Personalized health care and business success: can informatics bring us to the promised land?

Perrow's models of organizational technologies provide a framework for analyzing clinical work processes and identifying the management structures and informatics tools to support each model. From this perspective, health care is a mixed model in which knowledge workers require flexible management and a variety of informatics tools. A Venn diagram representing the content of clinical decisions shows that uncertainties in the components of clinical decisions largely determine which type of clinical work process is in play at a given moment. By reducing uncertainties in clinical decisions, informatics tools can support the appropriate implementation of knowledge and free clinicians to use their creativity where patients require new or unique interventions. Outside health care, information technologies have made possible breakthrough strategies for business success that would otherwise have been impossible. Can health informatics work similar magic and help health care agencies fulfill their social mission while establishing sound business practices? One way to do this would be through personalized health care. Extensive data collected from patients could be aggregated and analyzed to support better decisions for the care of individual patients as well as provide projections of the need for health services for strategic and tactical planning. By making excellent care for each patient possible, reducing the "inventory" of little-needed services, and targeting resources to population needs, informatics can offer a route to the "promised land" of adequate resources and high-quality care.

Toward data standards for clinical nursing information.

OBJECTIVE: Develop standard terms and codes for recording nursing care information in patient records to permit relevant data to be abstracted into a shared database for effectiveness research. DESIGN: A collaborative effort by the University of Virginia, Thomas Jefferson University Hospital, and the University Hospital Consortium to develop a set of terms to represent specific examples of nursing diagnoses/patient care problems, nursing interventions/patient care activities, and patient outcomes. Terms found in standards of care are being compiled, classified, and coded. RESULTS: Standard terminology and codes have been developed for 209 nursing diagnoses/patient care problems, 122 expected patient outcomes, and 545 interventions/patient care activities. The terms come from five nursing units in one hospital and from two units in a second hospital. Preliminary findings suggest that in the specialty areas for which terms have been developed, the terms are adequate to capture these types of nursing data in the patient record.

Are medical informatics and nursing informatics distinct disciplines? The 1999 ACMI debate.

The 1999 debate of the American College of Medical Informatics focused on the proposition that medical informatics and nursing informatics are distinctive disciplines that require their own core curricula, training programs, and professional identities. Proponents of this position emphasized that informatics training, technology applications, and professional identities are closely tied to the activities of the health professionals they serve and that, as nursing and medicine differ, so do the corresponding efforts in information science and technology. Opponents of the proposition asserted that informatics is built on a re-usable and widely applicable set of methods that are common to all health science disciplines, and that "medical informatics" continues to be a useful name for a composite core discipline that should be studied by all students, regardless of their health profession orientation.

Designing information systems for nursing practice: data base and knowledge base requirements of different organizational technologies.

One of the major causes of failure of information system design is the failure of developers to take into account the organizational environment, thereby leading to an unusable system. The first step in designing an effective system is to describe the user's view of the system, a view that incorporates how the system will help users to manage information in their particular organizational environment. For nurses involved in designing a nursing information system, a useful way of considering the organizational environment is provided by Perrow. The organizational technologies described by Perrow can be viewed as different models of nursing practice, each with particular requirements for a knowledge base and a data base. Nurses can identify the model that most closely corresponds to actual or desired nursing practice in their agencies and use the model's associated knowledge base and data base requirements as a guide to specifying the information system to be developed.

Clinical nursing informatics. Developing tools for knowledge workers.

Current research in clinical nursing informatics is proceeding along three important dimensions: (1) identifying and defining nursing's language and structuring its data; (2) understanding clinical judgment and how computer-based systems can facilitate and not replace it; and (3) discovering how well-designed systems can transform nursing practice. A number of efforts are underway to find and use language that accurately represents nursing and that can be incorporated into computer-based information systems. These efforts add to understanding nursing problems, interventions, and outcomes, and provide the elements for databases from which nursing's costs and effectiveness can be studied. Research on clinical judgment focuses on how nurses (perhaps with different levels of expertise) assess patient needs, set goals, and plan and deliver care, as well as how computer-based systems can be developed to aid these cognitive processes. Finally, investigators are studying not only how computers can help nurses with the mechanics and logistics of processing information but also and more importantly how access to informatics tools changes nursing care.

Setting a national research agenda in nursing informatics.

An active program of research assures the development and evaluation of nursing informatics solutions to the challenges of contemporary patient care. Experts in nursing informatics research participated in a two-part electronic mail survey of research priorities. Priorities identified included formalization of nursing vocabularies, design and management of databases for nursing information, development of technologies to support nursing practice, use of telecommunications technology in nursing, patient use of information technology, identification of nurses' information needs, and systems modeling and evaluation. Many of these priorities are similar to those advanced in the 1993 US PHS NINR PEP Report on Nursing Informatics. Additionally, the findings suggest the need for greater emphasis on the application of emerging technology to nursing practice problems, and the expansion to consider patients as direct users of information systems.

Nursing and technology: a dialectic.

Caring and expertise are fundamental to nursing. Technology, although often viewed as inimical to these human qualities in the provision of care, has the potential to support caring and enhance expertise. Nurses whose expertise embraces both technology and nursing can design and implement technologies that will help them fulfill their commitments to patients. Appropriate, well-designed, flexible technologies can improve the care of individuals and enlarge the store of nursing knowledge and expertise.

From minimum data to maximum impact: using clinical data to strengthen patient care.

Society mandates that health care be both effective and affordable. Currently, data about costs of care are more readily obtainable than data about quality, especially in relation to nursing and other nonphysician aspects of patient care. Assessing effectiveness of care requires standardized data aggregated in databases for comparisons across times, conditions, and institutions. Historical and contemporary efforts to identify elements of a minimum data set and develop standards have brought progress but have not resolved all the critical issues. A project involving the University Hospital Consortium and its member institutions has produced a valid and reliable set of standard terms and codes compatible with an existing patient-level database. Future developments need to include better methods for determining resource consumption and for capturing clinical data. The time is near when databases built from clinical data will lead to knowledge that will strengthen patient care.

From minimum data to maximum impact: using clinical data to strengthen patient care.

Society mandates that health care be both effective and affordable. Currently, data about costs of care are more readily obtainable than data about quality, especially in relation to nursing and other nonphysician aspects of patient care. Assessing effectiveness of care requires standardized data aggregated in databases for comparisons across times, conditions, and institutions. Historical and contemporary efforts to identify elements of a minimum data set and develop standards have brought progress but have not resolved all the critical issues. A project involving the University Hospital Consortium and its member institutions has produced a valid and reliable set of standard terms and codes compatible with an existing patient-level database. Future developments need to include better methods for determining resource consumption and for capturing clinical data. The time is near when databases built from clinical data will lead to knowledge that will strengthen patient care.

Validity and reliability of standard terms and codes for patient care data.

A set of standard terms and codes for patient care data was derived from care planning and documentation materials submitted by 9 hospitals. The set contained 329 terms for Patient Problems, 308 terms for Patient Outcomes, and 1261 terms for Patient Care Actions. Six of the hospitals participated in a test of validity and reliability of the standard terms and codes. Manual audits were conducted on 465 patient records from two services in each hospital. All auditors achieved acceptable accuracy in coding. The auditors identified 18,995 items in the patient records as representing statements of Patient Problems, Patient Outcomes, or Patient Care Actions. The standard terms and codes matched 99.1% of these items. Thus, for the services audited, the standard terms and codes provided a valid representation of the Patient Problems, Patient Outcomes, and Patient Care Actions in the patient records.

Psychophysiological processes of stress in chronic physical illness: a theoretical perspective.

This paper proposes a theoretical framework and conceptual model for clinicians and investigators working with people who have a chronic physical illness. The framework is based upon nursing theory and classical propositions from psychology and physiology. The major premise of the model is that individuals with limited psychosocial attributes and a preponderance of unmet basic needs are more likely to perceive events as threatening and experience a maladaptive stress response, such as heightened symptoms and acute exacerbations of their illness. Conversely, those with strong attributes and a perception of need satisfaction are more likely to view events as challenging, thus avoiding symptomatic discomfort and enhancing personal growth. Implications for nursing practice and research are addressed.

A proposed expert system for nursing practice. A springboard to nursing science.

The knowledge on which nursing practice is based comes largely from traditional sources, expert nurses passing on the wisdom of their experience to novices. Nursing research, although increasing, is usually parallel to nursing practice, and its findings, at best, are implemented only after long delays. Consequently, the most effective nursing responses to a particular client problem may be undiscovered or unknown. Nursing information systems reflect the nature and usage of nursing knowledge. They offer standard care plans, but the knowledge and decision structures for individualizing care remain exclusively in the mind of the nurse. Nurses may have great freedom to enter information into the information system, but the information is rarely retrievable in a form suitable for evaluation or research. Nursing practice, and the knowledge on which it is based, could be enhanced through the use of a novel expert system. This paper describes how such a system could be developed, with examples from the authors' prototype programs. Taxonomies of data, diagnoses, objectives, and interventions would make it possible to compare patients and to determine the relative effectiveness of nursing interventions. A built-in evaluation component would provide feedback and correction. Everyday nursing practice would become a field for research, and the knowledge gained from research would immediately be fed back into practice. In its development and in its implementation, this kind of system would help to build nursing science.