process of achieving health, including all the process of achieving health, including all disciplines of clinicians, family caregivers, and the disciplines of clinicians, family caregivers, and the patient. patient.

Federal InitiativesFederal Initiatives

Government as Provider and Early AdopterGovernment as Provider and Early Adopter Federal agencies that provide direct care Federal agencies that provide direct care

have been early adopters of ERH-S. The have been early adopters of ERH-S. The veterans Health administration in the veterans Health administration in the Department of Veterans Affair (VA) and Department of Veterans Affair (VA) and the National Institutes of Health in the the National Institutes of Health in the Department of health and Human Services Department of health and Human Services (HHS) are two examples of the initiation of (HHS) are two examples of the initiation of systems in the 1970s that were actively systems in the 1970s that were actively used by clinicians.used by clinicians.

Dependable Systems for Dependable Systems for Quality CareQuality Care

Dependability comprises the following Dependability comprises the following six attributessix attributes

1. System reliability1. System reliability2. Service availability2. Service availability3. Confidentiality3. Confidentiality4. Data Integrity4. Data Integrity5. Responsiveness5. Responsiveness6. Safety6. Safety

Guidelines for Dependable Guidelines for Dependable SystemsSystems

All computer systems are vulnerable to All computer systems are vulnerable to both human-created threats, such as both human-created threats, such as malicious code attacks and software bugs, malicious code attacks and software bugs, and natural threats, such as hardware and natural threats, such as hardware aging and earthquakes. In the gray area aging and earthquakes. In the gray area between these lie system between these lie system incompatibilities, such as the incompatibilities, such as the incompatibility between Intel’s Centrino incompatibility between Intel’s Centrino mobile chip set and virtual private mobile chip set and virtual private networking client software, which caused networking client software, which caused notebook and laptop personal computers notebook and laptop personal computers (PCs) to experience “bluescreen” system (PCs) to experience “bluescreen” system crashes.crashes.

Guideline 1: Architect for Guideline 1: Architect for DependabilityDependability

Guideline 2: Anticipate FailuresGuideline 2: Anticipate Failures Guideline 3: Anticipate SuccessGuideline 3: Anticipate Success Guideline 4: Hire Meticulous Guideline 4: Hire Meticulous

ManagersManagers Guideline 5: Don’t Be Adventurous Guideline 5: Don’t Be Adventurous

Nursing Minimum Data Set Nursing Minimum Data Set systemssystems

The NMDS identifies, essential, common, and core The NMDS identifies, essential, common, and core data elements to be collected for all data elements to be collected for all patients/clients receiving nursing care. The NMDS patients/clients receiving nursing care. The NMDS is a standardized approach that facilitates the is a standardized approach that facilitates the abstraction of these minimum, common, essential abstraction of these minimum, common, essential core data elements to describe nursing practice core data elements to describe nursing practice form both paper ann electronic records.form both paper ann electronic records.

The early NMDS work in the United States spurred The early NMDS work in the United States spurred the development of NMDSs in numerous other the development of NMDSs in numerous other countries. To date seven countries have identified countries. To date seven countries have identified NMDS systems, including Australia, Canada, NMDS systems, including Australia, Canada, Belgium, Iceland. A perusal of these data sets Belgium, Iceland. A perusal of these data sets reveals a definite consensus on the importance of reveals a definite consensus on the importance of the nursing care elements across all countries the nursing care elements across all countries with identified NMDSs.with identified NMDSs.

Call for Standardized Contextual Call for Standardized Contextual DataData

Ample studies have demonstrated the Ample studies have demonstrated the significance of nurse staffing, patient/staff significance of nurse staffing, patient/staff ratios, professional autonomy and control, ratios, professional autonomy and control, organizational characteristics, unit internal organizational characteristics, unit internal environment, work delivery patterns, work environment, work delivery patterns, work group characteristics, external group characteristics, external environment, staff work satisfaction, environment, staff work satisfaction, education of staff, multidisciplinary education of staff, multidisciplinary coordination/collaborate and educational coordination/collaborate and educational level on the quality and outcomes of level on the quality and outcomes of patient care.patient care.

INFORMATICS THEORYINFORMATICS THEORY

Theories, Models and FrameworksTheories, Models and Frameworks

AbstractAbstract Nursing informatics is an established and Nursing informatics is an established and

growing area of specialization in nursing. growing area of specialization in nursing. All nurses employ information All nurses employ information technologies in their practice. Information technologies in their practice. Information technologies in their practice. Informatics technologies in their practice. Informatics nurses are key persons in the design, nurses are key persons in the design, development, implementation, and development, implementation, and evaluation of these technologies and in evaluation of these technologies and in development of the specialty’s body of development of the specialty’s body of knowledge.knowledge.

DefinitionsDefinitions Informatics and Healthcare InformaticsInformatics and Healthcare Informatics Informatics is a science that combines a domain science, Informatics is a science that combines a domain science,

computer science, information science, and cognitive computer science, information science, and cognitive science. Thus, it is a multidisciplinary science drawing form science. Thus, it is a multidisciplinary science drawing form varied theories and knowledge applications.varied theories and knowledge applications.

Healthcare informatics may be defined as the integration of Healthcare informatics may be defined as the integration of healthcare sciences, computer science, information healthcare sciences, computer science, information science, and cognitive science to assist in the management science, and cognitive science to assist in the management of healthcare information. Healthcare informatics is a of healthcare information. Healthcare informatics is a subdiscipline of informatics. Imagine a large umbrella subdiscipline of informatics. Imagine a large umbrella named informatics and imagine many persons under this named informatics and imagine many persons under this umbrella. Each person represents a different domain umbrella. Each person represents a different domain science, one of which is healthcare informatics.science, one of which is healthcare informatics.

Nursing InformaticsNursing Informatics In 1985, Kathryn Hannah proposed a definition In 1985, Kathryn Hannah proposed a definition

that nursing informatics is the use of information that nursing informatics is the use of information technologies in relation to any nursing functions technologies in relation to any nursing functions and actions of nurses. In their classic article on and actions of nurses. In their classic article on the science of nursing informatics, Graves and the science of nursing informatics, Graves and Corcoran presented a more complex definition of Corcoran presented a more complex definition of nursing informatics. Nursing informatics is a nursing informatics. Nursing informatics is a combination of computer science, information combination of computer science, information science and nursing science designed to assist in science and nursing science designed to assist in the management and processing of nursing data, the management and processing of nursing data, information, and knowledge to support the information, and knowledge to support the practice of nursing and the delivery of nursing practice of nursing and the delivery of nursing care.care.

Nursing Informatics as a SpecialtyNursing Informatics as a Specialty

In early 1992, the ANA established In early 1992, the ANA established nursing informatics as a distinct nursing informatics as a distinct specialty in nursing with a distinct specialty in nursing with a distinct body of knowledge. Unique among body of knowledge. Unique among the healthcare professions, this the healthcare professions, this designation as a specialty provides designation as a specialty provides official recognition that nursing official recognition that nursing informatics is indeed a part of informatics is indeed a part of nursing and that it has a distinct nursing and that it has a distinct scope of practice.scope of practice.

Models for Nursing InformaticsModels for Nursing Informatics Models are representations of some aspect of the Models are representations of some aspect of the

real world. Models show particular perspectives of real world. Models show particular perspectives of a selected aspect and many illustrate a selected aspect and many illustrate relationships. Models evolve as knowledge about relationships. Models evolve as knowledge about the selected aspect changes and are dependent the selected aspect changes and are dependent on the “world view” of those developing the on the “world view” of those developing the model. model.

Different scholars in nursing informatics have Different scholars in nursing informatics have proposed different models. Some of these models proposed different models. Some of these models are presented here to provide further are presented here to provide further perspectives on nursing informatics, to perspectives on nursing informatics, to demonstrate how differently scholars and demonstrate how differently scholars and practitioners may view what seems to be the practitioners may view what seems to be the same thing, and to show that nursing informatics same thing, and to show that nursing informatics is an evolutionary, theoretical, and practical is an evolutionary, theoretical, and practical science.science.

Data, Information, and KnowledgeData, Information, and Knowledge

Data, information, and knowledge Data, information, and knowledge are identified as current are identified as current metastructures or overarching metastructures or overarching concepts for nursing informatics with concepts for nursing informatics with specific definitions in the scope and specific definitions in the scope and standards of nursing informatics standards of nursing informatics practice. Data are “discrete entities practice. Data are “discrete entities that are described objectively that are described objectively without interpretation”without interpretation”

Registered Nurses as Knowledge Registered Nurses as Knowledge workersworkers

Knowledge work is the exercise of Knowledge work is the exercise of specialist knowledge and competencies. specialist knowledge and competencies. The United States is becoming a nation of The United States is becoming a nation of knowledge workers. Futurists predict that knowledge workers. Futurists predict that in the second millennium the primary in the second millennium the primary domestic product of the United States will domestic product of the United States will be knowledge and related knowledge be knowledge and related knowledge services. Knowledge workers will be services. Knowledge workers will be valued contributors to these products.valued contributors to these products.

CompetenciesCompetencies

Benner’s work, built on the Dreyfus Benner’s work, built on the Dreyfus model of skill acquisition that model of skill acquisition that describes the evolution of novice to describes the evolution of novice to experts, merits discussion for nursing experts, merits discussion for nursing informatics. This desired change in informatics. This desired change in skills involves the evolution from a skills involves the evolution from a novice level to advanced beginner to novice level to advanced beginner to competent to proficient to finally an competent to proficient to finally an expert level.expert level.

Electronic Health RecordElectronic Health Record

Today’s healthcare environment is Today’s healthcare environment is characterized by significant emphasis on characterized by significant emphasis on establishing the E.H.R in all settings. establishing the E.H.R in all settings. Discussion of the associated database and Discussion of the associated database and data elements is critical in the data elements is critical in the implementation of the E.H.R. Data sets are implementation of the E.H.R. Data sets are comprised of data elements brought comprised of data elements brought together for a specific reason. When together for a specific reason. When values are assigned to the elements in a values are assigned to the elements in a data set, the resulting data mot often are data set, the resulting data mot often are stored in a database.stored in a database.

TerminologiesTerminologies To convey important data and information To convey important data and information

to others, the communication must be to others, the communication must be understood by the listeners and be understood by the listeners and be interpreted as having meaning. This is interpreted as having meaning. This is best accomplished by using standard best accomplished by using standard communication formats and terminologies, communication formats and terminologies, and recognized conventions for describing and recognized conventions for describing the concepts being presented. Concept the concepts being presented. Concept representation involves the set of terms representation involves the set of terms and relationships that describe the and relationships that describe the phenomena, processes, and practices of a phenomena, processes, and practices of a discipline such as nursing.discipline such as nursing.

NANDANANDA

NANDA-I has evolved from an alphabetical NANDA-I has evolved from an alphabetical listing in the mid-1980s to a conceptual listing in the mid-1980s to a conceptual system that guides the classification of system that guides the classification of nursing diagnoses in a taxonomy and nursing diagnoses in a taxonomy and includes definitions and defining includes definitions and defining characteristics. Currently NANDA-I includes characteristics. Currently NANDA-I includes 167 recognized diagnoses that are very 167 recognized diagnoses that are very different from the pathology and mortality different from the pathology and mortality focus of the ICD-9 CM terms used for focus of the ICD-9 CM terms used for medicine and third party payment claims.medicine and third party payment claims.

Nursing Intervention Classification Nursing Intervention Classification (NIC)(NIC)

The fourth edition of NIC contains The fourth edition of NIC contains 514 nursing interventions that 514 nursing interventions that describe the treatments nurses describe the treatments nurses perform, updated linkages with perform, updated linkages with NANDA diagnoses, and core NANDA diagnoses, and core interventions identified for 44 interventions identified for 44 specialty practice areas. These terms specialty practice areas. These terms differ from the surgically biased CPT-differ from the surgically biased CPT-4 code set terms used by medicine 4 code set terms used by medicine and third party programs.and third party programs.

Nursing Outcomes Classification Nursing Outcomes Classification (NOC)(NOC)

The latest edition of NOC has 330 The latest edition of NOC has 330 research-based outcomes to provide research-based outcomes to provide standardization of expected patient, standardization of expected patient, caregiver, family and community caregiver, family and community outcomes for measuring the effect of outcomes for measuring the effect of nursing interventions. nursing interventions.

American Medical Informatics American Medical Informatics AssociationAssociation

The AMIA is an individual membership The AMIA is an individual membership organization dedicated to the development and organization dedicated to the development and application of medical informatics in the support application of medical informatics in the support of patient care, teaching, research and healthcare of patient care, teaching, research and healthcare administration. (Note: AMIA believes that the administration. (Note: AMIA believes that the term “medical informatics” represent of all the term “medical informatics” represent of all the diverse interests, issues, and aspects of diverse interests, issues, and aspects of informatics in healthcare.) AMIA serves as an informatics in healthcare.) AMIA serves as an authoritative body in the field of medical authoritative body in the field of medical informatics and frequently represents the United informatics and frequently represents the United States in the informational arena of medical States in the informational arena of medical informatics in international forums and is the U.S. informatics in international forums and is the U.S. member of the International Medical Informatics member of the International Medical Informatics Association (IMIA).Association (IMIA).

Healthcare Information and Healthcare Information and Management Systems SocietyManagement Systems Society

The HIMSS represents a membership of The HIMSS represents a membership of over 14,000 individuals and 200 over 14,000 individuals and 200 corporations interested in healthcare corporations interested in healthcare informatics, clinical systems, information informatics, clinical systems, information systems, management engineering and systems, management engineering and telecommunications. HIMSS members are telecommunications. HIMSS members are responsible for developing many of responsible for developing many of today’s key innovations in healthcare today’s key innovations in healthcare delivery and administration, including tele-delivery and administration, including tele-health, CPRs or EHRs, community health health, CPRs or EHRs, community health information networks, and information networks, and portable/wireless healthcare computing.portable/wireless healthcare computing.

National League for NursingNational League for Nursing The mission of the National League for The mission of the National League for

Nursing (NLN) is to advance quality Nursing (NLN) is to advance quality nursing education that prepares the nursing education that prepares the nursing workforce to meet the needs of nursing workforce to meet the needs of diverse populations in an ever-changing diverse populations in an ever-changing healthcare environment. Recent healthcare environment. Recent organizational restructuring consolidated organizational restructuring consolidated numerous councils into four advisory numerous councils into four advisory councils with many integrated objectives councils with many integrated objectives related to information management and related to information management and technology applications in the educational technology applications in the educational environment.environment.

Advanced Terminology systemsAdvanced Terminology systems

The failure to achieve a single, integrated The failure to achieve a single, integrated terminology with broad coverage of the terminology with broad coverage of the healthcare domain has been characterized healthcare domain has been characterized as the “vocabulary problem.” Evolving as the “vocabulary problem.” Evolving criteria for healthcare terminologies for criteria for healthcare terminologies for implementation in computer-based implementation in computer-based systems suggest that concept-oriented systems suggest that concept-oriented approaches are needed to support the approaches are needed to support the data needs of today’s complex, data needs of today’s complex, knowledge-driven healthcare and health knowledge-driven healthcare and health management environment.management environment.

Background and DefinitionsBackground and Definitions The primary motivation for The primary motivation for

standardized terms in nursing is the standardized terms in nursing is the need for valid, comparable data that need for valid, comparable data that can be used across information can be used across information system applications to support system applications to support clinical decision-making and the clinical decision-making and the evaluation of processes and evaluation of processes and outcomes of care.outcomes of care.

The Vocabulary ProblemThe Vocabulary Problem Several reasons for the vocabulary problem have Several reasons for the vocabulary problem have

been posited in health and nursing informatics been posited in health and nursing informatics literature. First, the development of multiple literature. First, the development of multiple specialized terminologies has resulted in areas of specialized terminologies has resulted in areas of overlapping content, areas for which no content overlapping content, areas for which no content exits, and large numbers of codes and terms. exits, and large numbers of codes and terms. Second, existing terminologies are most often Second, existing terminologies are most often developed to provide sets of terms and definitions developed to provide sets of terms and definitions of concepts for human interpretation with of concepts for human interpretation with computer interpretation as only as secondary computer interpretation as only as secondary goal.goal.

Concept OrientationConcept Orientation An appreciation for the approaches An appreciation for the approaches

discussed in this chapter has a discussed in this chapter has a prerequisite an understanding of what it prerequisite an understanding of what it means for a terminology to be concept-means for a terminology to be concept-oriented. The health informatics literature oriented. The health informatics literature provides an evolving framework that provides an evolving framework that enumerates the criteria that render enumerates the criteria that render healthcare terminologies suitable for healthcare terminologies suitable for implementation in computer-based implementation in computer-based systems.systems.

Components of Advanced Terminology Components of Advanced Terminology SystemsSystems

Within the context of the high-level Within the context of the high-level information model provided by the information model provided by the Nursing Minimum Data Set (NMDS).Nursing Minimum Data Set (NMDS).

Terminology ModelTerminology Model A terminology model is a concept-A terminology model is a concept-

based representation of a collection based representation of a collection of domain-specific terms that is of domain-specific terms that is optimized for the management of optimized for the management of terminological definitions. It terminological definitions. It encompasses both schemata and encompasses both schemata and schemata and type definitions.schemata and type definitions.

Representation LanguageRepresentation Language Terminology models may be formulated Terminology models may be formulated

ans elucidated in an ontology language, ans elucidated in an ontology language, Knowledge Representation Specification Knowledge Representation Specification syntax (KRSS) or Web Ontology Language. syntax (KRSS) or Web Ontology Language. Ontology languages represent classes Ontology languages represent classes (also referred to as concepts, categories or (also referred to as concepts, categories or types) and their properties (also referred types) and their properties (also referred to as relations, slots, roles or attributes).to as relations, slots, roles or attributes).

Computer-Based ToolsComputer-Based Tools A representation language may be A representation language may be

implemented using description logic within implemented using description logic within a software system or by a suite of a software system or by a suite of software tools. The functionality of these software tools. The functionality of these tools varies but may include among other tools varies but may include among other things management and internal things management and internal organization of the model, and reasoning organization of the model, and reasoning on the model, such as automatic on the model, such as automatic classification of composed concepts based classification of composed concepts based on their formal definition e.g. “medication on their formal definition e.g. “medication teaching” is a kind of “teaching”.teaching” is a kind of “teaching”.

Advantages of Advanced Terminology Advantages of Advanced Terminology SystemsSystems

Computer-based systems that Computer-based systems that support clinical uses such as support clinical uses such as electronic health records and electronic health records and decision support require more decision support require more granular (i.e. less abstract) data than granular (i.e. less abstract) data than that typically contained in that typically contained in terminologies designed primarily for terminologies designed primarily for manual use or for the purpose of manual use or for the purpose of classification.classification.

Advanced Terminological Approaches in Advanced Terminological Approaches in NursingNursing

Recently, there have been a number of Recently, there have been a number of initiatives that support the development of initiatives that support the development of advanced-oriented terminology systems advanced-oriented terminology systems for the nursing domain. Following a brief for the nursing domain. Following a brief description of three of these initiatives description of three of these initiatives (ISO 18104:2003, the Galen Project, and (ISO 18104:2003, the Galen Project, and SNOMED), a nursing term is represented SNOMED), a nursing term is represented under GALEN and SNOMED approaches in under GALEN and SNOMED approaches in order to illustrate similarities and order to illustrate similarities and difference between representations.difference between representations.

GALENGALEN A concept-oriented approach has A concept-oriented approach has

been developed within the GALEN been developed within the GALEN Program. GALEN can be used in a Program. GALEN can be used in a range of ways, form directly range of ways, form directly supporting clinical applications to supporting clinical applications to supporting the authoring, supporting the authoring, maintenance, and quality assurance maintenance, and quality assurance of other kinds of terminologies.of other kinds of terminologies.

SNOMED RTSNOMED RT At the same time, an alternative At the same time, an alternative

concept-oriented approach was concept-oriented approach was developed, through collaboration developed, through collaboration between the college of American between the college of American Pathologists and Kaiser Permanente, Pathologists and Kaiser Permanente, based on SNOMED International.based on SNOMED International.

Implementing and Upgrading Implementing and Upgrading Clinical Information SystemsClinical Information Systems

What is a clinical Information System?What is a clinical Information System? Nursing involvement in the design Nursing involvement in the design

and implementation of a CIS is and implementation of a CIS is required at many levels. Nurses have required at many levels. Nurses have been instrumental members of been instrumental members of departmental teams in addition to departmental teams in addition to their active involvement in nursing-their active involvement in nursing-focused projects.focused projects.

Planning PhasePlanning Phase The planning phase of the project The planning phase of the project

begins once an organization has begins once an organization has determined that an existing need or determined that an existing need or problem nay be filled or solved by problem nay be filled or solved by the development or implementation the development or implementation of a CIS or application.of a CIS or application.

Clinical Information System Committee Clinical Information System Committee Structure and Project StaffStructure and Project Staff

The nursing administrator’s The nursing administrator’s involvement in the establishment of involvement in the establishment of a CIS committee structure is a CIS committee structure is paramount to the success of the paramount to the success of the project. The nursing administrator, in project. The nursing administrator, in conjunction with the information conjunction with the information system’s management team, works system’s management team, works to develop a committee structure to develop a committee structure and participation to best guarantee and participation to best guarantee the success of the project.the success of the project.

Clinical Information System Steering CommitteeClinical Information System Steering Committee Before a CIS is developed or selected, the Before a CIS is developed or selected, the

organization must appoint a CIS steering organization must appoint a CIS steering committee. The CIS steering committee generally committee. The CIS steering committee generally includes representatives from the following areas:includes representatives from the following areas:

1. Hospital administration/hospital finance1. Hospital administration/hospital finance2. Nursing administration2. Nursing administration3. Medical Staff3. Medical Staff4. Information systems department at the director 4. Information systems department at the director

or manager levelor manager level5.Major ancillary departments (laboratory, 5.Major ancillary departments (laboratory,

radiology, pharmacy, dietary, medical radiology, pharmacy, dietary, medical records/patient registration, patient accounting)records/patient registration, patient accounting)

6.Health Information management (medical 6.Health Information management (medical records)records)

7. Legal affairs7. Legal affairs8. Outside consultants (as needed)8. Outside consultants (as needed)9. Other appointed members (as needed)9. Other appointed members (as needed)

Project Team – the project team is led by an Project Team – the project team is led by an appointed project manager and includes a appointed project manager and includes a designated team leader for each of the major designated team leader for each of the major departments affected by the system selection, departments affected by the system selection, implementation, or upgrade proposed. implementation, or upgrade proposed.

Objectives:Objectives:1. understand the technology and technology 1. understand the technology and technology

restrictions, if any, of a proposed systemrestrictions, if any, of a proposed system2. understand the impact of intradepartmental 2. understand the impact of intradepartmental

decisionsdecisions3. Make decisions at the intradepartmental level for 3. Make decisions at the intradepartmental level for

the overall good of the CIS within the the overall good of the CIS within the organizationorganization

4. Become the key resource for their application4. Become the key resource for their application

Departmental Teams – The charge of the Departmental Teams – The charge of the departmental teams is:departmental teams is:

1. To thoroughly understand the 1. To thoroughly understand the department’s information needsdepartment’s information needs

2. To gain a full understanding of the 2. To gain a full understanding of the software’s features and functionssoftware’s features and functions

3. To merge the system’s capabilities with 3. To merge the system’s capabilities with the department’s operationsthe department’s operations

4. To assist in the system testing effort4. To assist in the system testing effort5. To participate in developing and 5. To participate in developing and

conducting end-user educationconducting end-user education6. To provide a high level of support during 6. To provide a high level of support during

the initial activation period of the new the initial activation period of the new system.system.

Definition of the Problem – Definition of the problem Definition of the Problem – Definition of the problem and/or stated goal precisely is essential and and/or stated goal precisely is essential and often not readily apparent. Not until the often not readily apparent. Not until the information requirements of the problem and/or information requirements of the problem and/or stated goal and outcomes are precisely defined stated goal and outcomes are precisely defined with the real characteristics of the problem be with the real characteristics of the problem be revealed:revealed:

For example:For example: Unfair nurse staff assignments may relate Unfair nurse staff assignments may relate

to an invalid patient classification tool to an invalid patient classification tool (inaccurate grouping of patients) rather (inaccurate grouping of patients) rather than to workload measurements and/or than to workload measurements and/or acuity score.acuity score.

Duplicate health department reports may Duplicate health department reports may result in inappropriate statistics being result in inappropriate statistics being collected instead of the collection of collected instead of the collection of unique atomic-level data elements.unique atomic-level data elements.

System Analysis PhaseSystem Analysis Phase The system analysis phase, the second The system analysis phase, the second

phase of developing a CIS, is the fact-phase of developing a CIS, is the fact-finding phase. All data requirements finding phase. All data requirements related to the problem defined in the related to the problem defined in the project scope agreement are collected and project scope agreement are collected and analyzed to gain a sound understanding of analyzed to gain a sound understanding of the current system, how it is used and the current system, how it is used and what is needed form the new system.what is needed form the new system.

Data CollectionData Collection The collection of data reflecting the The collection of data reflecting the

existing problem or goal is the first step in existing problem or goal is the first step in the system analysis phase. As a result of the system analysis phase. As a result of thorough data collection, refinements to thorough data collection, refinements to the project scope agreement may occur. the project scope agreement may occur. Added benefits to the organization may be Added benefits to the organization may be realized through the small refinements.realized through the small refinements.

Workflow DocumentWorkflow Document The workflow document assimilates The workflow document assimilates

the data collected into logical the data collected into logical sequencing of task and sub-tasks sequencing of task and sub-tasks performed by the end users for each performed by the end users for each goal or problem area.goal or problem area.

Data AnalysisData Analysis The analysis of the collected data is The analysis of the collected data is

the second step in the system the second step in the system analysis phase. The analysis provides analysis phase. The analysis provides the data for development of an the data for development of an overview of the nursing problem overview of the nursing problem and/or stated goal defined in the and/or stated goal defined in the project scope agreement.project scope agreement.

Data ReviewData Review The third step in the analysis phase The third step in the analysis phase

is to review the data collected in the is to review the data collected in the feasibility study, the workflow feasibility study, the workflow documents, and the functional documents, and the functional specification and provide specification and provide recommendations to the project recommendations to the project steering committee for the new steering committee for the new system. system.

Benefits IdentificationBenefits Identification The overall anticipated benefits from The overall anticipated benefits from

the system are documented in the the system are documented in the fourth step in the system analysis fourth step in the system analysis process.process.

The System Design PhaseThe System Design Phase In the system design phase, the design In the system design phase, the design

details of the system and the detailed details of the system and the detailed plans for implementing the system are plans for implementing the system are developed for both the functional and the developed for both the functional and the technical components of the system. technical components of the system. Acceptance of the system proposal by the Acceptance of the system proposal by the steering committee heralds the beginning steering committee heralds the beginning of the system design phase.of the system design phase.

Functional SpecificationsFunctional Specifications The functional specifications use the The functional specifications use the

functional design document develop functional design document develop in the system analysis phase of a CIS in the system analysis phase of a CIS and builds on the design formulating and builds on the design formulating a detailed description of ALL system a detailed description of ALL system inputs, outputs, and processing logic inputs, outputs, and processing logic required to complete the scope of required to complete the scope of the project.the project.

Data Manipulation and OutputData Manipulation and Output There are several considerations for There are several considerations for

handling data manipu8lation and handling data manipu8lation and output. The detailed functional output. The detailed functional specifications are critical to the specifications are critical to the system’s acceptance; each screen, system’s acceptance; each screen, data flow, and report the user can data flow, and report the user can expect to see is analyzed.expect to see is analyzed.

Technical SpecificationsTechnical Specifications In the system design phase, technical In the system design phase, technical

personnel work closely with the project personnel work closely with the project and departmental teams to ensure the and departmental teams to ensure the technical components of the proposed technical components of the proposed system work in concert with technology system work in concert with technology and end-user needs and to assist in the and end-user needs and to assist in the development of the implementation plan.development of the implementation plan.

HardwareHardware In the case of new software In the case of new software

development, the technical project development, the technical project manager ensure the new software manager ensure the new software uses the best technology platform uses the best technology platform available. available.

Application SoftwareApplication Software The project’s technical manager is The project’s technical manager is

responsible for establishing the responsible for establishing the technical specifications outlining the technical specifications outlining the operational requirements for the new operational requirements for the new systemsystem

Interface SystemsInterface Systems An interface system defines those An interface system defines those

programs and processes required to programs and processes required to transmit data between two disparate transmit data between two disparate systems. The project’s technical systems. The project’s technical manager coordinates all interfacing manager coordinates all interfacing activities for the new application.activities for the new application.

The Testing PhaseThe Testing Phase The system, whether newly developed or The system, whether newly developed or

commercially available, must be tested to commercially available, must be tested to ensure that all data are processed ensure that all data are processed correctly and the desired outputs are correctly and the desired outputs are generated. Testing verifies that the generated. Testing verifies that the computer programs are written corre4ctly computer programs are written corre4ctly and ensures that when implemented in the and ensures that when implemented in the production (live) environment, the system production (live) environment, the system will function as planned.will function as planned.

Document SystemDocument System The preparation of documents to The preparation of documents to

describe the system for all users is describe the system for all users is an ongoing activity, with an ongoing activity, with development of the documentation development of the documentation occurring as the various system occurring as the various system phases and steps are completed.phases and steps are completed.

User’s ManualUser’s Manual The user’s manual highlights how to The user’s manual highlights how to

use the system and describes what use the system and describes what outputs the system can produce.outputs the system can produce.

Reference ManualReference Manual The reference manual is used by the The reference manual is used by the

project team members to understand project team members to understand how the system works.how the system works.

Operator’s Maintenance ManualOperator’s Maintenance Manual The manual enables operators to The manual enables operators to

keep the system up and running by keep the system up and running by providing the functional and providing the functional and technical specifications needed for technical specifications needed for the system. the system.

The Training PhaseThe Training Phase It is essential to train the end users It is essential to train the end users

on how to use the system properly. A on how to use the system properly. A CIS will function only as well as its CIS will function only as well as its users understands its operation and users understands its operation and the operations streamline the work.the operations streamline the work.

The Implementation PhaseThe Implementation Phase The implementation phase organizes all The implementation phase organizes all

the steps into a detailed plan describing the steps into a detailed plan describing the series of events required to begin the series of events required to begin using the system or application in the using the system or application in the production or live environment and details production or live environment and details the necessary computer and software the necessary computer and software maintenance operations required to keep maintenance operations required to keep the system running.the system running.

The Evaluation PhaseThe Evaluation Phase Describes and assesses, in details Describes and assesses, in details

the new system’s performance. the new system’s performance. Using the criteria established in the Using the criteria established in the planning system design phases, the planning system design phases, the evaluation process summarizes the evaluation process summarizes the entire system, identifying both the entire system, identifying both the strengths and weaknesses of the strengths and weaknesses of the implementation process.implementation process.

Cost-Benefit AnalysisCost-Benefit Analysis Is necessary to determine if the Is necessary to determine if the

system is worth its price. The cost-system is worth its price. The cost-benefit analysis relates system cost benefit analysis relates system cost and benefits to system design, level and benefits to system design, level of use, timeframe, and equipment of use, timeframe, and equipment costs.costs.

Upgrading Clinical Information Upgrading Clinical Information SystemsSystems

The upgrading of a system may be The upgrading of a system may be undertaken for a number of reasons. undertaken for a number of reasons. Software vendors often provide Software vendors often provide enhancements and upgrades to their enhancements and upgrades to their system.system.

WorkstationsWorkstations Becomes the mode to gain access to Becomes the mode to gain access to

multiple applications. The user does multiple applications. The user does not have to know or understand what not have to know or understand what type of hardware or software he or type of hardware or software he or she is accessing, only that there is she is accessing, only that there is acces to a broad array of acces to a broad array of information.information.

System IssuesSystem Issues As new technologies are evaluated As new technologies are evaluated

and upgrading is considered, the and upgrading is considered, the design team or departmental team design team or departmental team must reassess the original functional must reassess the original functional requirements.requirements.

Future TrendsFuture Trends The introduction of the computer-based The introduction of the computer-based

patient record (CPT) has been patient record (CPT) has been recommended by the Institute of Medicine recommended by the Institute of Medicine report. The report recommends the new report. The report recommends the new system designs should expand to improve system designs should expand to improve the fundamental resource in healthcare the fundamental resource in healthcare beyond the automating of patient records.beyond the automating of patient records.

Practice ApplicationPractice Application

Historical PerspectiveHistorical Perspective More than 150 years ago, Florence More than 150 years ago, Florence

Nightingale spoke about the critical Nightingale spoke about the critical importance of nursing informatics in importance of nursing informatics in patient care. “Decision making must be patient care. “Decision making must be based upon the use of accurate data” she based upon the use of accurate data” she said. The nursing pioneer also spoke of said. The nursing pioneer also spoke of frustration from the difficulties of frustration from the difficulties of extracting such critical patient-related extracting such critical patient-related data form hospital records:data form hospital records:

In attempting to arrive at the truth, I have In attempting to arrive at the truth, I have applied everywhere for information, but in applied everywhere for information, but in scarcely an instance have I been able to scarcely an instance have I been able to obtain hospital records for any purposes of obtain hospital records for any purposes of comparison. If they could be obtained they comparison. If they could be obtained they would enable us to decide many other would enable us to decide many other questions besides the ones alluded to. questions besides the ones alluded to. They would show subscribers how their They would show subscribers how their money was being spent, what amount of money was being spent, what amount of good was really being done with it, or good was really being done with it, or whether the money was not doing mischief whether the money was not doing mischief rather than good (Nightingale, 1859, rather than good (Nightingale, 1859, p.187)p.187)

It was more than a century after It was more than a century after Florence Nightingale’s era that Florence Nightingale’s era that computers made their appearance computers made their appearance on the hospital landscape. The first on the hospital landscape. The first hospital information systems arrived hospital information systems arrived in late 1950s to the mid 1960s, in late 1950s to the mid 1960s, although these systems focused although these systems focused primarily on processing financial and primarily on processing financial and administrative.administrative.

Critical Care ApplicationsCritical Care Applications

Critical care nursing is the nursing Critical care nursing is the nursing specialty that deals with human specialty that deals with human responses to life-threatening responses to life-threatening problems. Critical care is the problems. Critical care is the multidisciplinary healthcare specialty multidisciplinary healthcare specialty that cares for patients with acute, that cares for patients with acute, life-threatening illness or injury.life-threatening illness or injury.

Information Technology Capabilities and Information Technology Capabilities and Applications in Critical Care SettingsApplications in Critical Care Settings

Several major capabilities:Several major capabilities: Process, store, and integrate physiologic and diagnostic Process, store, and integrate physiologic and diagnostic

information form various sourcesinformation form various sources Present deviations form preset ranges by an alarm or an Present deviations form preset ranges by an alarm or an

alertalert Accept and store patient care documentation in a lifetime Accept and store patient care documentation in a lifetime

clinical repositoryclinical repository Trend data in a graphical presentationTrend data in a graphical presentation Device Connectivity InfrastructureDevice Connectivity Infrastructure Bedside monitoring devices are capable of sending Bedside monitoring devices are capable of sending

information to software applications. In concept, the term information to software applications. In concept, the term Medical Information Bus (MIB) is used to classify the Medical Information Bus (MIB) is used to classify the backbone of information exchange, allowing data to be backbone of information exchange, allowing data to be moved form one point to another.moved form one point to another.

Physiologic Monitoring SystemsPhysiologic Monitoring Systems In the NASA programs of the 1960s, In the NASA programs of the 1960s,

physiologic monitors were developed physiologic monitors were developed to oversee the vital signs of the to oversee the vital signs of the astronauts. By the 1970s, these astronauts. By the 1970s, these monitors had found their way into monitors had found their way into hospital setting, where they replaced hospital setting, where they replaced manual methods of gathering patient manual methods of gathering patient vital signs.vital signs.

Hemodynamic Monitors Hemodynamic Monitors

Advanced hemodynamic monitoring Advanced hemodynamic monitoring systems allow for calculation of systems allow for calculation of hemodynamic indices and limited data hemodynamic indices and limited data storage. Hemodynamic monitoring can be storage. Hemodynamic monitoring can be used to:used to:– Measure hemodynamic parametersMeasure hemodynamic parameters– Closely examine cardiovascular functionClosely examine cardiovascular function– Evaluate cardiac pump output and volume Evaluate cardiac pump output and volume

statusstatus– Recognize patterns (arrhythmia analysis) and Recognize patterns (arrhythmia analysis) and

extract featuresextract features

Arrhythmia MonitorsArrhythmia Monitors

Computerized monitoring and Computerized monitoring and analysis of cardiac rhythm have analysis of cardiac rhythm have proved reliable and effective in proved reliable and effective in detecting potentially lethal heart detecting potentially lethal heart rhythms. Standards for testing and rhythms. Standards for testing and reporting the performance of reporting the performance of arrhythmia analysis systems have arrhythmia analysis systems have been developed by the American been developed by the American Heart Association.Heart Association.

Critical Care Information SystemsCritical Care Information Systems A CCIS is a system designed to collect, A CCIS is a system designed to collect,

store, organize, retrieve and manipulate store, organize, retrieve and manipulate all data related to care of the critically ill all data related to care of the critically ill patient. It os focused on individual patient. It os focused on individual patients and the information directly patients and the information directly related to the patients’ care.related to the patients’ care.

The primary purpose of a CCIS is the The primary purpose of a CCIS is the organization of a patient’s current and organization of a patient’s current and historical data for use by all care providers historical data for use by all care providers in patient care.in patient care.

Community Health ApplicationsCommunity Health Applications

CHN is a synthesis of nursing practice and CHN is a synthesis of nursing practice and public health practice applied to promoting public health practice applied to promoting and preserving the health of populations. and preserving the health of populations. The scope is not limited to a particular The scope is not limited to a particular age, diagnostic group, or practice setting. age, diagnostic group, or practice setting. It requires a comprehensive understanding It requires a comprehensive understanding and knowledge of the framework of the and knowledge of the framework of the community, its resources, and the community, its resources, and the sociocultural issues impacting people sociocultural issues impacting people within the community.within the community.

Home HealthHome Health

Medicare and Medicaid LegislationMedicare and Medicaid Legislation With the enactment of the Medicare With the enactment of the Medicare

and Medicaid Legislation in 1965, and Medicaid Legislation in 1965, reimbursement for home care was reimbursement for home care was allowed. Home healthcare is a very allowed. Home healthcare is a very broad term used to describe the broad term used to describe the provision of preventive, therapeutic, provision of preventive, therapeutic, restorative, and supportive restorative, and supportive healthcare in the home.healthcare in the home.

Balanced Budget ActBalanced Budget Act With the enactment of the Balanced Budget Act With the enactment of the Balanced Budget Act

of 1997, the need for information moved beyond of 1997, the need for information moved beyond billing information, statistical information, and the billing information, statistical information, and the tracking of clinical data. Beginning, October 1, tracking of clinical data. Beginning, October 1, 2000, the Center for Medicare and Medicaid 2000, the Center for Medicare and Medicaid Services (CMS) instituted a prospective payment Services (CMS) instituted a prospective payment system (PPS) for medicare home.system (PPS) for medicare home.

Outcome Measures – Concurrently, a focus on Outcome Measures – Concurrently, a focus on quality initiatives further supported the need for quality initiatives further supported the need for IT. CMS began using the OASIS data set for the IT. CMS began using the OASIS data set for the purpose of monitoring outcomes and adverse purpose of monitoring outcomes and adverse events based on risk-adjusted patient events based on risk-adjusted patient characteristics for all Medicare-certified HHAs.characteristics for all Medicare-certified HHAs.

Public HealthPublic Health

The Institute of Medicine (IOM) defines The Institute of Medicine (IOM) defines public health as a “coordinated effort public health as a “coordinated effort at the local, state, and federal levels at the local, state, and federal levels whose mission is fulfilling society’s whose mission is fulfilling society’s interest in assuring conditions in interest in assuring conditions in which people can be healthy”.which people can be healthy”.

Public Health ChallengesPublic Health Challenges

Currently, public health is facing many new Currently, public health is facing many new challenges for information as a result of issues challenges for information as a result of issues such as bio-terrorism, health plans recognizing such as bio-terrorism, health plans recognizing the need to evaluate prevention activities to the need to evaluate prevention activities to improve the quality of life and reduce costs, improve the quality of life and reduce costs, healthcare providers recognizing the need, healthcare providers recognizing the need, reduce costs, healthcare providers recognizing reduce costs, healthcare providers recognizing the need to integrate public data into individual the need to integrate public data into individual health records, and health departments needing health records, and health departments needing to monitor the impact and health departments to monitor the impact and health departments needing to monitor the impact of community-wide needing to monitor the impact of community-wide interventions for improving the health of interventions for improving the health of populations in communities.populations in communities.

Data SetsData Sets

A uniform data set is a minimum set of A uniform data set is a minimum set of items of information with uniform items of information with uniform definition and categories, concerning definition and categories, concerning the specific dimension of the service the specific dimension of the service or practice setting that meets the or practice setting that meets the essential information needs of essential information needs of multiple data users within the scope multiple data users within the scope of the service or practice setting.of the service or practice setting.

Selected Data SetsSelected Data Sets

Several uniform data sets were Several uniform data sets were developed by different organizations developed by different organizations and governmental agencies for and governmental agencies for depicting their standardized depicting their standardized vocabularies. The NLN developed one vocabularies. The NLN developed one of the first prototypes for a basic of the first prototypes for a basic minimum data set for CHN even minimum data set for CHN even though it is no longer used.though it is no longer used.

Uniform Data Set for Home Care and Uniform Data Set for Home Care and HospiceHospice

IN 1993, the National Association of IN 1993, the National Association of Home care (NAHC) Resource Home care (NAHC) Resource Committee initiated a task force to Committee initiated a task force to develop a uniform data set for home develop a uniform data set for home care and hospice.care and hospice.

Outcome and Assessment Outcome and Assessment Information Set (OASIS)Information Set (OASIS)

This is a group of items that represents the This is a group of items that represents the core items of a comprehensive core items of a comprehensive assessment for an adult home health assessment for an adult home health patient and forms the basis for measuring patient and forms the basis for measuring patient outcomes for purposes of OBQI patient outcomes for purposes of OBQI (CMS 2003). Most data items in the OASIS (CMS 2003). Most data items in the OASIS were derived as part of CMS-funded were derived as part of CMS-funded national research program, co-funded by national research program, co-funded by the Robert Wood Johnson Foundation to the Robert Wood Johnson Foundation to develop a system of outcome measures develop a system of outcome measures for home healthcare.for home healthcare.

CLINICAL ITEMSCLINICAL ITEMS

Data element name –Medical DiagnosisData element name –Medical Diagnosis Definition: Any medical diagnoses that affect the Definition: Any medical diagnoses that affect the

care provided by the home care organization as care provided by the home care organization as defined by ICD-CM codes:defined by ICD-CM codes:

Principal: The diagnosis most responsible for the Principal: The diagnosis most responsible for the admission of the patient/client for home care admission of the patient/client for home care servicesservices

Other: All other diagnoses that affect the care Other: All other diagnoses that affect the care provided by the home care organizationprovided by the home care organization

Not Applicable: If the home care services are not Not Applicable: If the home care services are not related to healthcare needs (e.g. homemaker)related to healthcare needs (e.g. homemaker)

Outcome-Based Quality Outcome-Based Quality ImprovementImprovement

IN early 2002, the OBQI framework IN early 2002, the OBQI framework was established (similar to a data was established (similar to a data set). It includes two components: set). It includes two components: outcome analysis and outcome outcome analysis and outcome enhancement. enhancement.

Health Plan Employer Data and Health Plan Employer Data and Information Set (HEDIS)Information Set (HEDIS)HEDIS is a set of standardized HEDIS is a set of standardized performance measures designed to performance measures designed to ensure that purchasers and ensure that purchasers and consumers have the information for consumers have the information for reliability comparing the reliability comparing the performance of managed healthcare performance of managed healthcare plans.plans.

Vocabulary LanguagesVocabulary Languages Vocabularies are validated clinical Vocabularies are validated clinical

reference languages, taxonomies, or reference languages, taxonomies, or terminologies that make healthcare terminologies that make healthcare knowledge more usable and accessible. knowledge more usable and accessible. The language, vocabulary, or taxonomy The language, vocabulary, or taxonomy enables a consistent way of capturing, enables a consistent way of capturing, sharing, and aggregating health data sharing, and aggregating health data across sites of care.across sites of care.

Omaha SystemOmaha System Is a researched –based, comprehensive Is a researched –based, comprehensive

taxonomy designed to generate taxonomy designed to generate meaningful data following usual or routine meaningful data following usual or routine documentation of client care. It consists of documentation of client care. It consists of three components the problem three components the problem classification scheme, intervention classification scheme, intervention scheme, and problem rating scale scheme, and problem rating scale outcomes. The systems provides a method outcomes. The systems provides a method for linking clinical data to demographic, for linking clinical data to demographic, financial, administrative and staffing data.financial, administrative and staffing data.

Community Health SystemsCommunity Health Systems– Categorical program systemsCategorical program systems– Registration systemsRegistration systems– Management Information systemsManagement Information systems– Statistical Reporting systemsStatistical Reporting systems

TelemedicineTelemedicine Is being implemented to replace Is being implemented to replace

face-to-face home visits. It refers to face-to-face home visits. It refers to the electronic transfer of medical the electronic transfer of medical information and services (voice, data information and services (voice, data and video) form one site to another and video) form one site to another using telecommunication using telecommunication technologies.technologies.

Ambulatory Care systemsAmbulatory Care systems

On April 27, 2004 President George Bush On April 27, 2004 President George Bush announced a goal to establish electronic health announced a goal to establish electronic health records (EHRs) for all citizens within a 10-year records (EHRs) for all citizens within a 10-year time frame. He created the position of a national time frame. He created the position of a national health information technology coordinator to health information technology coordinator to develop a nationwide interoperable health develop a nationwide interoperable health information technology infrastructure. One information technology infrastructure. One responsibility for the national coordinator is to responsibility for the national coordinator is to improve “ the coordination of care and improve “ the coordination of care and information among hospitals, laboratories, information among hospitals, laboratories, physician offices, and other ambulatory care physician offices, and other ambulatory care providers through an effective infrastructure for providers through an effective infrastructure for the secure and authorized exchange of health the secure and authorized exchange of health care information.care information.

Where Ambulatory Clients are being Where Ambulatory Clients are being TreatedTreated

As a response to increasing cost of As a response to increasing cost of providing healthcare, the healthcare providing healthcare, the healthcare industry has moved away from the industry has moved away from the expensive inpatient, acute care expensive inpatient, acute care environment to caring for clients in environment to caring for clients in various ambulatory care setting.various ambulatory care setting.

Issues for Ambulatory CareIssues for Ambulatory Care Issues surrounding those who work in Issues surrounding those who work in

ambulatory care are similar across the ambulatory care are similar across the healthcare enterprise including increased healthcare enterprise including increased accountability, the need for continuous accountability, the need for continuous and documented service improvements, and documented service improvements, pressure to control utilization, and the pressure to control utilization, and the protection of confidential information. protection of confidential information. Effective reimbursement of services is Effective reimbursement of services is paramount for continued operation.paramount for continued operation.

Applications Necessary in the Ambulatory Applications Necessary in the Ambulatory EnvironmentEnvironment

Ambulatory care information systems, Ambulatory care information systems, usually computer-assisted are designed to usually computer-assisted are designed to store, manipulate, and retrieve store, manipulate, and retrieve information for planning, organizing, information for planning, organizing, directing, and controlling administrative directing, and controlling administrative and clinical activities associated with the and clinical activities associated with the provision and use of ambulatory care provision and use of ambulatory care services and facilities.services and facilities.

Financial BenefitsFinancial Benefits Financial benefits of the Financial benefits of the

implementation of an automated implementation of an automated information system include a cost-information system include a cost-effective and timely bill submission effective and timely bill submission process resulting in decreased days process resulting in decreased days in accounts receivable and the in accounts receivable and the reduction of rejected claims.reduction of rejected claims.

Administrative BenefitsAdministrative Benefits

Administrative benefits of implementing an Administrative benefits of implementing an automated information system include a automated information system include a reduction in the size of the record room, reduction in the size of the record room, reduced time spent finding and delivering reduced time spent finding and delivering charts, increase in the privacy of data, charts, increase in the privacy of data, formats that are legible and comply with formats that are legible and comply with legal regulations, and the promotion of legal regulations, and the promotion of quality assurance and improved patient quality assurance and improved patient satisfaction.satisfaction.

Clinical BenefitsClinical Benefits Clinically, the automated healthcare Clinically, the automated healthcare

record can provide a problem list, record can provide a problem list, automated ambulatory care provider order automated ambulatory care provider order entry (ACPOE), a medication record, vital entry (ACPOE), a medication record, vital signs, progress motes, result from the signs, progress motes, result from the laboratory and radiology departments, laboratory and radiology departments, flow sheets, growth charts, immunization flow sheets, growth charts, immunization records, medication allergies, profiles, records, medication allergies, profiles, alerts and reminders and a follow-up alerts and reminders and a follow-up system.system.

Internet tools for advanced Nursing PracticeInternet tools for advanced Nursing Practice

Informatics solutions for Emergency Preparedness Informatics solutions for Emergency Preparedness and responseand response

Changes in the Federal System Affecting Changes in the Federal System Affecting Emergency Preparedness and ResponseEmergency Preparedness and Response

A new Definition of CommunityA new Definition of Community Community health has traditionally been defined in the Community health has traditionally been defined in the

United States as the provision of healthcare outside the United States as the provision of healthcare outside the hospital infrastructure. As such, the public health hospital infrastructure. As such, the public health departments have been viewed as the major delivery departments have been viewed as the major delivery system of healthcare. Unfortunately, over time the public system of healthcare. Unfortunately, over time the public health infrastructure has been deteriorating to the point health infrastructure has been deteriorating to the point that many of the rural health department settings did not that many of the rural health department settings did not even have fax machines to receive notices about potential even have fax machines to receive notices about potential public health threats. The anthrax scares made this public health threats. The anthrax scares made this situation most apparent, as all sorts of white powder situation most apparent, as all sorts of white powder mixtures were sent through the laboratory system of the mixtures were sent through the laboratory system of the state public health departments.state public health departments.

Federal Responsibilities for Healthcare ProvidersFederal Responsibilities for Healthcare Providers The U.S. Department of Health and Human The U.S. Department of Health and Human

Services (DHHS) is responsible for the education Services (DHHS) is responsible for the education of healthcare professionals in preparedness for of healthcare professionals in preparedness for emergencies, including potential terrorism. emergencies, including potential terrorism. Several units under the auspices of DHHS. Three Several units under the auspices of DHHS. Three of the units focus on emergency planning and of the units focus on emergency planning and response: The CDC the Agency for Healthcare response: The CDC the Agency for Healthcare Research and Quality (AHRQ), and HRSA. Each of Research and Quality (AHRQ), and HRSA. Each of these agencies plays a critical role in emergency these agencies plays a critical role in emergency planning and response.planning and response.

New Visibility of CDC Promotes New Visibility of CDC Promotes Informatics SolutionsInformatics Solutions

The CDC is recognized as the lead The CDC is recognized as the lead federal agency for protecting the federal agency for protecting the health and safety of people-at home health and safety of people-at home and abroad, providing credible and abroad, providing credible information to enhance health information to enhance health decisions, and promoting health decisions, and promoting health through strong partnerships.through strong partnerships.

Role of AHRQ in stimulating New Informatics Role of AHRQ in stimulating New Informatics SolutionsSolutions

AHRQ’s involvement in bio-terrorism AHRQ’s involvement in bio-terrorism comes from the recognition that comes from the recognition that clinicians, hospitals, and healthcare clinicians, hospitals, and healthcare systems have essential roles in public systems have essential roles in public health infrastructure.health infrastructure.

– Decision support systemsDecision support systems– Syndromic surveillanceSyndromic surveillance– Helping Clinicians recordHelping Clinicians record

Vendor ApplicationsVendor Applications

Current Trends Toward Prime Current Trends Toward Prime Vendors, EHRs, and Systems Vendors, EHRs, and Systems Integration Integration

There are a wide variety of software There are a wide variety of software products offered by an array of diverse products offered by an array of diverse vendors that nurses use to plan, vendors that nurses use to plan, document, manage, and evaluate patient document, manage, and evaluate patient care, “ Niche” applications focus on a care, “ Niche” applications focus on a discrete set of nursing functions, e.g. care discrete set of nursing functions, e.g. care planning. “Departmental” systems address planning. “Departmental” systems address a more comprehensive set of functions for a more comprehensive set of functions for a single point of service e.g. labor and a single point of service e.g. labor and delivery; or department eg. Cardiology; or delivery; or department eg. Cardiology; or closely aligned group of departments, eg. closely aligned group of departments, eg. Perioperative suite.Perioperative suite.

New TechnologiesNew Technologies New and emerging hardware and New and emerging hardware and

software technologies, eg. Handheld software technologies, eg. Handheld devices, are increasingly being devices, are increasingly being incorporated in nursing applications. incorporated in nursing applications. Key goals are to improve quality of Key goals are to improve quality of care, mobility of caregivers, and care, mobility of caregivers, and collaboration among the care team.collaboration among the care team.

Historical PerspectiveHistorical Perspective Historically, nurse executives have not Historically, nurse executives have not

widely embraced IT as a strategic business widely embraced IT as a strategic business tool. For a variety of reasons, nurses in the tool. For a variety of reasons, nurses in the field have often lacked a deep field have often lacked a deep understanding of the power of IT, With the understanding of the power of IT, With the ubiquity of technology in healthcare and ubiquity of technology in healthcare and everyday life, savvy nursing leaders everyday life, savvy nursing leaders increasingly view IT as viable means to increasingly view IT as viable means to address resource shortages, care delivery address resource shortages, care delivery challenges and fiscal pressures.challenges and fiscal pressures.

Current SituationCurrent Situation Today, the majority of nursing-related Today, the majority of nursing-related

patient care applications are acquired as patient care applications are acquired as part of HER decisions. Since nurse part of HER decisions. Since nurse executives historically did not drive most executives historically did not drive most HER purchasing criteria or decisions, HER purchasing criteria or decisions, systems were all too often selected based systems were all too often selected based on the priorities of more powerful on the priorities of more powerful constituents and occasional users, e.g. constituents and occasional users, e.g. MDs. IN these cases, nursing often does MDs. IN these cases, nursing often does not fully embrace the system or take full not fully embrace the system or take full advantage of its capabilities.advantage of its capabilities.

Vendor ResponseVendor Response In response to market demand, HCIT In response to market demand, HCIT

vendors are delivering more robust vendors are delivering more robust and tightly integrated clinical and tightly integrated clinical solutions that better address the solutions that better address the needs of all care providers for more needs of all care providers for more coordinated, streamlined patient coordinated, streamlined patient care delivery.care delivery.

Vendor ComparisonVendor Comparison Four purposes of this chapter, side-Four purposes of this chapter, side-

by-side, feature function product by-side, feature function product comparisons will not be presented comparisons will not be presented given the sheet number of vendors given the sheet number of vendors offering nursing solutions and time offering nursing solutions and time sensitive nature of the information.sensitive nature of the information.

Care Flow DiagramCare Flow Diagram The care flow diagram is a conceptual The care flow diagram is a conceptual

model that represents a patient-centric, model that represents a patient-centric, interdisciplinary, inpatient-oriented view of interdisciplinary, inpatient-oriented view of a clinical information system that supports a clinical information system that supports a fully integrated HER. It includes care a fully integrated HER. It includes care components e.g. care planning and components e.g. care planning and documentation that are automated in HER documentation that are automated in HER systems as well as, in whole or part, in systems as well as, in whole or part, in niche and departmental applications.niche and departmental applications.

Key Clinical System Nursing and Key Clinical System Nursing and Multidisciplinary Care ComponentsMultidisciplinary Care Components

Patient AccessPatient Access The patient record is initiated in the The patient record is initiated in the

admission, discharge, and transfer (ADT) admission, discharge, and transfer (ADT) system or administrative portion of the system or administrative portion of the HER. The collection of initial registration HER. The collection of initial registration and admission data establishes a patient and admission data establishes a patient record and begins the clinical and financial record and begins the clinical and financial encounter with the provider organization.encounter with the provider organization.

Administrative ApplicationAdministrative Application

Administrative Application of Administrative Application of Information Technology for Nursing Information Technology for Nursing ManagersManagers

Nursing Management Today: Challenges, Chances, Nursing Management Today: Challenges, Chances, ChoicesChoices

Ironically, the constituencies shaping healthcare Ironically, the constituencies shaping healthcare – global leaders, healthcare CIOs and CEOs, – global leaders, healthcare CIOs and CEOs, vendors, and patients – are accidental jurists in vendors, and patients – are accidental jurists in the court of healthcare IT futures. They do not the court of healthcare IT futures. They do not care about shaping tomorrow’s healthcare; they care about shaping tomorrow’s healthcare; they just want their problems solved. But because just want their problems solved. But because they are such key players, their problems shape they are such key players, their problems shape healthcare information technology solutions.healthcare information technology solutions.

Issues are:Issues are: The nursing shortageThe nursing shortage Increased demand for patient safetyIncreased demand for patient safety The need for visibilityThe need for visibility

The Nursing shortageThe Nursing shortage Within 10 years, 40% of working Within 10 years, 40% of working

registered nurses (RNs) will be 50 years registered nurses (RNs) will be 50 years or older. As those RNs retire, the supply or older. As those RNs retire, the supply of working RNs will be 20% below of working RNs will be 20% below requirements by the year 2020.requirements by the year 2020.

The primary factors are contributing to The primary factors are contributing to the current shortage, including:the current shortage, including:

steep populationsteep population Increased Demand for Patient SafetyIncreased Demand for Patient Safety The need for visibilityThe need for visibility

Nursing Management’s Administrative Nursing Management’s Administrative NeedsNeeds

In 2002, the American Healthcare In 2002, the American Healthcare Association (AHA) commissioned Association (AHA) commissioned Pricewaterhouse coopers (PwC) to Pricewaterhouse coopers (PwC) to survey some of the American survey some of the American hospitals about their patient care and hospitals about their patient care and paperwork experiences.paperwork experiences.

Applications and Implications of Applications and Implications of Information Technology for Nursing Information Technology for Nursing ManagementManagement

In the 1980s, nursing IT education-In the 1980s, nursing IT education-what little there was of it-taught the what little there was of it-taught the use of computers as tools for word use of computers as tools for word processing, spreadsheet analysis, processing, spreadsheet analysis, graphics production and statistical graphics production and statistical applications.applications.

Definition of a Nursing Information SystemDefinition of a Nursing Information System In today’s information age, nurses are In today’s information age, nurses are

expected to keep pace with rapidly expected to keep pace with rapidly advancing technology. Appropriate use of advancing technology. Appropriate use of computers and information systems can computers and information systems can help nurses make well-informed decisions help nurses make well-informed decisions regarding management and patient care regarding management and patient care issues.issues.

The “Real” Cost of Administrative The “Real” Cost of Administrative SystemsSystems

To determine the true cost of To determine the true cost of automation, one must take three automation, one must take three things into account:things into account:

Cost of the hardware and softwareCost of the hardware and software Cost of educationCost of education Intellectual resourcesIntellectual resources

The Need for Nursing Data StandardsThe Need for Nursing Data Standards For some time, there have been standards For some time, there have been standards

motivating nursing to focus on effective motivating nursing to focus on effective and efficient administration. Established and efficient administration. Established by the American Nurses Association (ANA) by the American Nurses Association (ANA) in 1988, these standards remain the in 1988, these standards remain the prevailing measures by which professional prevailing measures by which professional nurses evaluate practice.nurses evaluate practice.

How Nursing Benefits for Nursing How Nursing Benefits for Nursing Administrators and ManagersAdministrators and Managers

Several administrative applications are Several administrative applications are available on computers for nurse available on computers for nurse administrators.administrators.

Nurse Managers’ Data NeedsNurse Managers’ Data Needs In general, nursing managers use In general, nursing managers use

computer systems to collect data needed computer systems to collect data needed for planning, budgeting, and reporting, for planning, budgeting, and reporting, which ensure quality care.which ensure quality care.

Nurse Executives’ Data NeedsNurse Executives’ Data Needs Nurse executives’ needs and the Nurse executives’ needs and the

application they use include:application they use include:– managing organized needs and the managing organized needs and the

applications and the environment in which applications and the environment in which clinical nursing is practiced.clinical nursing is practiced.

– Ensuring the standards of nursing practice Ensuring the standards of nursing practice are established and implemented, and are are established and implemented, and are consistent with standards of professional consistent with standards of professional organizations and regulatory agencies.organizations and regulatory agencies.

– Evaluating care delivery models and of Evaluating care delivery models and of services provided to individuals and services provided to individuals and aggregatesaggregates

Evidence-Based NursingEvidence-Based Nursing Is the process by which the nurses Is the process by which the nurses

make clinical decisions using the make clinical decisions using the best available research evidence, best available research evidence, their clinical expertise and patient their clinical expertise and patient preferences. These areas of research preferences. These areas of research competence are: interpreting and competence are: interpreting and using research, evaluating practice using research, evaluating practice and conducting research.and conducting research.

What Nursing Administrators Need to What Nursing Administrators Need to know about Selecting a Systemknow about Selecting a System

BY putting the patient at the center BY putting the patient at the center of the cost equation, managing care of the cost equation, managing care makes the caregiver a critical makes the caregiver a critical determinant of success. But determinant of success. But caregivers can only be successful caregivers can only be successful with the proper technological tools.with the proper technological tools.

Nursing Administration’s Role in IT Nursing Administration’s Role in IT ImplementationImplementation

Times are tight and dollars are short in Times are tight and dollars are short in healthcare. With organizations questioning healthcare. With organizations questioning all expenditures, it is no surprise that they all expenditures, it is no surprise that they are increasingly asking “Why?” when it are increasingly asking “Why?” when it comes to nursing information systems. If comes to nursing information systems. If nursing is to have the technology it needs, nursing is to have the technology it needs, it better well have an answer to that it better well have an answer to that question.question.

The Future of Computerized Nursing The Future of Computerized Nursing Administrative SystemsAdministrative Systems

Several critical needs- form Several critical needs- form globalization to the culture of change globalization to the culture of change and the rise of the information age- and the rise of the information age- will fuel development and will fuel development and deployment of future IT.deployment of future IT.

Translate of Evidence, Clinical Practice Translate of Evidence, Clinical Practice Guidelines, and Automated Implementation Guidelines, and Automated Implementation

ToolsTools

Much of this chapter is based on the Much of this chapter is based on the classic description of guidelines and classic description of guidelines and computer implementation by computer implementation by McQueen and McCormick in 2001. McQueen and McCormick in 2001. However, this revised chapter However, this revised chapter contain a new major section which contain a new major section which discusses scientific evidence and the discusses scientific evidence and the development of clinical evidence-development of clinical evidence-based guideline tools.based guideline tools.

Fundamentals of Clinical PracticeFundamentals of Clinical Practice The current pace of change with The current pace of change with

healthcare knowledge and technology healthcare knowledge and technology continues to accelerate. Computers and continues to accelerate. Computers and decision support systems provide tools for decision support systems provide tools for healthcare providers to manage this healthcare providers to manage this exponential increase in information so that exponential increase in information so that the most effective treatment decisions can the most effective treatment decisions can be made that will result in the optimal be made that will result in the optimal outcomes for the patient.outcomes for the patient.

ImplementationImplementation What is Implementation is defined as What is Implementation is defined as

applying textual information to real applying textual information to real situations. Successful situations. Successful implementation implies compliance implementation implies compliance and the ability to manage change.and the ability to manage change.

Effect of GuidelinesEffect of Guidelines Much is still being learned about the effect Much is still being learned about the effect

of guidelines on the outcomes of clinical of guidelines on the outcomes of clinical practice. Since the early studies by practice. Since the early studies by Grimshaw and Russell, published Grimshaw and Russell, published evaluations of guideline effectiveness evaluations of guideline effectiveness report statistically significant report statistically significant improvements in professional performance improvements in professional performance and significant improvement in patient and significant improvement in patient outcomes.outcomes.

Evaluation of GuidelinesEvaluation of Guidelines Evaluation of the effects of clinical practice Evaluation of the effects of clinical practice

guideline use by practitioners focuses now guideline use by practitioners focuses now on the computerization of guidelines. Due on the computerization of guidelines. Due to the myriad of complex factors that to the myriad of complex factors that impact outcomes, there is a lack of impact outcomes, there is a lack of conclusive evidence about what works and conclusive evidence about what works and does not work when using guidelines in does not work when using guidelines in real situations.real situations.

Putting Nursing Guidelines into Putting Nursing Guidelines into Practice: Finding WHAT WorksPractice: Finding WHAT Works

The lessons learned form nursing The lessons learned form nursing care plans are applicable: guidelines care plans are applicable: guidelines that sit on a shelf will collect dust that sit on a shelf will collect dust and not contribute to improved and not contribute to improved outcomes.outcomes.

Computers as a Tool to Facilitate Computers as a Tool to Facilitate Evidence-Based Practice and Guideline Evidence-Based Practice and Guideline ImplementationImplementation

This section presents new information for This section presents new information for providers seeking computerized tools to providers seeking computerized tools to promote guideline implementation. Since promote guideline implementation. Since the third edition, there has been the third edition, there has been movement into developing, implementing, movement into developing, implementing, evaluating, and determining outcomes evaluating, and determining outcomes from computerizing guidelines.from computerizing guidelines.

Computers and GuidelinesComputers and Guidelines At their best, automated tools are the most powerful At their best, automated tools are the most powerful

resource available to facilitate guideline implementation. resource available to facilitate guideline implementation. For many reasons, computers are potentially an ideal For many reasons, computers are potentially an ideal match for guidelines: match for guidelines:

– computers permit centralized storage and retrieval of computers permit centralized storage and retrieval of guidelinesguidelines

– computers facilitate communication between different computers facilitate communication between different providers or between providers and patients.providers or between providers and patients.

– Computers enhance the speed, timeliness and presentation Computers enhance the speed, timeliness and presentation of feedback and other reportsof feedback and other reports

– Computers expand the accessibility of guidelines and related Computers expand the accessibility of guidelines and related decision analysis toolsdecision analysis tools

– Computers make decision analysis infinitely easier and more Computers make decision analysis infinitely easier and more powerfulpowerful

– Computers provide a means for integrating guidelines with Computers provide a means for integrating guidelines with clinical information about effectiveness and outcomes.clinical information about effectiveness and outcomes.

Decision Support SystemsDecision Support Systems Decision analysis offers a way to link the Decision analysis offers a way to link the

probability of a clinical course to the probability of a clinical course to the likelihood of specific outcomes. The results likelihood of specific outcomes. The results of clinical decisions can then be predicted, of clinical decisions can then be predicted, and the probability of alternative and the probability of alternative strategies can be quantified. Decision strategies can be quantified. Decision models, data, and complex analyses are models, data, and complex analyses are required.required.

Computerized Reminder SystemsComputerized Reminder Systems Many common reminder systems are Many common reminder systems are

not automated. Laminated cards, not automated. Laminated cards, posters, preprinted forms within posters, preprinted forms within charts, and pocket guides are all charts, and pocket guides are all reminders familiar to most providers.reminders familiar to most providers.

Online Access to GuidelinesOnline Access to Guidelines Online communication provides a Online communication provides a

convenient, cost-effective vehicle for convenient, cost-effective vehicle for information dissemination and information dissemination and exchange. Online tools are most exchange. Online tools are most powerful when integrated within an powerful when integrated within an overall communication strategy and overall communication strategy and targeted to the specific information targeted to the specific information needs of each stakeholder.needs of each stakeholder.

Data Mining and Knowledge DiscoverData Mining and Knowledge Discover Decision-making in healthcare is a Decision-making in healthcare is a

knowledge-intensive activity that may knowledge-intensive activity that may surpass the ability of cognitive surpass the ability of cognitive processing. The impact of disease processing. The impact of disease processes, care processes, and processes, care processes, and environmental influences all combine to environmental influences all combine to present continually shifting target for present continually shifting target for decision-makers in healthcare.decision-makers in healthcare.

Innovative Approaches to Information Innovative Approaches to Information Management in HealthcareManagement in Healthcare

The move toward integrated health The move toward integrated health systems and the tracking of data systems and the tracking of data from cradle to grave has highlighted from cradle to grave has highlighted the need for a method by which the the need for a method by which the vast amounts of data being collected vast amounts of data being collected can be analyzed and visualized.can be analyzed and visualized.

Knowledge Discovery in Large Data Knowledge Discovery in Large Data SetsSets

KDD is defined by Abbott (2000) as KDD is defined by Abbott (2000) as the “melding of human expertise the “melding of human expertise with statistical and machine learning with statistical and machine learning techniques to identify features, techniques to identify features, patterns, and underlying rules in patterns, and underlying rules in large collections of healthcare data.large collections of healthcare data.

Differentiation of Verification versus Differentiation of Verification versus Discovery ApproachesDiscovery Approaches

How are traditional approaches How are traditional approaches different from KDD? Current different from KDD? Current statistical models based on statistical models based on regression offer the possibility of in-regression offer the possibility of in-depth analysis but may require depth analysis but may require unrealistic assumptions about the unrealistic assumptions about the distribution and interdependence of distribution and interdependence of data or errors.data or errors.

Background of knowledge Discovery in Large Background of knowledge Discovery in Large Data SetsData Sets

Analyzing large data sets in the quest to Analyzing large data sets in the quest to find “nuggets” of useful and interesting find “nuggets” of useful and interesting patterns of information has been labeled patterns of information has been labeled with many different titles. The terms, such with many different titles. The terms, such as knowledge extraction, data mining, as knowledge extraction, data mining, data pattern processing, data archaeology, data pattern processing, data archaeology, and information discovery, can be found in and information discovery, can be found in much of the literature.much of the literature.

The Use of Bayesian Networks in Healthcare The Use of Bayesian Networks in Healthcare KDDKDD

BNs have emerged in recent years as a BNs have emerged in recent years as a powerful data mining technique for powerful data mining technique for handling uncertainty in complex domains handling uncertainty in complex domains and a fundamental technique for pattern and a fundamental technique for pattern recognition and classification. The BN recognition and classification. The BN represents the joint probability distribution represents the joint probability distribution and domain (or expert) knowledge in a and domain (or expert) knowledge in a compact and understandable way.compact and understandable way.

Explaining Bayesian NetworksExplaining Bayesian Networks The BN is a state-of-the art representation The BN is a state-of-the art representation

of probabilistic knowledge. The BN is of probabilistic knowledge. The BN is drawn from a well-known example from drawn from a well-known example from literature. Represent knowledge literature. Represent knowledge qualitatively through a graphical diagram qualitatively through a graphical diagram (BN structure) with nodes (representing (BN structure) with nodes (representing variables) and edges (arrows representing variables) and edges (arrows representing relationships). Quantitatively, the degree relationships). Quantitatively, the degree of dependency is expressed by of dependency is expressed by probabilistic terms (parameters).probabilistic terms (parameters).

Consumer’s Use of InformaticsConsumer’s Use of Informatics

– Consumer and Patient use of Consumer and Patient use of computers for healthcomputers for health

– Information seeking about health Information seeking about health matters is a common use of computers matters is a common use of computers by patients and consumers. According by patients and consumers. According to a 2002 HarrisInteractive survey, to a 2002 HarrisInteractive survey, approximately two-thirds of the adult approximately two-thirds of the adult U.S. population has access to the U.S. population has access to the Internet, of these, about 80% had used Internet, of these, about 80% had used the computer recently for health-the computer recently for health-related matters.related matters.

Decision support for consumersDecision support for consumers Electronic mail continues to be the “killer app” Electronic mail continues to be the “killer app”

of the Internet. Many e-mail users find it of the Internet. Many e-mail users find it particularly useful for health-related matters. particularly useful for health-related matters. They may communicate informally with friends They may communicate informally with friends and family about health. They may use e-mail and family about health. They may use e-mail to keep family informed about the health status to keep family informed about the health status of one of the family. They may engage in online of one of the family. They may engage in online support groups whose focus is on a particular support groups whose focus is on a particular disease or condition or they may communicate disease or condition or they may communicate directly with their healthcare providers about directly with their healthcare providers about their own or a family member’s condition.their own or a family member’s condition.

Personal Health RecordsPersonal Health Records Even though patients’ medical Even though patients’ medical

records are more available to them records are more available to them now, thanks to the HIPAA privacy now, thanks to the HIPAA privacy rule, many consumers are daunted rule, many consumers are daunted by the size, complexity, illegibility, by the size, complexity, illegibility, and sheer number of institutionally-and sheer number of institutionally-based medical records that based medical records that accumulate over a person’s lifetime.accumulate over a person’s lifetime.

Decision SupportDecision Support A broad range of decision-support applications is A broad range of decision-support applications is

available to the interested consumer. Some available to the interested consumer. Some incorporate multimedia presentations of patients incorporate multimedia presentations of patients who have the condition that is the subject of the who have the condition that is the subject of the search (for example, search (for example, www.dipex.orgwww.dipex.org has videos has videos on several cancer subjects as well has heart on several cancer subjects as well has heart conditions, epilepsy and others). Others conditions, epilepsy and others). Others incorporate statistics –based presentations on incorporate statistics –based presentations on alternatives in areas such as treatment of early-alternatives in areas such as treatment of early-stage prostate cancer or hormone replacement stage prostate cancer or hormone replacement therapy.therapy.

Disease ManagementDisease Management Technological support for joint Technological support for joint

patient-provider collaboration in patient-provider collaboration in disease management is a promising disease management is a promising application area, though not yet application area, though not yet widespread. Patients or family widespread. Patients or family caregivers are enrolled in a program caregivers are enrolled in a program and participate using one of a and participate using one of a number of technologies.number of technologies.

Issues in Consumer Computing for HealthIssues in Consumer Computing for Health Variability in Quality of Information Available to Variability in Quality of Information Available to

ConsumersConsumers Because there are no quality controls on the Because there are no quality controls on the

content of health information available on the content of health information available on the Internet, health professionals have been Internet, health professionals have been concerned about the influence of unreliable concerned about the influence of unreliable information on consumer and patient behavior. information on consumer and patient behavior. Research shows, however, that the fears may be Research shows, however, that the fears may be unfounded. Ferguson observed that although unfounded. Ferguson observed that although both health professionals and patients are both health professionals and patients are concerned with the quality of information concerned with the quality of information available on the World Wide Web, patients are available on the World Wide Web, patients are less so.less so.