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HandbookofInformaticsforNursesHealthcareProfessionals6thEdition_9780134748436.pdf

Handbook of Informatics for Nurses and

Healthcare Professionals TONI HEBDA I KATHLEEN HUNTER I PATRICIA CZAR

SIXTH EDITION

Handbook of Informatics for Nurses and Healthcare Professionals

Sixth Edition

Toni Hebda, PhD, RN-C, CNE MSIS Professor MSN Program Chamberlain College of Nursing, Downers Grove, IL 60515

Kathleen Hunter, PhD, FAAN, RN-BC, CNE Professor MSN Program Chamberlain College of Nursing, Downers Grove, IL 60515

Patricia Czar, RN Information Systems Consultant Pittsburgh, PA

330 Hudson Street, NY NY 10013

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Publisher: Julie Alexander Director of Portfolio Management, Nursing: Katrin Beacom Editorial Assistant: Erin Sullivan Managing Content Producer: Melissa Bashe Content Producer: Michael Giacobbe Design Coordinator: Mary Siener Vice President of Sales and Marketing: David Gesell Vice President, Director of Marketing: Brad Parkins Director, Digital Studio: Amy Peltier Digital Project Manager: Jeff Henn Full-Service Project Management and Composition: SPi Global Full-Service Project Managers: Sreemeenakshi Raghothaman, Anitha Vijayakumar, SPi Global Editorial Project Manager: Dan Knott, SPi Global Manufacturing Buyer: Maura Zaldivar-Garcia, LSC Communications, Inc. Cover Designer: Laurie Entringer

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Notice: Care has been taken to confirm the accuracy of information presented in this book. Theauthors, editors, and the publisher, however, cannot accept any responsibility for errors or omissionsor for consequences from application of the information in this book and make no warranty, expressor implied, with respect to its contents.

Cataloging in Publication data is available at the Library of Congress

ISBN 10: 0-13-471101-7 ISBN 13: 978-0-13-471101-0

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iii

Preface ix Acknowledgments xiii Contributors xv Reviewers xvii About the Authors xix

1 An Overview of Informatics in Healthcare 1 Jennifer A. Brown, Taryn Hill, Toni Hebda

Informatics 2

The Relevance of Informatics for Healthcare 3

Creating an Informatics Culture 8

Caring for the Patient Not the Computer 12

Future Directions 13

Summary 14

2 Informatics Theory and Practice 20 Maxim Topaz

Overview of Theory 20

Critical Theories Supporting Informatics 22

Informatics Specialties within Healthcare 30

Informatics Competencies for Healthcare Practitioners 33

TANIC AND NICA 37

Future Directions 37

Summary 38

3 Effective and Ethical Use of Data and Information 42 Toni Hebda, Kathleen Hunter

Overview of Data and Information 42

Using Data for Quality Improvement 44

Data Management 46

Big Data, Data Analytics, and Data Modeling 47

Ethical Concerns with Data and Information Use 52

Future Directions 52

Summary 53

4 Electronic Resources for Healthcare Professionals 58 Brenda Kulhanek

Information Literacy 58

Critical Assessment of Online Information 59

Social Media—Responsibilities and Ethical Considerations 61

Healthcare Information and Services 62

Online Services for Healthcare Professionals 64

Professional Organizations and Watchdog Groups 65

Healthcare Websites of Interest for Healthcare Providers 66

ELearning 67

Using Information Technology to Organize and Use Information Effectively 68

Future Directions 70

Summary 70

5 Using Informatics to Support Evidence-Based Practice and Research 73 Melody Rose

History 74

Levels of Evidence 75

Applying Information Literacy to Find the Highest Levels of Evidence 77

Contents

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iv Content

Integration of EBP into Clinical Systems and Documentation 78

Managing Research Data and Information 80

Creating and Maintaining the Infrastructure to Support Research 81

Ethical and Legal Principles for Handling Data and Information in Research 83

Practices for Collecting and Protecting Research Data 84

Supporting Dissemination of Research Findings 86

Effecting Practice Change 87

Future Directions 88

Summary 89

6 Policy, Legislation, and Regulation Issues for Informatics Practice 94 Sunny Biddle, Jeri A. Milstead

The Policy Process 95

Legislation and HIT/Informatics 98

Regulation (Rule-Making) and Implications for Informatics 101

Accreditation 104

Policy Making, Interprofessional Teams, and Informatics 106

Future Directions 108

7 Electronic Health Record Systems 112 Rayne Soriano, Kathleen Hunter

Meaningful Use 114

Benefits of EHRSs 119

Current Status of EHRSs 121

Considerations When Implementing the EHRS 123

Future Directions 128

Summary 129

8 Healthcare Information Systems 135 Carolyn Sipes, Jane Brokel

Clinical Information Systems 136

Administrative Information Systems 139

Smart Technology 141

Current Topics in Healthcare Information Systems 143

Summary 145

9 Strategic Planning, Project Management, and Health Information Technology Selection 149 Carolyn Sipes

Overview of Strategic Planning 150

Information Management Components 152

One Vendor versus Best of Breeds 155

Configurability 156

Interoperability 156

Ease of Use/Usefulness of Systems 156

Planning at the Project Level—The Project Management Process 157

The Informatics Nurse’s Role as Project Manager 161

Essential Skills in Other Advanced Nurse Practice Roles 162

Future Directions 163

Summary 164

10 Improving the Usability of Health Informatics Applications 167 Nancy Staggers

Introduction to Usability 168

Definitions of Terms and Interrelationships of Concepts 169

The Goals of Usability 171

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Content v

Information System Security 242

Security Mechanisms 249

Administrative and Personnel Issues 256

Levels of Access 257

Audit Trails 260

Handling and Disposal of Confidential Information 260

Special Considerations with Mobile Computing 262

Security for Wearable Technology/Implanted Devices/Bedside Technology 263

Future Directions 266

Summary 266

14 Information Networks and Information Exchange 271 Jane M. Brokel

Introduction 271

Health Information Network Models 272

Clinical Data Networks or Health Information Networks 273

Interoperability 274

International Standards 278

Nationwide Health Information Network 279

Implications of Interoperability 280

Process and Use Cases for Health Information Exchange 280

Key Factors 281

Driving Forces 284

Current Status 285

Obstacles 285

Future Directions 286

Summary 287

Usability and the System Life Cycle 172

Human–Computer Interaction Frameworks 172

Usability Methods 175

Usability Tests 179

Steps in Conducting Usability Tests 183

Future Directions 185

Summary 186

11 System Implementation, Maintenance, and Evaluation 191 Sue Evans

System Implementation 192

System Installation 203

System Evaluation 206

Summary 207

12 Workforce Development 210 Diane Humbrecht, Brenda Kulhanek

Workforce Population 210

Devising a Workforce Development Preparation Plan 212

Identifying the Scope of Efforts 214

Target Technology and Related Competencies 217

Education Methods 219

Training Resources 225

Evaluating Success 226

When Information Technology Fails (Training on Backup Procedures) 228

Future Directions 229

Summary 229

13 Information Security and Confidentiality 238 Ami Bhatt, Patricia Mulberger

Privacy, Confidentiality, Security, and Consent 239

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vi Content

15 The Role of Standardized Terminology and Language in Informatics 293 Susan Matney

Introduction to Terminology 293

Languages and Classification 297

Benefits of Implementing Standardized Terminologies 309

National Healthcare Reporting Requirements 312

Issues and Concerns 313

Future Directions 313

Summary 314

16 Continuity Planning and Management (Disaster Recovery) 320 Carolyn S. Harmon

Introduction and Background 320

What Is Continuity Planning? 321

Steps in the Developing a Preparedness Program 324

Advantages of Continuity Planning 328

Disasters Versus System Failure 329

Continuity and Recovery Options 329

Planning Pitfalls 337

Using Post-Disaster Feedback to Improve Planning 338

Legal and Accreditation Requirements 338

Future Directions 340

Summary 340

17 Using Informatics to Educate 343 Diane A. Anderson, Julie McAfooes, Rebecca J. Sisk

Why Informatics? 344

Preparing the Learner 344

Educational Software Sources 344

Barriers and Benefits 345

Necessary Tools 346

Simulation and Virtual Learning Environments 354

Future Directions 363

Summary 363

18 Consumer Health Informatics 370 Melody Rose, Toni Hebda

Evolution 371

Driving Forces 372

Issues 372

Consumer Health Informatics Applications 377

The Role of the Informatics Nurse with CHI 385

The Future of CHI 388

Summary 389

19 Connected Healthcare (Telehealth and Technology-Enabled Healthcare) 398 Lisa Eisele

Introduction 398

History of Connected Health 399

Current State 400

Driving Forces 400

Connected Health Modalities 403

Implications for Practitioners 408

The Role of the INS in Connected Health 412

Future Directions 413

Summary 414

20 Public Health Informatics 418 Marisa L. Wilson

Introduction 418

Exploring Public Heath 419

Public Health Mandate 419

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Content vii

Public Health Informatics 422

Public Policy Driving Informatics Change 425

Current Public Health Informatics Systems 426

New Technological Sources of Public Health Information 428

Future Directions 430

Summary 432

Appendix A: Hardware and Software 435 Athena Fernandes

Appendix B: The Internet and the Worldwide Web 439 Athena Fernandes

Appendix C: An Overview of Tools for the Informatics Nurse 441 Carolyn Sipes

Glossary 446 Index 454

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ix

The idea for Handbook of Informatics for Nurses & Healthcare Professionals first came from the realiza-tion that there were few resources that provided practical information about computer applications and information systems in healthcare. From its inception, this book served as a guide for nurses and other health- care professionals who needed to learn how to adapt and use computer applications and informatics in the work- place. Over time, this text became a reliable resource for students in a variety of healthcare professions who needed to develop informatics competencies. This book serves undergraduates who need a basic understanding, as well as those who require more depth, such as infor- matics nurse specialists, clinical nurse leaders, doctoral students, and other healthcare professionals.

After a thorough revision in response to reviewers and users of the book, the sixth edition reflects the rapid changes in healthcare information technology (HIT) and informatics. The authors endeavour to provide an understanding of the concepts, skills, and tasks that are needed for healthcare professionals today and to achieve the federal government’s national information technology goals to help transform healthcare delivery.

The sixth edition builds upon the expertise pro- vided by contributors currently involved in day-to-day informatics practice, education, and research. Both the primary editors and the contributors share an avid inter- est and involvement in HIT and informatics, as well as experience in the field, involvement in informatics groups, and a legacy of national and international pre- sentations and scholarly publications.

New to This Edition • New! All chapters thoroughly revised to reflect the

current and evolving practice of health information technology and informatics

• New! Chapter on informatics theory and prac- tice connects theoretical concepts to applications (chapter 2)

• New! Coverage of technology and caring and their symbiotic relationship

• New! Content on ethical use of information lays encompasses appropriate and inappropriate behav- iour and actions, and of right and wrong.

• New! Information on analytics and data science that explains how Big Data applies to healthcare

• New! Cutting-edge content on wearable and mobile technology security, and its impact on nursing and patient care

• New! Academic electronic health record resources and the role they play in educating the next generation of healthcare providers on documentation principles

• New! Hardware and software appendix (appendix A)

• New! Guide to the Internet (appendix B)

• New! An Overview of Tools for the Informatics Nurse (appendix C)

Changes to This Edition • The sixth edition streamlines content by combining

chapters with topics that fit together, and shifting hardware, software, and information on the Inter- net to new appendices.

• This edition reworks previous content on informa- tion systems training and presents it within the context of workforce development. The content still retains the emphasis upon privacy and confidential- ity, introduction of information policies, educational methods and resources. New content on evaluation models and training on backup procedures has also been added.

• Former content on integration, interoperability and health information exchange is now presented within the context of information networks and information exchange.

• Moves from defining evidence-based practice to a discussion of levels of evidence and using informat- ics to support evidence-based practice and research.

• Separate chapters on policy, legislation, regulatory, reimbursement, and accreditation issues were com- bined to better show the connection among these

Preface

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x Preface

areas and the relationship between them and infor- mation system design and use.

• Experts from various health disciplines cover the latest on the interprofessional aspects of infor- matics with more emphasis on interdisciplinary approaches.

• Increases focus on current electronic health record issues while decreasing coverage of the historical evolution of EHRs.

• Highlights strategic planning and project management.

• Underscores the importance of patient engagement and shared decision making.

• Expands content on simulation and virtual learning environments.

Hallmark Features Learning Objectives—Learning Objectives appear at the beginning of each chapter and identify what readers can expect to learn in the chapter.

Future Directions—As the last section in each chapter, Future Directions forecasts how the topic covered in the chapter might evolve in the upcoming years.

Case Study Exercises—Case studies at the end of each chapter discuss common, real-life appli- cations, which review and reinforce the concepts presented in the chapter.

Summary—The Summary at the end of each chapter highlights the key concepts and information from the chapter to assist in the review.

References—Resources used in the chapter appear at the end.

Glossary—The glossary familiarizes read- ers with the vocabulary used in this book and in healthcare informatics. We recognize that healthcare professionals have varying degrees of computer and informatics knowledge. This book does not assume that the reader has prior knowledge of computers. All computer terms are defined in the chapter, in the glossary at the end of the book, and on the Online Student Resources Web site.

Organization The book is divided into three sections: Information and Informatics, Information Systems Development Life Cycle, and Specialty Applications. The major themes of privacy, confidentiality, and information security are woven throughout the book. Likewise, project manage- ment is a concept introduced in the strategic planning chapter and carried through other chapters. Chapters include content on the role of the informatics profes- sional, future directions relative to the topic, summary bullet points, and a case study.

Section I: Information and Informatics This section provides a foundation for why information and informatics are important to healthcare. It details the relationship between policy, legislation, regulation and accreditation and reimbursement and information system use.

• Chapter 1: Provides a definition of informatics and its significance for healthcare, discusses healthcare professionals as knowledge workers, addresses the need for uniform data and the relationship between data, big data, and evidence. This chapter also addresses the increased prevalence of information technology in healthcare, major issues in healthcare that are driving the adoption of information tech- nology, what is necessary to create an informatics culture, and includes a special section on caring and technology.

• Chapter 2: Provides information on informatics theory and practice, and nursing informatics as a discipline.

• Chapter 3: Emphasizes effective and ethical use of data and information, and includes a discussion of big data challenges and issues. Data characteristics, types, integrity, and management are covered. Cli- nician and informaticist roles pertaining to this area are discussed.

• Chapter 4: Addresses electronic resources for healthcare professionals, basic concepts and appli- cations of the Internet, including criteria for evalu- ating the quality of online information.

• Chapter 5: Discusses informatics to support evidence-based practice and research. Concepts include levels of evidence, information literacy, managing research data and information, creating

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Preface xi

and maintaining the infrastructure needed to sup- port research, dissemination of evidence, and effect- ing practice change.

• Chapter 6: Examines the relationship between pol- icy, legislation, accreditation, reimbursement and HIT design and use.

• Chapter 7: Provides information on electronic health records including definition, components, incentives for adoption, benefits, current status, selection criteria, implications for collection of meaningful data and big data, current issues, and future directions.

• Chapter 8: Provides an overview of types of health- care information systems, including clinical infor- mation systems and administrative information systems, as well as decision support, knowledge representation, and smart data.

Section II: Information Systems Development Life Cycle This section covers information and issues related to the information systems development life cycle.

• Chapter 9 This chapter discusses the importance of strategic planning for information management, HIT acquisition and use and provides an overview of project management and information system selection considerations. The role of informatics professionals, particularly informatics nurse spe- cialists, in the planning process and project manage- ment are addressed, as is the process to introduce change.

• Chapter 10: Addresses the concepts of usability and health informatics applications inclusive of the role that usability plays in the system life cycle and methods of usability assessment.

• Chapter 11: Covers information system implemen- tation, maintenance, and evaluation.

• Chapter 12: Provides a comprehensive look at workforce development in relation to health infor- mation technology use.

• Chapter 13: Discusses information security and confidentiality, including practical information on ways to protect information housed in informa- tion systems and on mobile devices and addresses security for wearable and implantable information technology.

• Chapter 14: Provides detailed information about health information exchanges.

• Chapter 15: Provides an overview of the role of standardized terminology and language in infor- matics. Also includes an outline of individual lan- guages and classifications used in healthcare.

• Chapter 16: Discusses the relationship between strategic planning for the organization and the sig- nificance of maintaining uninterrupted operations for patient care. Also touches on legal requirements to maintain and restore information. Much of this chapter is geared for the professional working in information services.

Section III: Specialty Applications This section covers specialty applications of informatics.

• Chapter 17: Details ways that information tech- nology and informatics can support education of healthcare professionals, including sections on sim- ulation and virtual learning environments.

• Chapter 18: Emphasizes the relationship between health and information literacy, patient engage- ment, shared decision-making, changing healthcare delivery models, patient satisfaction, outcomes, and healthcare reform. Discusses applications of con- sumer health informatics.

• Chapter 19: Examines telehealth and connected healthcare applications, starting with a historical perspective and including driving forces, appli- cations, and implications for providers as well as informatics professionals.

• Chapter 20: Explores public health informatics and its use to maintain and improve population health.

Three appendices are included. Appendix A pro- vides basic information on hardware and software for the reader who needs a better understanding of this area. Appendix B provides information on the Internet. Appendix C provides an overview of some tools for the informatics nurse.

Instructor Resources Lecture PowerPoint showcases key points for each chapter.

Test Generator offers question items, making test creation quick and simple.

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xii Preface

Student Resources New! eText offers a rich and engaging experi- ence with interactive exercises. Readers can ac- cess online or via the Pearson eText app. Note: Faculty can opt to package an eText access code card with the print textbook, or students can purchase access to the eText online.

Notice Care has been taken to confirm the accuracy of information pre- sented in this book. The authors, editors, and the publisher, however, cannot accept any responsibility for errors or omissions or for conse- quences from application of the information in this book and make no warranty, express or implied, with respect to its contents.

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xiii

Special thanks to Kathy Hunter, who agreed to join me on this 6th edition, lending her knowledge, insights, and support when I most needed it and never said “no” despite her many other commitments. A special thanks to Patricia Czar, RN, without whom there would be no

Handbook of Informatics for Nurses & Healthcare Professionals today. Pat actively contributed to the book from the original outline through to the present, provid- ing her knowledge, insights, organizational skills, support, and friendship. Pat was active in informatics for more than 25 years, serving as manager of clini- cal systems at a major medical center where she was responsible for planning, design, implementation, and ongoing support for all of the clinical information systems. Pat was also active in several informatics groups, presented nationally and internationally, and served as a mentor for many nursing and health infor- matics students. She is now fully retired and enjoying time with her family.

We acknowledge our gratitude to our loved ones for their support as we wrote and revised this book. We are grateful and excited to have work from our contributors who graciously shared their knowledge and expertise for this edi- tion. We are grateful to our co-workers and professional colleagues who provided encouragement and support throughout the process of conceiving and writing this book. We appreciate the many helpful comments offered by our reviewers. Finally, we thank Lisa Rahn, Michael Giacobbe, Susan Hannahs, Daniel Knott, Taylor Scuglik, and all of the persons who worked on the production of this edi- tion for their encouragement, suggestions, and support.

Thank You

This edition brings in work from multiple contributors for a robust coverage of topics throughout the book. We thank them for their time and expertise. We would also like to thank all of the reviewers who carefully looked at the entire manuscript. You have helped shape this book to become a more useful text for everyone.

Acknowledgments

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Contributors

Diane A. Anderson, DNP, MSN, RN, CNE Chapter 17: Using Informatics to Educate Associate Professor, MSN Specialty Tracks ~ Nurse Educator, Chamberlain College, Downers Grove, IL

Ami Bhatt, DNP, MBA, RN, CHPN, CHCI Chapter 13: Information Security and Confidentiality Dr. Bhatt is currently enrolled in the DNP to PhD program at University of Nevada, Las Vegas, NV

Sunny Biddle, MSN, RN Chapter 6: Policy, Legislation, and Regulation Issues for Informatics Practice Circulating Nurse in the Operating Room at Genesis Healthcare in Zanesville, OH and Clinical Instructor for Central Ohio Technical College in Newark, OH

Jane M. Brokel, PhD, RN, FNI Chapter 8: Healthcare Information Systems Chapter 14: Information Networks and Information Exchange Section Instructor at Simmons College, Boston, MA Adjunct faculty for the University of Iowa College of Nursing, Iowa, City, IA

Jennifer A. Brown, MSN, RN, HNB-BC Chapter 1: An Overview of Informatics in Healthcare Faculty, Bronson School of Nursing at Western Michigan University in Kalamazoo, Michigan in the undergraduate and RN-BSN programs.

Lisa Eisele, MSN, RN Chapter 19: Connected Healthcare (Telehealth and Technology-enabled healthcare) Chief - Quality, Performance & Risk Management Manchester VA Medical Center, Manchester VA

Sue Evans, MSN RN-BC Chapter 11: System Implementation, Maintenance, and Evaluation Informatics Nurse II University of Pittsburgh Medical Center East, Monroeville, PA

Athena Fernandes DNP, MSN, RN-BC Appendix A: Hardware and Software Appendix B: A Guide to the Internet and World Wide Web Senior Physician Systems Analyst, Penn Medicine Chester County Hospital, West Chester, PA

Carolyn S. Harmon, DNP, RN-BC Chapter 16: Continuity Planning and Management Clinical Assistant Professor and Program Director for the Masters of Nursing Informatics and the Masters of Nursing Administration at University of South Carolina, Columbia, SC

Toni Hebda, PhD, RN-BC, MSIS, CNE Chapter 3: Effective and Ethical Use of Data and Information Chapter 18: Consumer Health Informatics Professor, Chamberlain College of Nursing MSN Program, Downers Grove, IL

Taryn Hill, PhD, RN Caring for the Patient Not the Computer in Chapter 1: An Overview of Informatics in Healthcare Dean of Academic Affairs for Chamberlain College of Nursing, Columbus, OH

Diane Humbrecht, DNP, RN Chapter 12: Workforce Development Chief Nursing Informatics Officer, Abington Jefferson Health, Abington, PA

Kathleen Hunter, PhD, RN-BC, CNE Chapter 3: Effective and Ethical Use of Data and Information Chapter 7: Electronic Health Record Systems Professor, Chamberlain College of Nursing MSN Program, Downers Grove, IL

Brenda Kulhanek, PhD, MSN, MS, RN-BC Chapter 4: Electronic Resources for Healthcare Professionals Chapter 12: Workforce Development AVP of Clinical Education for HCA in Nashville, TN

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xvi Contributors

Susan Matney, PhD, RN-C, FAAN Chapter 15: The Role of Standardized Terminology and Language in Informatics Senior Medical Informaticist, Intermountain Healthcare, Murray, UT

Julie McAfooes, MS, RN-BC, CNE, ANEF, FAAN High-fidelity simulation, software, support, and certification in Chapter 17: Using Informatics to Educate Web Development Manager for the online RN-to-BSN Option at the Chamberlain of Nursing, Downers Grove, IL

Jeri A. Milstead, PhD, RN, NEA-BC, FAAN Chapter 6: Policy, Legislation, and Regulation Issues for Informatics Practice Professor and Dean Emerita, University of Toledo College of Nursing, Toledo, OH

Patricia Mulberger, MSN, RN-BC Special Considerations with Mobile Computing in Chapter 13: Information Security and Confidentiality Clinical Informatics Quality Supervisor, Kalispell Regional Healthcare, Kalispell MT

Melody Rose, DNP, RN Chapter 5: Using Informatics to Support Evidence-based Practice and Research Chapter 18: Consumer Health Informatics Assistant Professor of Nursing. Cumberland University Jeanette C. Rudy School of Nursing, Lebanon, TN

Carolyn Sipes, PhD, CNS, APN, PMP, RN-BC Chapter 8: Healthcare Information Systems Chapter 9: Strategic Planning, Project Management, and Health Information Technology (IT) Selection Appendix C: An Overview of Tools for the Informatics …