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Home , Health informatics

Number 11 September 2001

referred to as informaticians. What is Nursing Increasingly, however, there is a need for all nurses to integrate nursing informat- ics competencies into their practices. and Why While there is no standard definition for the concept of nursing informatics, the is it so Important? following definition was proposed in the 1999 National Nursing Informatics 1 nformation is key to effective regarding the delivery of care by sup- Project (NNIP) discussion paper: decision-making and integral to plying access to health information Nursing Informatics (NI) is the application of quality nursing practice. Much of about clients, allowing data-entry, and to Iwhat nurses do involves information – and offering electronic access to sci- nursing. NI promotes the generation, manage- from assessing the needs of entific knowledge. In Canada, much ment and processing of relevant data in order patients, to developing care plans, to work remains to be done to make the to use information and develop knowledge that communicating patient information to EHR a reality. supports nursing in all practice domains. other health professionals, to analyzing Advances in Applications of nursing informatics are staffing and budget reports – in fact, have created new roles for nurses, and illustrated in figure 1. nurses work in an information-intensive environment. FIGURE 1. Advances in information technology SAMPLE APPLICATIONS OF NURSING INFORMATICS (i.e., and software) over the last 25 years have created significant Clinical Practice Administration opportunities for nurses to be aware of • Recording of patient assessment data • Analysis of MIS reports generated from current information when making deci- in an a spreadsheet software application • Recording of workload and interven- • Review of outcome indicators using a sions. We have faster computers to tions as a by-product of electronic decision-support software application process data, more sophisticated soft- charting • Recording of workload and interventions ware to assist in the transformation of as a by-product of electronic charting Education data into useful information, and power- • Distance /teaching via the ful technologies such as internet Research the internet to enable the secure trans- • Recording of workload and interven- • Evaluation of nurse-sensitive outcome measures using a standard minimum mission of information among health tions as a by-product of electronic charting data set service organizations and professionals. • Use of knowledge bases via the internet • Recording of workload and interventions Advances in information technology as a by-product of electronic charting have accelerated efforts to implement information systems such as the electronic health record. The electronic health record (EHR) is a collection of all emphasized the need for all nurses to Building blocks of nursing of an individual’s interactions with the health care system that will be become more knowledgeable about The foundation of nursing informatics is available electronically (subject to health information concepts and the based on the concepts of data, informa- privacy, confidentiality and security technology that is designed to manage tion and knowledge. Because information guidelines and legislation) to health and process information. Many nurses and knowledge are essential for nurses care professionals anywhere in the recognize informatics, derived from the when interpreting data and making country. EHRs have the potential to French term informatique, as an area of decisions, it is important to know the enhance nurses’ decision-making nursing specialization. Nurses with expertise in informatics are often difference between these concepts.

50 DRIVEWAY, OTTAWA ON K2P 1E2 TEL: (613) 237-2133 1-800-361-8404 FAX: (613) 237-3520 WEB SITE: www.cna-nurses.ca E-MAIL: [email protected] Data are discrete observations that are All three concepts can be stored in across disciplines and across the con- not interpreted, organized or struc- computers and software programs can tinuum of health services need to be tured. Information is data that has been be developed to assist in the interpre- structured and defined in a standard or interpreted, organized or structured to tation of the data and the develop- common way – this means that not provide meaning to the data. And ment of new nursing knowledge. While only do we need standards for com- knowledge is the synthesis of informa- the concepts of data, information and mon concepts but we also need stan- tion to identify relationships that knowledge are different, the concepts dards that are compatible across infor- provide further insight to an issue or as a whole are typically referred to mation systems used by different subject area. When you think about it, generically as information. health professions, across the continu- these concepts are the building blocks um of health service delivery, and with- Common language for of all nursing communications. Nurses common concepts in and across provinces and territories. collect data when assessing and moni- Notwithstanding all the challenges, toring the health of clients and record The need for health information stan- there has been significant progress their observations in the client’s chart; dards has never been greater. The over the last decade in the develop- they exchange service requests to, and International Organization for 2 ment of health information stan- receive results from, the clinical labora- Standardization (ISO) defines stan- dards. Highlights of relevant work tory and departments; they dards as: documented agreements containing are provided here. receive and review admission data and technical specifications or other precise criteria discharge summaries; they review infor- to be used consistently as rules, guidelines, or (a) Nursing Terminology mation on the results of clinical trials; definitions of characteristics to ensure that At the international level, the they communicate client information materials, products, processes, and services are International Council of Nurses (ICN) between service providers; they sum- fit for their purpose. Today, there are many is leading the development of a univer- marize, calculate and interpret work- different types of health information sal language for defining and describ- load indices for their nursing unit for standards including technical stan- ing nursing practice – the International and management purposes; dards for and soft- Classification for Nursing Practice (ICNP®). and they consult evidence-based clini- ware, data standards to enable the The purpose of ICNP® is to provide a cal guidelines and protocols to guide development of quality and compara- tool for describing and documenting their practice. As knowledge workers, ble information, and information key elements that represent clinical nurses use sources such as these to exchange standards or protocols to nursing practice. ICNP® provides nurs- influence decision-making. facilitate the sharing of information. ing with a common framework that facilitates cross-mapping of existing Specific examples of data, information The development and implementa- nursing vocabularies and classifica- and knowledge relevant to nursing are tion of computer health information sys- tions to enable comparison of nursing provided below. tems or automated health information sys- tems requires some form of structured data across organizations, health sec- Data vocabulary or terminology with com- tors, and countries. The alpha version • Age mon definitions for common terms to of ICNP® was released in 1996 for • Number of home care visits enable the effective management and review and feedback. A significantly • Blood pressure processing of data. This may seem revised beta version was released in • Disease simple but is quite a challenge when 1999 and has been translated into • Weight you consider the complexity of issues more than 20 languages. • Number of workload units of service nurses have to deal with. In addition, (b) Health Information: Information nurses and other health professionals Nursing Components • Prevalence of patient falls by nursing unit, often use different terms and mea- In Canada, CNA’s HI: NC (Health by month – this year compared to last year surement instruments to describe the Information: Nursing Components) • Prevalence of stage 1-4 decubitus same thing. For example, functional ulcers, by quarter Working Group has continued to build status, decubitus ulcers, patient falls on the work started in the early 1990s • % distribution of workload units of ser- and patient self-care are often vice and intervention by activity catego- to develop a standardized minimum defined and measured differently. ry,by nursing unit, by month data set for nursing. There is now a Knowledge To complicate matters further, the national consensus that critical nursing • Effectiveness of hip pads in preventing advent of multidisciplinary health pro- care data elements include client status, hip fractures grams, regionalization and integrated nursing intervention and client outcome. • Decubitus ulcers treatment protocols health systems has increased the need While nurses have reached a consen- • Relationship between different nurse-staff for integrated health information sys- mix configurations, nursing interventions sus on the kinds of data elements tems that cut across traditional bound- and client outcomes required, they now must begin moving aries. Concepts that are common • Care maps for specific health conditions these concepts to implementation by

CANADIAN NURSES ASSOCIATION, 50 DRIVEWAY, OTTAWA ON K2P 1E2

TEL: (613) 237-2133 1-800-361-8404 FAX: (613) 237-3520 www.cna-nurses.ca E-MAIL: [email protected] 2 ensuring that they are included within standardized collection of health Privacy, confidentiality and information systems. This involves interventions, regardless of the service security of health information nurses assessing the health needs of provider or service setting. Nurses have identified the protection of clients and collecting client-specific (d) Classification Standard for personal health information as a critical interventions in a standardized way in Health Conditions issue in the context of rapidly evolving order to gain a better understanding 4 To accompany the CCI, CIHI also health information technologies. This of the impact of those interventions comes as no surprise since nurses, enhanced the new version of the on client outcomes. more than any other health profession, International Statistical Classification use, collect and record health informa- Many experts believe that nursing of Diseases and Related Health tion extensively in the delivery of care. resource intensity3 and unique nurse identifier Problems, Tenth Revision for Canadian Individuals and organizations responsi- – a number or designation that could use (ICD-10-CA). An example of codes ble for the development of systems enable data from several sources to be in ICD-10-CA that are relevant to nurs- designed to collect, process, store, and linked anonymously to an individual – ing is presented below: share health information have a respon- are also key to representing nursing sibility to ensure that these systems are practice within a larger system of ICD-10-CA secure in order to maintain the integrity client-centred health information. It is L89 Decubitus Ulcers (DU) and confidentiality of personal informa- important for nurses to understand L89.0 DU limited to erythema only (red- tion. Without this respect for protecting and be involved in discussions and ness) without skin breakdown (stage1) the privacy of an individual’s health activities around these concepts. L89.1 DU limited to breakdown of skin (stage 2) information, the public would lose con- fidence in the critical role that health The Canadian Institute for Health L89.2 DU with fat layer exposed (stage 3) Information (CIHI) is currently working information plays in our health care L89.3 DU with depth involving muscle system. At the same time, appropriate with nursing stakeholder groups to (stage 4) access to health information and data determine the feasibility of imple- L89.4 DU with depth involving bone may have important benefits for menting a unique identifier for nurses. (stage 5) L89.5 DU with joint space involvement individual Canadians and for the CIHI completed a discussion paper on (stage 6) as a whole.5 unique service provider identifiers that L89.6 DU with necrosis involving mus- With rapid advances in information is posted on its web site (www.cihi.ca). cle/bone (stage X) technology, nurses need basic knowl- L89. 9 DU without mention of severity Improved workload measurement edge of concepts relating to privacy, systems that come closer to measur- confidentiality and security of health infor- ing accurately the intensity of nurs- Nurses provided input to the develop- mation, especially if they are involved ing resources consumed by different ment of both the CCI and ICD-10-CA. in the development of health informa- types of patients or health programs CIHI plans to maintain both classifica- tion systems. While related, these are critical for allocating resources tions on an ongoing basis to ensure concepts are very different. appropriately. CIHI plans to establish their continued relevancy and utility to Privacy in relation to health information an expert working group to review the field. Nurses should play a key role is the right of an individual to deter- many of the issues relating to nurs- in ensuring that changes and enhance- mine, when, how and to what extent ing workload measurement systems ments to the classification are relevant they will share information about them- and to make recommendations to their information needs. selves with others. Confidentiality on the regarding future developments and (e) Client Outcomes other hand, refers to the obligations of implementation efforts. With regard to the identification of one person to protect the personal information of another person. The pro- (c) Classification Standard for client outcomes that are relevant to the tection of the confidentiality of personal Health Interventions work that nurses do, the Ontario Nursing and Health Outcomes Project health information has always been a CIHI completed the development of has done significant work in identifying fundamental principle of our health a new Canadian Classification for client outcomes that are sensitive to care system. The Code of Ethics for Registered Health Interventions (CCI) that is nursing. The client outcomes that have Nurses (CNA, 1997) states that nurses safe- currently being implemented in a been identified to date include: func- guard the trust of clients that information number of provinces. The CCI was tional status, self-care, symptom con- learned in the context of a professional relation- developed to be consistent with con- trol (dyspnea, nausea, fatigue, pain), ship is shared outside the health care team only cepts and terminology contained in patient satisfaction with nursing care, with the client’s permission or as legally the ICNP®. The classification contains adverse occurrences such as nosocomi- required. Finally, security refers to the pro- a comprehensive list of diagnostic, al infections, patient falls and decubi- cedures and technologies that are used therapeutic, support and surgical tus ulcers. Future plans include devel- to restrict access to, and maintain the interventions, allowing for the oping pilot projects in acute, long-term integrity of health information. and community care.

CANADIAN NURSES ASSOCIATION, 50 DRIVEWAY, OTTAWA ON K2P 1E2

TEL: (613) 237-2133 1-800-361-8404 FAX: (613) 237-3520 www.cna-nurses.ca E-MAIL: [email protected] 3 The establishment of various stan- broad by nature. By implementing accuracy; security safeguards; openness; dards related to privacy, confidentiality recognized operational guidelines, individual access; and challenging com- and security have evolved over the health organizations can demon- pliance form the basis of the standard. years. Figure 2 presents the relation- strate to the public and others their Finally, in implementing operational ship between these concepts and commitment to the protection of per- guidelines, various procedures and relevant standards.6 sonal information. security systems are used, each based Figure 2. Matching Concepts and Standards – Examples of operational guidelines on specific technical standards. There Privacy, Confidentiality, and Security in Canada that are relevant to the are just too many technical standards health system include: the recently related to information systems security PRIVACY Legislation e.g., Bill C-6 updated Guidelines for the Protection of to discuss here; however, a few exam- Health Information produced by COACH ples that are relevant to nurses include CONFIDENTIALITY Operational Guidelines – Canada’s technical standards relating to: e.g., CSA Model Code Association – and the Canadian •the identification (e.g., passwords) and Standards Association’s Model Code for SECURITY Technical Standards authentication (e.g., digital signature) of the Protection of Personal Information. e.g., standards relating users of health information; to digital signatures, The COACH guidelines address practi- • the provision of audit trails or passwords, firewalls cal issues related to the protection of records of access activity relating to health information and the mainte- health information; and Federal/provincial/territorial laws and nance of data integrity and information regulations uphold privacy and the pro- system security and are used as a guide • the protection from unauthorized tection of personal information. Because by health organizations across the access (e.g., firewall) to health these laws and regulations vary in terms country. The CSA model code is a vol- information. of scope and comprehensiveness across untary national standard for the protec- Where can I get more information? the country, federal/provincial/territorial tion of personal information that was Watch CNA’s web site! Articles focusing officials are currently working toward the approved by the Standards Council of on electronic health record, classification of development of a harmonized frame- Canada in 1996. The CSA standard data and nursing resource intensity will work for the protection of health infor- addresses two broad issues: the way be published on the web site mation in Canada. organizations collect, use, disclose and (www.cna-nurses.ca) starting in the protect personal information; and the Operational guidelines are required fall 2001. Also listed are several other right of individuals to have access to to ensure that an appropriate level of resources on the topics of nursing personal information about them- confidentiality of health information informatics and informatics in general. selves, and, if necessary, to have the is met. Within Canada, governments information corrected. Ten interrelated Provincial/territorial nursing associations and various organizations and agen- principles relating to accountability; and the Canadian Nursing Informatics cies have developed guidelines to identifying purpose; limitations on Association, listed on CNA’s web site, assist in the implementation of leg- data collection; limitations on use and are excellent sources for up-to-date islative frameworks that are very disclosure of information; consent; information on nursing informatics.

1 The NNIP was sponsored by the Canadian Association of University Schools of Nursing, the Registered Nurses Nursing Now is a series of short Association of British Columbia, the Academy of Canadian Executive Nurses, the Nursing Informatics Special Interest papers that explore issues and Group of COACH, and CNA. One goal was to develop consensus on a definition of nursing informatics for Canada. A discussion paper was developed to elicit feedback from stakeholders in national nursing organizations, educational institu- trends in Canadian Nursing. This is tions, and nursing employers. Most respondents were in favour of the proposed definition. the 11th in the series. 2 The International Organization for Standardization (ISO): http://www.iso.ch/ Nursing Now is published by the 3 Policy, Regulation and Research A combination of the amount of care and the skill level at which the care is provided. (Thomson, J. D. 1984. The measurement of nursing intensity. Health Care Financing Review, 6, 47-54). The intensity of the nursing response to Division of the Canadian Nurses the conditions in patients that create the demand for nursing care. (O’Brien-Pallas, L., Irvince, D., Peereboom, E., Association (CNA). Murray, M. 1997. Measuring nursing workload: Understanding the variability. Nursing Economic$, 15[4], 171-182). Free copies are available to all 4 In March 2000, a workshop (Vision 2020 Workshop on Information and Communications Technologies in Health Care CNA members. For additional from the Perspective of the Nursing Profession) was held to discuss information and communication technologies in the information and/or additional health sector from the nursing perspective. A report from the workshop is available at the Office of Health and the copies contact CNA Publications. Information Highway (OHIH) web site: http://www.hc-sc.gc/ohih-bsi/ 5 Canadian Nurses Association position statement: Privacy of personal health information. (2001). This publication is also available on 6 CNA’s web site at www.cna-nurses.ca Based on similar figure in Background Document (1997). Working Group 3: Privacy, Confidentiality, Data Integrity, and Security of the Partnership for Health Informatics/Telematics. Canadian Institute for Health Information. Ottawa, ON. ISSN 1206-3878

CANADIAN NURSES ASSOCIATION, 50 DRIVEWAY, OTTAWA ON K2P 1E2

TEL: (613) 237-2133 1-800-361-8404 FAX: (613) 237-3520 www.cna-nurses.ca E-MAIL: [email protected]

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