Synaptic circuits and their variations within different columns in the visual system of Drosophila.

We reconstructed the synaptic circuits of seven columns in the second neuropil or medulla behind the fly's compound eye. These neurons embody some of the most stereotyped circuits in one of the most miniaturized of animal brains. The reconstructions allow us, for the first time to our knowledge, to study variations between circuits in the medulla's neighboring columns. This variation in the number of synapses and the types of their synaptic partners has previously been little addressed because methods that visualize multiple circuits have not resolved detailed connections, and existing connectomic studies, which can see such connections, have not so far examined multiple reconstructions of the same circuit. Here, we address the omission by comparing the circuits common to all seven columns to assess variation in their connection strengths and the resultant rates of several different and distinct types of connection error. Error rates reveal that, overall, <1% of contacts are not part of a consensus circuit, and we classify those contacts that supplement (E+) or are missing from it (E-). Autapses, in which the same cell is both presynaptic and postsynaptic at the same synapse, are occasionally seen; two cells in particular, Dm9 and Mi1, form ≥ 20-fold more autapses than do other neurons. These results delimit the accuracy of developmental events that establish and normally maintain synaptic circuits with such precision, and thereby address the operation of such circuits. They also establish a precedent for error rates that will be required in the new science of connectomics.

Nursing Knowledge: Big Data Science-Implications for Nurse Leaders.

The integration of Big Data from electronic health records and other information systems within and across health care enterprises provides an opportunity to develop actionable predictive models that can increase the confidence of nursing leaders' decisions to improve patient outcomes and safety and control costs. As health care shifts to the community, mobile health applications add to the Big Data available. There is an evolving national action plan that includes nursing data in Big Data science, spearheaded by the University of Minnesota School of Nursing. For the past 3 years, diverse stakeholders from practice, industry, education, research, and professional organizations have collaborated through the "Nursing Knowledge: Big Data Science" conferences to create and act on recommendations for inclusion of nursing data, integrated with patient-generated, interprofessional, and contextual data. It is critical for nursing leaders to understand the value of Big Data science and the ways to standardize data and workflow processes to take advantage of newer cutting edge analytics to support analytic methods to control costs and improve patient quality and safety.

EHR Documentation: The Hype and the Hope for Improving Nursing Satisfaction and Quality Outcomes.

The phenomenon of "data rich, information poor" in today's electronic health records (EHRs) is too often the reality for nursing. This article proposes the redesign of nursing documentation to leverage EHR data and clinical intelligence tools to support evidence-based, personalized nursing care across the continuum. The principles consider the need to optimize nurses' documentation efficiency while contributing to knowledge generation. The nursing process must be supported by EHRs through integration of best care practices: seamless workflows that display the right tools, evidence-based content, and information at the right time for optimal clinical decision making. Design of EHR documentation must attain a balance that ensures the capture of nursing's impact on safety, quality, highly reliable care, patient engagement, and satisfaction, yet minimizes "death by data entry." In 2014, a group of diverse informatics leaders from practice, academia, and the vendor community formed to address how best to transform electronic documentation to provide knowledge at the point of care and to deliver value to front line nurses and nurse leaders. As our health care system moves toward reimbursement on the basis of quality outcomes and prevention, the value of nursing data in this business proposition will become a key differentiator for health care organizations' economic success.

Validation of the Impact of Health Information Technology (I-HIT) Scale: an international collaborative.

In 2005, the Healthcare Information Management Systems Society (HIMSS) Nursing Informatics Community developed a survey to measure the impact of health information technology (HIT), the I-HIT Scale, on the role of nurses and interdisciplinary communication in hospital settings. In 2007, nursing informatics colleagues from Australia, England, Finland, Ireland, New Zealand, Scotland and the United States formed a research collaborative to validate the I-HIT across countries. All teams have completed construct and face validation in their countries. Five out of six teams have initiated reliability testing by practicing nurses. This paper reports the international collaborative's validation of the I-HIT Scale completed to date.

Guideposts to the future--an agenda for nursing informatics.

As new directions and priorities emerge in health care, nursing informatics leaders must prepare to guide the profession appropriately. To use an analogy, where a road bends or changes directions, guideposts indicate how drivers can stay on course. The AMIA Nursing Informatics Working Group (NIWG) produced this white paper as the product of a meeting convened: 1) to describe anticipated nationwide changes in demographics, health care quality, and health care informatics; 2) to assess the potential impact of genomic medicine and of new threats to society; 3) to align AMIA NIWG resources with emerging priorities; and 4) to identify guideposts in the form of an agenda to keep the NIWG on course in light of new opportunities. The anticipated societal changes provide opportunities for nursing informatics. Resources described below within the Department of Health and Human Services (HHS) and the National Committee for Health and Vital Statistics (NCVHS) can help to align AMIA NIWG with emerging priorities. The guideposts consist of priority areas for action in informatics, nursing education, and research. Nursing informatics professionals will collaborate as full participants in local, national, and international efforts related to the guideposts in order to make significant contributions that empower patients and providers for safer health care.

Health care in 2020.

While this case study uses an example of a home health team, it is meant to describe a system in which clinicians and healthcare organizations specialize and develop expertise by performing a large volume of specific services, procedures for given medical conditions or diagnoses. We introduce the concept of "consumer as a direct employer" of healthcare services. In this model, nurses may work as independent contractors, or as a member of a team contracting out as a unit, as in our example of the Rhine Home Health Team. Nrses also may work as employees to healthcare organizations as they do today.

Teaching undergraduate nursing students critical thinking: An innovative informatics strategy.

Simulated e-Health Delivery System (SEEDS) uses a clinical information system (CIS) to teach students how to process data from virtual patient case studies and work with information technology. SEEDS was developed in response to the Institute of Medicine recommendation that students be taught about information systems in order to improve quality patient care and reduce errors. Curriculum implications, implementation of the system, and technology challenges are discussed.

Transforming Clinical Documentation in EHRs for 2020: Recommendations from University of Minnesota's Big Data Conference Working Group.

In 2014, a group of diverse informatics leaders from practice, academia, and the software industry formed to address how best to transform electronic documentation to provide knowledge at the point of care and to deliver value to front line nurses and nurse leaders. This presentation reports the recommendations from this Working Group geared towards a 2020 framework. The recommendations propose redesign to optimize nurses' documentation efficiency while contributing to knowledge generation and attaining a balance that ensures the capture of nursing's impact on safety, quality, yet minimizes "death by data entry."

Bedside, classroom and bench: collaborative strategies to generate evidence-based knowledge for nursing practice.

The rise of evidence-base practice (EBP) as a standard for care delivery is rapidly emerging as a global phenomenon that is transcending political, economic and geographic boundaries. Evidence-based nursing (EBN) addresses the growing body of nursing knowledge supported by different levels of evidence for best practices in nursing care. Across all health care, including nursing, we face the challenge of how to most effectively close the gap between what is known and what is practiced. There is extensive literature on the barriers and difficulties of translating research findings into practical application. While the literature refers to this challenge as the "Bench to Bedside" lag, this paper presents three collaborative strategies that aim to minimize this gap. The Bedside strategy proposes to use the data generated from care delivery and captured in the massive data repositories of electronic health record (EHR) systems as empirical evidence that can be analysed to discover and then inform best practice. In the Classroom strategy, we present a description for how evidence-based nursing knowledge is taught in a baccalaureate nursing program. And finally, the Bench strategy describes applied informatics in converting paper-based EBN protocols into the workflow of clinical information systems. Protocols are translated into reference and executable knowledge with the goal of placing the latest scientific knowledge at the fingertips of front line clinicians. In all three strategies, information technology (IT) is presented as the underlying tool that makes this rapid translation of nursing knowledge into practice and education feasible.

Enabling technologies promise to revitalize the role of nursing in an era of patient safety.

The application of information technology (IT) in health care has the potential to transform the delivery of care, as well as the health care work environment, by streamlining processes, making procedures more accurate and efficient, and reducing the risk of human error. For nurses, a major aspect of this transformation is the refocusing of their work on direct patient care and away from being a conduit of information and communication among departments. Several of the technologies discussed, such as physician order entry and bar code technology, have existed for years as standalone systems. Many others are just being developed and are being integrated into complex clinical information systems (CISs) with clinical decision support at their core. While early evaluation of these systems shows positive outcome measurements, financial, technical, and organizational hurdles to widespread implementation still remain. One major issue is defining the role nurses, themselves, will play in the selection and implementation of these systems as they become more steeped in the knowledge of nursing informatics. Other challenges revolve around issues of job satisfaction and the attraction and retention of nursing staff in the midst of a serious nursing shortage. Despite these concerns, it is expected that, in the long run, the creation of an electronic work environment with systems that integrate all functions of the health care team will positively impact cost-effectiveness, productivity, and patient safety while helping to revitalize nursing practice.

An academic-business partnership for advancing clinical informatics.

A jointly funded partnership between the school of nursing at a large midwestern university and a premier health care information technology supplier represents a pioneering event for education and for the health care information technology industry. The impetus for this partnership arose from Institute of Medicine reports published in late 1999 and early 2001 addressing the quality, error, and waste in the health care system in the United States. The Simulated E-hEalth Delivery System (SEEDS) provides opportunities based on best practices in education to learn and practice clinical skills in a state-of-the-art environment using a live-production, clinical information system designed for care delivery. A pilot project that began with a small cohort of baccalaureate nursing students has been implemented and extended. SEEDS will also be extended to other health professional programs.

Rapid EHR development and implementation using web and cloud-based architecture in a large home health and hospice organization.

Health care organizations have long been limited to a small number of major vendors in their selection of an electronic health record (EHR) system in the national and international marketplace. These major EHR vendors have in common base systems that are decades old, are built in antiquated programming languages, use outdated server architecture, and are based on inflexible data models [1,2]. The option to upgrade their technology to keep pace with the power of new web-based architecture, programming tools and cloud servers is not easily undertaken due to large client bases, development costs and risk [3]. This paper presents the decade-long efforts of a large national provider of home health and hospice care to select an EHR product, failing that to build their own and failing that initiative to go back into the market in 2012. The decade time delay had allowed new technologies and more nimble vendors to enter the market. Partnering with a new start-up company doing web and cloud based architecture for the home health and hospice market, made it possible to build, test and implement an operational and point of care system in 264 home health locations across 40 states and three time zones in the United States. This option of "starting over" with the new web and cloud technologies may be posing a next generation of new EHR vendors that retells the Blackberry replacement by iPhone story in healthcare.

The future state of clinical data capture and documentation: a report from AMIA's 2011 Policy Meeting.

Much of what is currently documented in the electronic health record is in response toincreasingly complex and prescriptive medicolegal, reimbursement, and regulatory requirements. These requirements often result in redundant data capture and cumbersome documentation processes. AMIA's 2011 Health Policy Meeting examined key issues in this arena and envisioned changes to help move toward an ideal future state of clinical data capture and documentation. The consensus of the meeting was that, in the move to a technology-enabled healthcare environment, the main purpose of documentation should be to support patient care and improved outcomes for individuals and populations and that documentation for other purposes should be generated as a byproduct of care delivery. This paper summarizes meeting deliberations, and highlights policy recommendations and research priorities. The authors recommend development of a national strategy to review and amend public policies to better support technology-enabled data capture and documentation practices.