Nurses Exchanging Inform a T I O N : Understanding Electronic Health R E C O Rd Standards and I N T E Ro P E R a B I L I T Y

Nurses Exchanging Inform a t i o n : Understanding Electronic Health R e c o rd Standards and I n t e ro p e r a b i l i t y

Elizabeth Casey Halley Jane M. Bro k e l Joyce Sensmeier

The complexity in adopting health information technology (IT) stan - ealth care inform a t i o n d a rds is not from lack of standard s . R a t h e r, there are a vast nu m b e r systems began in the of standards that overlap and some that are missing.The objective of late 1970s and were this art i cle is to provide nu rses with an understanding of the impor - described as modular tance of the National Health IT Agenda and be empowered to influ - Hdesigned systems with a specific ence the processes to ensure nu rsing is represented. S ev e r a l focus to admit and discharg e aspects include harmonization and adoption of standards necessary patients or order diagnostics tests to ach i eve intero p e r a b i l i t y, and the strategies for nu rsing leaders to (Peterson & Jelger, 1988). Clinical a dvocate for adoption of those standard s . computers were used to calculate c a rdiac outputs or to measure © 2009 Society of Urologic Nurses and Associates rates and pre s s u res within the U rologic Nurs i n g, p p . 3 0 5 - 3 1 4 . h e a rt. The storage of clinical data was not captured except by a nurse documenting data on Key Wo rd s : E l e c t ron ic health record (EHR), EHR intero p e r a b i l i t y, paper re c o rds. Historically, nurs- Health Information Te chnology Standard s , i n t e ro p- es have used a variety of tech- erability specification, National Health IT Age n d a , nologies, but they have used p e rsonal health record (PHR), Use Cases, them more often to support other Te chnology Informatics Guiding Education Refo r m p rofessional departments or (TIGER) Initiative.

O b j e c t i v e s Elizabeth Casey Halley, R N , M BA , is the P rincipal Healthcare Consultant, MITRE, 1 . Discuss the importance of interoperability in health care. and a Co-Fa c i l i t a t o r, Technology Info rm a t i c s Guiding Education Refo r m (TIGER) 2 . Explain the difference between an electronic medical record, an Standards and Interoperability Colla - electronic health record, and a personal health record. b o ra t i ve, McLean, VA . 3. Describe the National Health IT Agenda and its implication on J oyce Sensmeier, M S , R N - B C , C P H I M S , for nurses. F H I M S S , is the Vice President, Info rm a t i c s 4. Identify the goals of the TIGER Initiative. Healthcare Info r mation and Management Systems Society, Chicago, IL, and Co- Fa c i l i t a t o r, TIGER Standards and I n t e r o p e rability Collabora t i ve.

Jane M. B ro k e l , P h D, R N , is an Assistant P r o fe s s o r, University of Iowa College of Nursing, Iowa City, IA; a member of the State of Iowa Electronic Health Info r m a t i o n E xe c u t i ve Committee and Advisory Council; Statement of Discl o s u r e : The authors reported no actual or potential conflict of interest in relation to this continuing nursing education art i c l e. an Info r matics Researcher, Trinity Health, N ovi, MI; and is the Guest Editor of this N o t e : O b j e c t i ves and CNE Evaluation Fo rm appear on page 314. issue of Urologic Nursing.

UROLOGIC NURSING / September-October 2009 / Volume 29 Number 5 305 administrative statistics. These Ta ble 1. basic technical functions were Core Concepts i n t e rmittently used by nurses to communicate with other clinical Core Concept D e s c r i p t i o n d e p a rtments. Early technologies Electronic Health The electronic health record (EHR) is defined as an elec- for the exchange of inform a t i o n Record (EHR) tronic record of health-related info rmation on an individual re q u i red standard codes (often that confo rms to nationally recognized interoperability stan- a c ronyms) that were used to ord e r dards and that can be created, managed, and consulted by the correct diagnostic tests and a u t h o ri zed clinicians and staff across more than one healthcare organization (DHHS Office of the National Coordinator procedures. Nurses exchanged for Health Info rmation Te c h n o l o g y, 2008). i n f o rmation using many of these early information systems. Electronic Medical The electronic medical record (EMR) is defined as an elec- To d a y, health inform a t i o n Record (EMR) tronic record of health-related info rmation on an individual technology (IT) is developed to that can be created, gathered, managed, and consulted by i n c reas e the capabilities of a u t h o ri zed clinicians and staff within one health care organ- exchanging protected health ization (DHHS Office of the National Coordinator for Health i n f o rmation beyond the hospital I n fo rmation Te c h n o l o g y, 2008). or clinic. As in the past, there are I n t e r o p e ra b i l i t y I n t e r o p e rability is the essential factor in building the infra- s t a n d a rd clinical terms and steps s t r ucture to create, transmit, store, and manage health- for exchanging this inform a t i o n . related info r mation (DHHS Office of the National These emerging technologies Coordinator for Health Info r mation Te c h n o l o g y, 2008). used in health care settings, I n t e r o p e ra b i l i t y I n t e r o p e rability specifications provide implementation guid- schools, and communities de- S p e c i f i c a t i o n ance for the health IT and harm o n i zed interoperability stan- mand standard methods of use. d a r d s. The purpose of this article, in p a rt, is to inform nurses of how National Health To address the fundamental need for harm o n i zed health IT health IT standards are form u l a t- IT Agenda standards to enable the exchange of health info r m a t i o n , ed within the United States to s eve ral public and public initiatives were enacted. A m o n g p romote interoperability (techni- these effo r ts was the National Health IT Agenda activities i n i t i a t i ve by the President of the United States in 2004. cal exchanging of patient information, such as allergies and Personal Health The personal health record (PHR) is defined as an electron- health conditions) among sys- Record (PHR) ic record of health-related info rmation on an individual that tems and discuss the active ro l e c o n fo r ms to nationally recognized interoperability standards taken by nurses to support prac- and that can be drawn from multiple sources while being tice, education, and re s e a rc h managed, shared, and controlled by the individual (DHHS using health IT. The overall goal Office of the National Coordinator for Health Info rm a t i o n is to present what nurses must Te c h n o l o g y, 2008). know to use health inform a t i o n Use Case Use Cases would be the first national wo rk to describe the technology to its fullest, which requirements for the interoperability standards that wo u l d will benefit themselves, patients, guide the wo rk of technology vendors for ambu l a t o ry and inpatient systems. Use Cases identified the health info rm a- families, and other disciplines. tion necessary within the wo rk f l ow of all clinical and bu s i- Definitions of the core concepts ness stakeholders as they related to three perspective s : to describe health IT systems are p r ov i d e r, consumer, and population health. p rovided in Table 1. The role of informatics nurses as educators, re s e a rchers, and designers was to give clinicians [TIGER] Standards and Inter- ized users (Thede & Sewell, 2009). the informatics tools, principles, operability Wo r k g roup, 2009). Nurses are empowered to make theories, and practices to make i n f o rme d decisions to pro v i d e health care safer, effective, eff i- s a f e r, higher-quality patient and Importance of Interoperability cient, patient-centered, timely, family care when data are cap- and equitable. Informatics nurses Evolving health IT and inter- t u r ed, shared, and reused multi- help nurses to interweave en- operability standards are founda- ple times. abling technologies transpare n t l y tional elements to enable the use Key diff e rences between an into nursing practice and educa- of information technology acro s s EMR, EHR, and PHR are high- tion, making information technol- the health care industry. Inter- lighted in Table 1 and are re l a t e d ogy the stethoscope for the 21st operability is the ability to share to who can access the inform a- c e n t u ry (Technology Inform a t i c s patient information among health tion. The evolution of health IT Guiding Education Reform i n f o rmation systems by author- will move toward the inclusion

306 UROLOGIC NURSING / September-October 2009 / Volume 29 Number 5 of patients and families having a mission (FCC). AHRQ provides a (see Table 3), an outreach eff o rt p o rtal for accessing and updating National Resource Center We b was implemented to ensure that their information within a secure site for health IT, which posts nurses were aware of and engaged network. many tools and best practices in the identification and adoption Chief nursing officers (CNOs) f rom multiple organizations on- of health IT interoperability stan- c u rre ntly receive education and line (AHRQ, 2005). These plan- d a r ds. It became apparent that for pursue continuing education in ning and implementation pro j e c t s the nursing perspective to be i n f o rmatics competencies. They p r ovide a wealth of re s o u rces for incorporated into the health IT have part n e red with their infor- local communities and hospitals. i n t e roperability initiatives, nurses matics nurse colleagues to lead In 2006, the Secre t a ry of the would need to: i n f o r mation technology-based DHHS accelerated the National • Understand and embrace implementations within health Health IT initiative by establish- these initiatives. c a re settings and during ongoing ing the American Health In- • Get involved with Use Case system upgrades. Nurse educa- f o r mation Community (AHIC). d e v e l o p m e n t . tors have begun to embrace infor- The AHIC was a federal advisory • Respond to public comment matics competencies and are g roup to the Secre t a ry of the o p p o rt u n i t i e s . integrating these new inform a- DHHS that identified priority • Attend educational work- tion management and patient a reas from which scenarios for s h o p s . c a re technology skills and use were developed. These are • Incorporate health IT stan- knowledge into basic nursing now known as Use Cases (see d a rds into systems. c u rricula (American Association Table 2) (DHHS, 2009). These • P a rticipate in committees at of Colleges of Nursing [AACN], Use Cases re p r esent the first the federal, state, and local 2008). Nurses across the U.S. will national eff o rt to describe the l e v e l s . need to function successfully in re q u i rements for the intero p e r- In Fall 2007, nurses within e n v i ronments that are incre a s- ability standards that would p rofessional organizations, aca- ingly interd i s c i p l i n a ry and tech- guide the work of technology demic institutions, and vendor nology-enabled (Ball & McBride, vendors for ambulatory and inpa- organizations increased their 2006). Onsite trainers can be tient systems. The Use Cases engagement in these national used to educate and re a s s u re identified the health inform a t i o n activities. Nursing org a n i z a t i o n s nurses that patient care will not n e c e s s a ry within the workflow of have been successful in reaching a be compromised by the intru s i o n all clinical and business stake- variety of nursing specialties of a new health IT system. As holders as they related to thre e (including oncology, nurse practi- nurses gain knowledge of health perspectives: pro v i d e r, con- tioners, occupational health) to IT standards and intero p e r a b i l i t y, s u m e r, and population health. p r ovide feedback directly to the their importance to the adoption The Healthcare Inform a t i o n O ffice of National Coord i n a t o r of systems that deliver safe, eff e c- Technology Standards Panel and during public comment peri- tive, and efficient patient care (HITSP) received the Use Cases, ods for AHIC Use Cases and will be invaluable. h a rmo nized standards, and de- HITSP interoperability specifica- veloped interoperability specifi- tions. This engagement ensure s cations that provide implementa- that nursing concepts are re c o g- National Health IT Agenda tion guidance for the health IT nized and incorporated within the During his 2004 State of the and interoperability standard s . national health IT initiatives and Union Address, Former Pre s i d e n t HITSP uses a public-private the standard setting process (per- G e o rge W. Bush announced the p rocess that takes the clinical sonal communication, D. Hunt, launch of a National Health IT Use Cases and harmonizes stan- June 6, 2008). Many nursing re c - mandate. The goal of this man- d a rds for adoption at the nation- ommendations are incorporated date was to make EHRs available al level. into the HITSP Use Case docu- to most Americans within the During this period, nurses ments through the work of the next 10 years (Federal Register, w e re involved in the standard s ’ O ffice of National Coord i n a t o r 2004). Since 2004, the National h a r monization eff o rts and re c o g- after HITSP panel appro v a l . Health IT Agenda has advanced nized the need to have bro a d e r The American Nurses with the creation of the Office of input from nurses from clinical Association (ANA) Scope and the National Coordinator for practice. Through the Te c h n o l o g y S t a n d a rds for Clinical Practice Health IT and the awarding of I n f o rmatics Guiding Education (see Table 4) (ANA, 2008) are n u m e rous government contracts R e f o rm (TIGER) Initiative (specifi- s t a n d a rds that guide workflow through agencies such as the cally the Standards and Inter- for practice and were very useful Agency for Healthcare Researc h operability Collaborative) and in as supporting documentation and Quality (AHRQ) and the c o n c e r t with other nursing infor- during the public comment peri- Federal Communications Com- matics professional org a n i z a t i o n s od in the development of the

UROLOGIC NURSING / September-October 2009 / Volume 29 Number 5 307 Ta ble 2. ing quality, integrity, security, American Health Information Community (AHIC) – Now Healthcare and confidentiality of personal, I n formation Te chnology Standards Panel (HITSP) Use Cases p rofessional, and org a n i z a t i o n a l 2006 Use Cases • H a rm o n i zed consumer empowe rment (includes registra t i o n or enterprise health care data and and collecting medication history) i n f o rmation (ANI, 2008; CNPII, • H a rm o n i zed electronic health record (include steps for 2007). CNPII disseminates knowledge about nursing’s inform a- l a b o ra t o ry result report i n g ) tion infrastru c t u res to support • H a rm o n i zed biosurveillance (includes the collection within nurses and develops the plan for a visit, utilization, and labora t o ry result data for infe c t i o u s managing and pre s e rvi ng nurs- diseases and more) i n g ’s information legacy. 2007 Use Cases • Emergency responder – Electronic health record In December 1995, nurses (includes pre-hospital care and emergency care) t h rough the CNPII established • Consumer empowe r m e n t : Consumer access to clinical the National Information and i n fo r mation Data Set Evaluation Center (NID- • Medication management (includes the medication cycle SEC) standards (ANA, 2003), of assessment and reconciliation, prescribing, ve r i f i c a t i o n which were the first eff o rts by and dispensing, evaluation and administra t i o n ) nurses to influence the design • Quality (includes reporting needs) and development of inform a t i o n technologies to meet the needs of 2008 Use Cases • Remote monitoring practicing nurses. These NIDSEC • Pa t i e n t - p r ovider secure messaging (includes ex t e r n a l s t a n d a rds identified the clinical c o m mu n i c a t i o n s ) t e rminologies to document nursing care, the linkages or branch- • Pe r s o n a l i zed health care ing pathways to efficiently docu- • Consultations and tra n s fers of care (includes shari n g ment and retrieve inform a t i o n i n fo r mation between multiple providers of health care) about patient care from EMR and • P u blic health case reporting EHR systems for workflow, and • I m munizations and response management the ability to store common data for exchanging continuity of care 2009 Use Cases • N ew b o r n screening nursing information (nursing minimum data set) across health- 2 0 0 9 • G e n e ral labora t o ry orders c a re information systems (ANA, 2003). To d a y, many of these stan- Extensions to • Order sets Existing d a rds are being incorporated into S t a n d a rd s • Medication gaps HITSP standards for decision • Clinical note details making to ensure the inclusion of • Common device connectivity nursing documentation to sup- • Medical home: P r o blem lists and practice-based registries p o rt nursing decision making in the care pro c e s s . • M a t e r nal and child health In January 2008, the Secre t a ry • L o n g - t e rm care – Assessments of the DHHS recognized the first • Consumer adverse event reporting set of interoperability standard s • Scheduling recommended by the American • P rior authorization in support of treatment, payment, and Health Information Community o p e rations and approved by HITSP. This first • Consumer preferences set included standards for exchanging laboratory results, a • Common data tra n s p o rt c o n s u m e r’s PHR, and biosurv e i l- S o u rc e : D H H S, 2008. lance information. As stated by f o rmer DHHS Secre t a ry Michael Leavitt, the problem to be solved t h r ough the National Health IT health IT standards. The Com- i n f o rmatio n infrastru c t u re and Agenda is as follows: “Infor- mittee for Nursing Practice influencing health inform a t i o n mation technology is a pivotal I n f o rmation Infrastru c t u re (CNPII) p o l i c y. The Alliance for Nursing p a r t of transforming our health has served nurses at the policy I n f o rmatics (ANI) also support s c a re system. We are at a critical level as a primary authority for CNPII eff o rts at the national and j u n c t u re. Working in close collab- ANA on the nursing practice state levels related to maintain- oration, the Federal govern m e n t

308 UROLOGIC NURSING / September-October 2009 / Volume 29 Number 5 Ta ble 3. and private sector can drive Alliance for Nursing Informatics and the Health Info r m a t i o n changes that will lead to fewer M a n agement Systems Society’s Nursing Informatics Committee medical errors, lower costs, less hassle, and better care” (Leavitt, • Alabama Society for Clinical Info rmatics (ASCI) 2005, p. 31). • A m e r ican Medical Info rmatics Association (AMIA) • A m e r ican Nursing Info rmatics Association (ANIA) Several National Health IT • Association of peri O p e ra t i ve Registered Nurses (AORN) Agenda Initiatives, including • Association of Wo m e n ’s Health, Obstetric and Neonatal Nurses (AWHONN) AHIC, HITSP, the Cert i f i c a t i o n • CARING Commission for Healthcare IT • Center for Nursing Classification and Clinical Effe c t i veness (CNC) (CCHIT), and the Nationwide • C e n t ral Savannah River Area Clinical Info rmatics Netwo rk (CSRA-CIN) Health Information Network • C e rne r Nursing Advisory Board (NHIN), are dependent on health • Connecticut Healthcare Info r matics Netwo rk (CHIN) IT standards. These standard s • Croatia Nursing Info rmatics Association (CroNIA) • D e l aware Va l l ey Nursing Computer Netwo r k (DVNCN) come from the numerous Inter- • Health Info rmatics of New Jersey (HINJ) national Standards Development • Healthcare Info rmation and Management Systems Society (HIMSS) O rganizations (SDOs), including • I n fo rmatics Nurses From Ohio (INFO) Health Level Seven (HL7), • MEDITECH Nurse Info r matics program I n t e r national Health Te r m- • M i d west Nursing Research Society – NI Research Section (MNRS) inology Standards Development • Minnesota Nursing Info r matics Group (MINING) O r ganization (IHTSDO), and • N A N DA International National Council for Pre s c r i p t i o n • N ew England Nursing Info rmatics Consortium (NENIC) • N o r th Carolina State Nurses Association Council on NI (NCNA CONI) D rug Programs, Inc. (NCPDP). • Pe rinatal Info rmation Systems User Group (PISUG) Health IT standards also come • Puget Sound Nursing Info r matics (PSNI) f rom re g u l a t o ry and cre d e n t i a l- • SNOMED CT Nursing Wo rking Group ing organizations, such as the • South Carolina Info rmatics Nursing Netwo rk (SCINN) Centers for Medicare and • Utah Nursing Info rmatics Netwo rk (UNIN) Medicaid Services (CMS), Food and Drug Administration (FDA), Related Org a n i z a t i o n s and The Joint Commission, to • A m e r ican Nurses Association (ANA) name a few. Nurses have re a l i z e d • A m e r ican Nurses Credentialing Center (ANCC) the significance of health IT stan- d a rds in the National Health IT Agenda and the important ro l e Ta ble 4. for nursing in embracing the Scope and Standards of Practices for the re q u i r ements for exchanging American Nurses Association common data formats to pro m o t e • N u r s i n g : Scope and Standards of Practice continuous care within and • C a r d i ovascular Nursing: Scope and Standards of Practice a c ross all levels of care. • Corrections Nursing: Scope and Standards of Practice TIGER Standards and Inter- • Faith Community Nursing: Scope and Standards of Practice operability Collaborative began • Genetics/Genomics Nursing: Scope and Standards of Practice taking an active role to ensure • HIV/AIDS Nursing: Scope and Standards of Practice that the nursing perspective is • Holistic Nursing: Scope and Standards of Practice c o n s i d e r ed, nursing input is • Home Health Nursing Scope and Standards of Practice • Hospice and Pa l l i a t i ve Nursing: Scope and Standards of Practice included throughout the pro c e s s , • Intellectual and Developmental Disabilities Nursing: Scope and Standards and the nursing community is of Practice engaged in these eff o rts. For • Neonatal Nursing: Scope and Standards of Practice example, the input of nurses has • Nursing Info rm a t i c s : Scope and Standards of Practice led to the addition of medication • Pain Management Nursing: Scope and Standards of Practice indications added to the data • Pe d i a t ric Nursing: Scope and Standards of Practice exchanged with medication lists. • Plastic Surgery Nursing: Scope and Standards of Practice The planned and perf o rmed nurs- • P s y c h i a t ric – Mental Health: Scope and Standards of Practice ing interventions were included • P u blic Health Nursing Scope and Standards of Practice • Radiology Nursing: Scope and Standards of Practice within standards for the common • School Nursing: Scope and Standards of Practice data transport among health care • Scope and Standards of Diabetes Nursing Practice (2nd Edition) p r o v i d e r s . • Scope and Standards of Gerontological Nursing Practice (2nd Edition) In 2009, President Barack • Scope and Standards of Neuroscience Nursing Practice Obama continued the emphasis • Scope and Standards of Vascular Nursing Practice on health IT by allocating sub- stantial funding for health IT in S o u rc e : ANA, 2009.

UROLOGIC NURSING / September-October 2009 / Volume 29 Number 5 309 the American Recovery and es and nursing students to fully cations, implementation guides, Reinvestment Act (ARRA) to step engage in the unfolding digital code sets, terminologies, and f o rw a rd in computerizing Amer- era of health care. Through its integration profiles. It is a well- icans’ health re c o rds. The goal agenda and action plans outlined defined approach that supports a was to reduce medical erro r s , at the inaugural TIGER Summit business process and: with the hope of saving billions of in Fall 2006, TIGER was charg e d • Has been agreed upon by a dollars in health care costs with providing tools and g roup of expert s . (ARRA, 2009). re s o u rces for nurses to become • Has been publicly vetted. educated in using technology and • P rovides rules, guidelines, or i n f o rmatics, and thereby empow- c h a r a c t e r i s t i c s . National Initiatives Impacting EHR e red to deliver safer, higher- q u a l i- • Helps ensure that materials, Standards and Interoperability ty patient care. More specifically, p roducts, processes, and T h e re are five core areas for the TIGER Standards and Inter- s e rvices are fit for their s t a n d a rds development use in operability Collaborative, which is intended purpose. health IT systems (Goossen et al., one of nine TIGER collaboratives, • Is available in an accessible 2004; Goossen, 2006). These five identified the AHIC Use Cases that f o rm a t . c o re areas are composed of the would impact nurses and began • Is subject to an ongoing following standards: 1) technolo- identifying educational methods review and revision pro c e s s gy and security stru c t u res , 2) to teach others about harm o n i z e d ( H I T S P, 2009). s t a n d a rdized terminologies, 3) an s t a n d a rds. This group worked In the context of health IT i n f o rmation framework and with eight other collaborative i n t e ro p e r a b i l i t y, standards must model for organizing data and w o r k g roups of nurses across the be maintained to meet the infor- i n f o rmation, 4) evidence-based c o u n t ry to fulfill the goals of the mation-sharing needs across care knowledge designs for clinician TIGER Initiative (ANI, 2008). The settings, providers, patients, and and patient use, and 5) engi- framework from the TIGER population health care enviro n- n e e red workflows redesigned to Summit defined a total of seven ments. The ability for computer e n s u re the best use of the technol- pillars for planning the action to systems to communicate with ogy and available data, inform a- achieve education of all nursing each other, share inform a t i o n , tion, and knowledge within the constituents in all specialties and and understand what is being health IT system. All core stan- fields (ANA, 2008). The Infor- s h a red is the fundamental inter- d a rds are being incorporated into mation Technology pillar empha- operability notion. It is thro u g h patient and consumer case stud- sized the need to embrace smart , the interoperable exchange of ies for educational purposes. In p e o p l e - c e n t e red, aff o rdable tech- health information that expected this way, all nurses will see the nologies that are universal, usable, d e c reases in costs will be re a l i z e d , workflow of how data, inform a- useful, and standard-based. such as eliminating duplicate tion, and knowledge are used This action plan identified tests, improving administrative e v e ryday on nursing units in hos- t h ree critical components for e fficiencies, increasing access to pitals, clinics, homes, schools, nurses. First, nurses need to patient clinical results, and pro- and communities. Several HITSP understand the importance of the viding information to d e c re a s e s t a n d a r ds currently guide the health IT industry standard s repetitive input. Improvement in design of health IT systems to being integrated into EHRs, the quality of care will be re a l i z e d e n s u re vendor technologies meet including clinical standards for by decreasing errors related to the needs of practicing nurses, practice and education. Second, lack of information, such as aller- physicians, and many others. nurses need to know what the re l- gic reactions to medication or These standards are presented in evant health IT standards harm o- c u rrent medication lists, and F i g u re 1 as Use Cases, which dis- nized by HITSP are as outlined in i n c reasing a patient’s access to his cuss the workflow of all health F i g u re 1. Third, nurses need to or her health inform a t i o n . c a re providers with many stake- establish the adoption and use of In conversation between two holders who will use the inform a- the HITSP standards within the people, standard language ru l e s tion. next 5 to 6 years so intero p e r a b l e a re re q u i red to understand the EHRs can be accessed securely by message being spoken, heard, or health organizations, clinics, read. If such a discussion occurs What Do Nurses Need To Know? p h a rmacies, or consumers acro s s over a telephone, the content is Nurses are the largest gro u p the U.S. sent and received using technolo- of health care professionals and gy standards to transmit the voic- have taken the lead to developing es between both parties. Health Standards and Interoperability new competencies and skills. The IT standards work in a similar TIGER Initiative was established As defined by HITSP, the fashion; standards provide stru c - in 2006 to enable practicing nurs- t e rm “standard” refers to specifi- t u red content and formatting to

310 UROLOGIC NURSING / September-October 2009 / Volume 29 Number 5 Figure 1. 2006-2009 HITSP Interoperability Specifications

S o u rc e : Used with permission from Raiford, 2009.

UROLOGIC NURSING / September-October 2009 / Volume 29 Number 5 311 e n s u re that the sending and and more. In addition, the TIGER Importance and Implications receiving system accurately com- S t a n d a rds and Intero p e r a b i l i t y For Nurses piles and interprets a message. Collaborative has provided sever- For example, a provider re v i e w s al educational forums, dissemi- The key for nurses to become nurse-documented pain assess- nated information re g a rd i n g IT competent includes learn i n g ments and enters a pain medica- national standards adoption ef- and demonstrating several im- tion order into an EHR system. A f o rts, provided public comment p o rtant skills. These competen- p h a rmacist receives the medica- f o rums, and coordinated nursing cies include computer skills t o tion order and processes it within input into the National Health IT p e rf o rm basic desktop software ; the pharmacy information sys- Agenda activities thro u g h o u t i n f o rmation literacy skills to use tem. Finally, the nurse re c e i v e s nursing informatics org a n i z a- d rug, laboratory, or disease data- the verified ord e r, administers tions. These organizations bridge bases; information and know- and documents the medication the gap between technology and ledge re s o u rces to access evi- d e l i v e ry in the clinical documen- nursing practice. dence-based protocols that sup- tation system, and receives a Nurses joining the pro f e s- p o rt decision-making; and i n f o r - reminder to reassess the patient’s sion will need to demonstrate matics knowledge and skills t o pain level within 30 to 60 min- technical skills in the use of evaluate information to impro v e utes. To ensure the proper med- computers and patient care tech- patient and population health. ication order information (pa- nologies for monitoring and Computer skill competencies also tient, medication, drug stre n g t h , gathering data, as well as patient include monitoring and medica- f o rm, dose, route, schedule, and c a re interventions, such as smart tion administration devices, com- indication) is filled properly by pumps and medication adminis- munication devices, documenta- the pharmacist and administere d tration bar code scanning de- tion electronic forms and flow c o rrectly by the nurse to the vices (AACN, 2008). The use of sheets, education modules, and patient, the provider uses a stan- clinical information systems will many other biomedical systems d a rd terminology that is under- include decision support sys- for patient care. Information liter- standable and meaningful to all tems used to gather evidence and acy competencies include the t h ree disciplines. There f o re, the guide practice. Electronic clini- demonstration of privacy, confi- s t a n d a rd pain score level or the cal information systems allow d e n t i a l i t y, and security policies, medication strength (units/min or the capture of data on quality, and using technical features to mg/kg/ day) are interpreted by all s a f e t y, and re g u l a t o ry re q u i re- s e c u r e and protect the health p roviders involved in the work- ments; monitor trends; and eval- i n f o rmation. These competencies f l o w. Once a patient is dis- uate outcomes and perf o rm a n c e . include the ability to critique and c h a rged, ensuring that the elec- These systems enable clinicians identify credible Internet re- t ronic version of the medication to search for inform a t i o n s o u rces and re s e a rch evidence list is securely and accurately t h rough databases while at the that may apply to specialty nurs- made available to the patient bedside. ing practice, such as uro l o g i c and/or providers re q u i res inter- Educational and knowledge nursing. operable health IT standards to be re s o u rce s will be available I n f o r matics competencies in place. t h rough online Web-based learn- include understanding the org a- ing using Desire - t o - L e a rn and nizational change management WebCT technologies within uni- n e c e s s a ry to continuously im- TIGER Actions to Help Nurses versities, at conferences thro u g h p rove patient care services and Various educational oppor- nursing organizations (such as redesigning the workflows of all tunities will be available to nurs- the Society of Urologic Nurses p roviders, so they may use best es through continuing education and Associates [SUNA]) and other evidence and health IT tools as a f o rums, formal academic course health IT organizations, including p r i m a ry means of patient safety. work, and nursing literature . American Medical Informatics In short, a nurse should not take U rologic Nursing is one of the Association (AMIA), Healthcare s h o rtcuts when using the tech- first specialty nursing practice Information and Management nology and associated devices j o u rnals to provide a special Systems Society (HIMSS), designed to protect patients and issue on nursing inform a t i c s . American Nursing Informatics health care professionals. The The articles within this journ a l Association (ANIA), and federal i n f o rmatics competency is impor- will highlight many areas for agencies (AHRQ), community and tant as the health care industry s t a n d a rds, such as term i n o l o g y, private colleges, and within your achieves interoperable systems s e c u r i t y, evidence-based nurs- home through Webinar confer- allowing the exchange of com- ing, preparation for health IT, ence sessions or in virtual confer- mon data and an ongoing need to educational needs for staff learn- ences where there is no longer a re p o rt any technical and content ing a new EMR or EHR system, need to travel to attend. issues or problems with the

312 UROLOGIC NURSING / September-October 2009 / Volume 29 Number 5 health IT systems (EMR, EHR, American Nurses Association (ANA). H e a l t h c a re Information Technology Stand- PHR, or biomedical devices). (2003). National Information and Data a r ds Panel (HITSP). (2009). H I T S P Set Evaluation Center (NIDSECS M ) i n t e roperability specifications. R e- To d a y, many other health pro f e s- s t a n d a rd s . Retrieved July 30, 2009, trieved July 30, 2009, from http:// sionals use standardized data f rom http://www. n u r s i n g w o r l d . o rg / w w w. h i t s p . o rg nurses enter or upload into the M a i n M e n u C a t e g o r i e s / T h e P r a c t i c e o f P ro Institute of Medicine (IOM). (2001). Cro s s i n g system from biomedical devices. f e s s i o n a l N u r s i n g / N u r s i n g S t a n d a rd s / D o the quality chasm: A new health sys - All errors or defects need to be c u m e n t a t i o n I n f o rm a t i c s / N I D S E C . a s p x tem for the 21st century, Wa s h i n g t o n , American Nurses Association (ANA). D.C.: National Academy Pre s s . resolved to protect the patient (2008). Scope and standards of nurs - Leavitt, M. (2005). The problem and the f rom harm. ing informatics practice. Silver solution. Retrieved July 30, 2009, fro m Springs, MD: ANA Publishing. h t t p : / / g o v i n f o . l i b r a r y. u n t . e d u / S u m m a ry American Recovery and Reinvestment Act i n t e ro p e r a b i l i t y / P D F s / P ro b l e m S o l u t i o (ARRA). (2009). The Act. R e t r i e v e d n . p d f In conclusion, the National July 30, 2009, from http://www. Peterson, H., & Jelger, U.G. (1988). Hospital Health IT Agenda continues to re c o v e ry.gov/?q=content/act i n f o rmation systems. In M.J. Ball, K.J. advance the standards that will Ball, M.J., & McBride, A.B. (2006). Hannah,, U. G. Jelger, & J. Peterson I n f o rmatics competencies in every (Eds.), Nursing informatics (pp. 192- move us to an interoperable com- nursing role. In C.A. We a v e r, C.W. 189). NewYork: Springer. munity of nurses. The vision for D e l a n e y, P. We b e r, & R.L. Carr (Eds.), R a i f o rd, R. (2009). R a i f o rd follow up public i n t e roperability is realized in Nursing and informatics for the 21st comment NCVHS meaningful use tes - small sectors where components C e n t u ry (pp. 223-226). Chicago: timony 4-29-09. Retrieved June 1, H I M S S . 2009, from http://www. n c v h s . h h s . of the health re c o rd can be Committee on Nursing Practice Inform a t i o n g o v / 0 9 0 4 2 9 p a c k a g e 1 . p d f accessed and used in remote sites. I n f r a s t ru c t u re. (2007). About the CNPII Technology Informatics Guiding Education Like other technologies, such as within the American Nurses Asso - R e f o rm (TIGER) Standards and monitors and ventilators, there has c i a t i o n . Retrieved July 30, 2009, I n t e roperability Collaborative Wo r k- always been a level of standard i z a- f rom http://nursingworld.org / n p i i / g roup. (2009). Collaborating to inte - c o m m i t t e e . h t m grate evidence and informatics into tion with a regulated process for Federal Register. (2004). P a rt VII: The nursing practice and education: An using devices safely and to the P resident. Executive Order 13335 – executive summary. Retrieved July 30, g reatest eff i c i e n c y. The National Incentives for the use of health infor - 2009, from the TIGER Initiative We b Health IT Agenda intends to mation technology and establishing site: http://www.tigersummit.com the position of the National Health Thede, L.Q., & Sewell, J.P. (2009). I n f o rm a t i c s e n s u re that health care pro v i d e r s I n f o rmation Technology Coord i n a t o r. and nursing: Competencies and appli - can share information about Retrieved July 30, 2009, fro m c a t i o n s ( 3 rd ed., pp. 266-306). New patients and know that the re c e i v- h t t p : / / e d o c k e t . a c c e s s . g p o . g o v / 2 0 0 4 / p d York: Wolters Kluwer. er and the sender are interpre t i n g f / 0 4 - 1 0 0 2 4 . p d f U.S. Department of Health and Human the information in the same way. Goossen, W. T. F., Ozboldt, J. G., Coenen, A., S e rvices (HHS). (2009). Use cases. Park, H., Mead, C., Ehnfors, M., et al. Retrieved July 30, 2009, fro m The use of standards can incre a s e (2004). Development of a pro v i s i o n a l h t t p : / / h e a l t h i t . h h s . g o v / p o rt a l / s e rv e r. p t a nurse’s eff i c i e n c y, ensure patient domain model for the nursing pro c e s s ? o p e n = 5 1 2 & o b j I D = 1 2 5 5 & p a re n t - s a f e t y, and improve the quality of for use within the Health Level 7 re f e r- n a m e = C o m m u n i t y P a g e & p a re n t i d = 3 c a re by reducing variability ence information model. J o u rnal of the & m o d e = 2 & i n _ h i _ u s e r i d = 1 0 7 4 1 & c a c h e American Medical Informatics Asso - d = t r u e (Institute of Medicine, 2001). This ciation, 11(3), 186-194. U.S. Department of Health and Human vision will move beyond focusing Goossen, W. R . F. (2006). Intelligent semantic S e rvices (DHHS) Office of the National on a single shift or visit to being i n t e roperability: Integrating knowl- C o o rdinator for Health Inform a t i o n able to make decisions based on a edge, terminology and inform a t i o n Te c h n o l o g y. (2008). The national p a t i e n t ’s lifetime of outcomes. models to support stroke care. In H.A. alliance for health information tech - Park, P. Murr a y, & C. Delaney. (Eds.), nology re p o rt to the Office of the C o n s u m e r- c e n t e red computer- s u p - National Coordinator for Health R e f e re n c e s p o rted care for healthy people: I n f o rmation Technology on defining Agency for Healthcare Research and Quality P roceedings of NI2006, the 9th key health information technology (AHRQ). (2005). Health inform a t i o n I n t e rnational Congress on Nursing t e rm s . Retrieved July 30, 2009, fro m technology: Best practices transform - I n f o rm a t i c s (pp 435-439). Amsterd a m , h t t p : / / w w w. n a h i t . o rg / i m a g e s / p d f s / H I ing quality, safety and eff i c i e n c y, Netherlands: IOS Pre s s . T Te rm s F i n a l R e p o rt _ 0 5 1 5 0 8 . p d f Retrieved July 30, 2009, fro m h t t p : / / h e a l t h i t . a h rq . g o v / p o rt a l / s e rv e r. p t ? o p e n = 5 1 2 & o b j I D = 6 5 0 & P a g e I D = 0 & p a re n t n a m e = O b j M g r & p a r e n t i d = 1 0 6 & m o d e = 2 & d u m m y = U rologic Nursing Editorial Board Statements of Discl o s u r e Alliance for Nursing Informatics (ANI). In accordance with ANCC-COA gove r ning rules Urologic Nursing E d i t o ria l Board state- (2008). About ANI. Retrieved July 30, ments of disclosure are published with each CNE offe ri n g . The statements of disclosure fo r 2009, from http://www. a l l i a n c e n i . this offe ring are published below. o rg/about.asp K aye K. G a i n e s , M S , A R N P, C U N P, disclosed that she is on the Speake r s ’ Bureau fo r American Association of Colleges of P f i ze r, Inc., and Nova r tis Oncology. Nursing (AACN). (2008). The essen - tials of baccalaureate education for Susanne A. Q u a l l i ch , A N P - B C , N P - C , C U N P, disclosed that she is on the Consultants’ p rofessional nursing practice, R e- Bureau for Coloplast. trieved July 30, 2009, from http:// w w w. a a c n . n c h e . e d u / e d u c a t i o n / p d f / All other U rologic Nurs i n g E d i t o rial Board members reported no actual or potential con- B a c c E s s e n t i a l s 0 8 . p d f flict of interest in relation to this continuing nursing education art i c l e.

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