Which system is integrate all the information and data of all the hospital department and manages health information using modern information techniques?

        Science has bestowed health care delivery system with excellent technological innovations. One such innovation is the computerization of the entire health care delivery system. Computerization has contributed enormously towards the reduction of medical errors and the problems associated with such errors (Gan et.al, 2005). Computerization of health care delivery includes computerization of the medical records popularly known as the Electronic Medical Record System (EMR), Electronic Prescriptions, Personal Digital Assistants, Computer Automated Cancer Detection and Computerized Theatre Management Applications. The implementation of voice recognition technology in mobile healthcare settings is yet another recent innovation (Chang et.al, 2008).

A study to assess the community hospital nurses' use of electronic health records and views of the impact of such records on job performance and patient outcomes has shown that nurses prefer electronic records to paper charts and are comfortable with technology (Kossman and Scheidenhelm, 2008).

        As we start the decade of the electronic health record (EHR) mandated by the president of the United States and the secretary of Health and Human Services (HHS), NI is moving to the forefront of the nursing profession and nursing information technology system. Nurses are becoming computer literate and the nursing profession is implementing practice standards for its clinical care and date standards for its nursing information technology systems.

         NI represents the transition of data and data information and knowledge into action. It represents the practice, administration, community health, nursing education, and nursing research applications. Also, it includes other new applications such as international aspects or peripheral to the field such as legal, consumer issues, or theoretical issues. The IT supports nurses to improve quality, ensure safety, measure outcomes, and determine costs.

         NURSING INFORMATICS is defined by the American Nurses Association (ANA, 2001) as:

            A specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge to support patients, nurses, and other providers in their decision-making in all roles and settings. This support is accomplished through the use of information structures, information process, and information technology.  (p.46)

         In the past 25 years, NI specialists emerged as a new specialty by the ANA. In 1981, there were approximately 15 nurses who identified this new specialty as their area of interest and expertise; in 1990 this number increased 500% to approximately 5,000 nurses; and by the year 2000 it increased approximately another 500%. However, by the year 2010, it is anticipated that majority of nurses entering the profession will be computer literate. It is also anticipated that every healthcare setting – acute care hospital, academic school of nursing, large community health agency or healthcare setting where nurses function – will employ at least one NI specialist and will implement some type of a CIS.

        What is CIS? A CIS is designed to support clinical nursing practice. It requires not only an understanding of professional nursing practice process but also technology that is the application for the science to function electronically. 

I N T R O D U C T I O N

        The computer is the most powerful technological tool to transform the nursing profession prior to the new century. The computer has transformed the nursing paper-based records to computer-based records. The computer and the internet have become essential to the modern day which functions a lot. “Computer” is an all encompassing term referring to information technology (IT), computer systems, and when they are used in nursing information systems (NISs), nursing applications, and/or nursing informatics (NI).

        “NI” has emerged as new term encompassing these technologies enabling nurses to manage health care and patient care more efficiently and effectively and, at the same time, make nurses more accountable. Computers in nursing care are used to manage information in patient care, monitor the quality of care, and evaluate the outcomes of care. Computers and networks are now used for communicating (sending/receiving) data and messages via the Internet, accessing resources, and interacting with patients on the World Wide Web.

MAJOR HISTORICAL PERSPECTIVE OF NURSING AND COMPUTERS

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

(1) six time periods: prior to the 1960s, the 1960s, the 1970s, the 1980s, the 1990s and post-2000; 

(2) four major nursing areas: nursing practice, administration, education, and research; 

(3) standards initiatives: nursing practice, nursing data, and health care data standards; 

(4) significant landmark events; 

(5) major landmark milestone chart listing those events that influenced the introduction of computers into the nursing profession including the key “computer/informatics” nurse that directed the activity.

SIX TIME PERIODS

PRIOR to the 1960s.

        Starting in the 1950s, and as the computer industry grew, the use of computers in the health care industry also grew. During this time, there were only a few experts who formed a cadre of pioneers that attempted to adapt computers to health care and nursing. During this time, the nursing profession was also undergoing major changes. The image of nursing was improving, nursing practices and services were expanding in scope and complexity, and the number of nurses was increasing. These events provided the impetus for the profession to embrace computers. 

The 1960s.

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

        During this period, computer technology advanced, while the number of health care facilities increased. The introduction of cathode ray tube (CRT) terminals, online data communication, and real-time processing added important dimensions to the computer systems providing more accessible and “user-friendly” machines.

The 1970s.

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

        During this period, several states and large community health agencies developed and/or contracted for their own computer-based management information systems. Generally, public health MISs provided statistical information required by local, state, and federal agencies for specific program funds, whereas home health agencies provided billing and other financial information required for reimbursement of patient services by Medicare, Medicaid, and other third-party payers.

The 1980s.

        During the 1980s, the field of informatics emerged in the health care industry and nursing. NI became an accepted specialty and many nursing experts entered the field. Technology challenged creative professionals and the use of computers in nursing became revolutionary. As computer systems were implemented, the needs of nursing took on a cause-and-effect modality; that is, as new computer technologies emerged and as computer architecture advanced, the need for nursing software evolved.

        During this period, many mainframe HISs emerged with nursing subsystems. These systems documented several aspects of the patient record; namely, order entry emulating the Kardex, results reporting, vital signs, and other systems that documented narrative nursing notes via word-processing packages. Discharge planning systems were developed and used as referrals to community health care facilities in the continuum of care.

        In the 1980s, the microcomputer or personal computer (PC) emerged. This revolutionary technology made computers more accessible, affordable, and usable by nurses and other health care providers. PCs brought computing power to the workplace and, more importantly, to the point-of-care. PC s served not only as terminals linked to the mainframe computers but also as stand-alone systems (workstations). They were user-friendly and allowed nurses to create their own applications.

The post-2000.

        The early years of the new millennium continued the torrid pace of hardware and software development and growth. This growth is reflected in healthcare and nursing, with developments such as wireless point-of-care, serious consideration for open source solutions, regional database projects, and increase IT solutions targeted at all healthcare environments. Further, clinical information systems became individualized in the electronic patient record (EPR) and patient specific systems considered for the lifelong longitudinal record or the electronic health record (EHR).

        Information technologies continued to advance with mobile technology such as with wireless tablet computers, personal digital assistants (PDAs), and smart cellular telephones. The development and subsequent refinement of voice over Internet protocol (VolP) promises to provide cheap voice communication for health care organizations. Post-2000 also witnessed the continued impact of legislation on the U.S healthcare industry.

FOUR MAJOR NURSING AREAS

NURSING PRACTICE

        Nursing practice has evolved and changed radically. It has become an integral part of the EHR. Computer systems with nursing and patient care data, nursing care plans are no longer separate subsystems of the computerized HISs, but rather integrated into one interdisciplinary patient health record in the EHR. The need for an interdisciplinary EHR resulted because of many initiatives proposed and promoted by the nursing profession as well as by other health care providers. They all require patient care data to track the care process. Further nursing practice data emerged with the introduction of several nursing terminologies that were recognized by the ANA as coded terminologies usable for the EHR. They are used to assess problems, document care, and track the care process, and measure outcomes. Thus, the electronic version nursing practice – the computer – has revolutionized and transformed nursing practice.

 NURSING ADMINISTRATION

        Nursing administration in hospitals has also changed with the introduction of the computer that links nursing departments together. Most policy and procedure manuals are accessed and retrieved by computer. Further, workload measures, acuity systems, and other nursing department systems are online and integrated with the hospital or patient's EHR system or in separate nursing department systems. The Internet is being used by nurses to access digital libraries, online resources, and research protocols at the bedside.

NURSING EDUCATION

        The computer has radically changed nursing education. Most universities and schools of nursing offer computer enhanced courses, online courses, and/or distance education. They are becoming universities without walls where students can attend a university anywhere in the world without being present. Campus-wide computer systems are available for students to communicate via e-mail, transfer data files, access the digital libraries, and retrieve online resources of millions of Internet WWW sites (Saba, 1996). These new educational strategies require different methods of teaching. Today, most faculty members use the Internet to teach courses via the Web and communication with their students via e-mail. They require new tools, techniques, and a full array of multimedia strategies to stimulate their students. The students on the other hand, have to be more active and assume more responsibility for their education. Time, distance, and cost are no longer barriers to educational programs (Joos and Nelson, 1992; Saba, 2000).

NURSING RESEARCH

        Nursing research provides the impetus to use the computer for analyzing nursing data. Software programs are available for processing both quantitative and qualitative research data. With the advancement of computer technology databases supporting nursing research emerged, principally for online searching and retrieving information from the electronic bibliographic literature systems or other databases that contain relevant health care content, such as drug data. The Internet also provides online access to the millions of Web resources around the world which have increased the capabilities and expanded the field of nursing research. 

STANDARD INITIATIVES 

NURSING PRACTICE STANDARDS

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

        Nursing practice standards have also been set by the Joint Commission on Accreditation of Hospital Organization (JCAHO) which stressed the need for adequate records on patients in hospitals and practice standards for the documentation of care by nurses (Namdi and Hutelmyer, 1970). They also recommended acuity systems to determine resource use as well as required care plans for documenting nursing care (JCAHO, 1994). Further, they have included in their recent manual the required contents of an EHR, such as what data should be collected and how the data should be organized on the electronic database (Corum, 1993). These standards have evolved and continue to increase as the federal requirements evolve and/or are implemented. 

NURSING DATA STANDARDS

        Nursing data standards have emerged as a new requirement for the EHR. The original data elements and historical details are described in the third edition; however, for this fourth edition is it important to understand that currently there are 13 nursing terminologies that have been recognized by the ANA and which are described in other sections of this book. The ANA is responsible for the recognition of the terminologies and for determining if they have met the criteria to be included in the National Library of Medicine (NLM) Unified Medical Language Systems (UMLS) (Humphreys and Lindberg, 1992; Saba, 1998). 

HEALTH CARE DATA STANDARDS ORGANIZATIONS

        It is critical to review the standards organizations that have emerged to either develop or recommend health care data standards that should be recommnded to the federal government as required health care data standards. The major ones are listed below but also described elsewhere in this book. The American National Standards Institute (ANSI) is a private nonprofit membership organization. It was instituted to coordinate and approve voluntary standards efforts in the United States. ANSI was combined with the Health Care Informatics Standards Board (HISB) to form ANSI-HISB to fulfill a request by the European standards coordinating organization (CEN TC/251) to represent the U.S. standards effort. 

        American Society for Testing and Materials (ASTM): The ASTM E-31 Committee on Healthcare Informatics is an accredited commitee that develops standards for health information and health information systems designed to assist vendors, users, and anyone interested in systematizing health information (Cendrowska et al., 1999; Hammond, 1994).

SIGNIFICANT LANDMARK EVENTS

        Computers were introduced into the nursing profession over 35 years ago. Major milestones of nursing are interwoven with the advancement of computer and information technologies, the increased need for nursing data, development of nursing applications, and changes making the nursing profession an autonomous discipline. The major developments in the use of information technologies and nursing, and in the introduction of NI, were chronologically described by program effort, or by organizational initiative. The landmark events were described by the following categories: (a) early conferences, meetings, (b) early academic initiatives, (c) initial ANA initiatives, (d) initial National League for Nursing (NLN) initiatives, (e) early international initiatives, (f) initial educational resources, and (g) significant collaborative events.