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2017
AACN Clinical Issues
Nursing Informatics, Outcomes,
and Quality Improvement
Kathleen G. Charters, PhD, RN, CPHIMS
■ Nursing informatics actively supports
nursing by providing standard language
systems, databases, decision support,
readily accessible research results, and
technology assessments. Through
normalized datasets spanning an entire
enterprise or other large demographic,
nursing informatics tools support
improvement of healthcare by answering
questions about patient outcomes and
quality improvement on an enterprise
scale, and by providing documentation for
business process definition, business
process engineering, and strategic
planning. Nursing informatics tools
provide a way for advanced practice
nurses to examine their practice and the
effect of their actions on patient
outcomes. Analysis of patient outcomes
may lead to initiatives for quality
improvement. Supported by nursing
informatics tools, successful advance
practice nurses leverage their quality
improvement initiatives against the
enterprise strategic plan to gain
leadership support and resources.
(KEYWORDS: nursing informatics,
outcomes, quality improvement, strategic
planning, clinical information systems)
Advanced practice nurses working in acute and
critical care environments are concerned about
improving the quality of healthcare.
282
Volume 14, Number 3, pp. 282–294
© 2003, AACN
They look for sources of data to inform their
efforts. Currently, the work of the advanced
practice nurse intersects with the specialty of
nursing informatics (NI).
One major source of frustration for ad-
vanced practice nurses results from putting data
into a clinical information system, then
discovering there is no useful way to retrieve that
data for analysis. If clinical documenta-tion that
reflects advanced practice is invisi-ble, the work
of the advanced practice nurse is not available for
evaluation or comparison within an institution or
across multiple insti-tutions nationally or
internationally. This ar-ticle presents ways that
NI assists advanced practice nurses in making
their work visible. It addresses standardized
language systems for collecting data reflecting the
nursing process and using that data to inform
quality improvement efforts.
Nursing informatics is dedicated to find-ing
ways to make clinical documentation vis-ible and
accessible for evaluation and com-parison. While
there are many indicators of healthcare quality,
outcome data often are used. Nursing
informatics provides ways for
▪▪▪▪▪▪▪▪▪▪
From the Department of Adult Health and Educa-tion,
Administration, Informatics, and Health Policy, University of
Maryland, Baltimore School of Nursing, Baltimore, Md.
Reprint requests to Kathleen G. Charters, PhD, RN,
CPHIMS, Department of Adult Health and Education,
Administration, Informatics, and Health Policy, Univer-sity
of Maryland, Baltimore School of Nursing, 655 West
Lombard Street, Baltimore, MD 21201-1579 (e-mail:
charters@son.umaryland.edu).
Vol. 14, No. 3 August 2003
capturing and evaluating outcome data. Re-
searchers depend on standardized outcome data
to build evidence-based practice. Qual-ity
improvement focuses on systematic im-
provement of healthcare processes through
comparative analysis, and is most successful
when quality improvement initiatives are aligned
with the enterprise strategic plan. When this
occurs, process change support and appropriate
resources will be available for quality
improvement initiatives. Ad-vanced practice
nurses can leverage this principle when
promoting change to im-prove the quality of
healthcare as measured by patient outcomes.
Nursing Informatics
According to the American Nurses Associa-tion
(ANA), the specialty of NI: focuses on the
representation of nursing data, informa-tion, and
knowledge (Graves & Corcoran, 1989; Henry,
1995) and the management and communication
of nursing information within the broader
context of health infor-matics. Nursing
informatics: provides a nurs-ing perspective,
illuminates nursing values and beliefs, denotes a
practice base for nurses in NI, produces unique
knowledge, distinguishes groups of practitioners,
fo-cuses on the phenomena of interest for
nursing, and provides needed nursing lan-guage
and word context (Brennan 1994) to health
informatics 1(p1)
The International Medical Informatics As-
sociation2 defines nursing informatics as “the
integration of nursing, its information, and in-
formation management with information pro-
cessing and communication technology, to
support the health of people worldwide.”2(p1)
These two definitions emphasize the role of
NI in helping nurses improve the flow of
information for the purpose of improving
healthcare. Nursing informatics supports an
“information-rich environment where patient
care and the many functions that support it are
of the highest quality.”3(p13)
Outcomes Evaluation and
Standardized Language Systems
One way to measure the quality of health-care is
to look at patient outcomes. Out-
INFORMATICS, OUTCOMES, AND QI 283
comes are linked to interventions, and in-
terventions are driven by assessments. When
assessments drive interventions to reach
specified outcomes, a clinical path-way may be
developed. When a plan is de-signed to achieve
specific outcomes, nurs-ing optimizes healthcare.
To support the study of this process of
healthcare delivery, NI contributes standard
classification sys-tems and standard vocabulary.
The consis-tent use of terms to identify and
describe nursing practice is the foundation for
pro-viding high-quality care for the lowest cost.4,5
Information Barriers
Barriers to providing high-quality care in-clude
the lack of shared information, result-ing partly
from the complexity of healthcare language;
fragmentation of clinical data; and limited data
reporting.6 In addition to health-care providers,
the government, purchasers, and consumers
demand quality healthcare.5,6 Consumers are
taking more responsibility for their own health
and healthcare, which in-creases demand for
healthcare information that a lay person can
comprehend. These demands, however, cannot
be met unless the information barriers are
overcome. Nurs-ing informatics provides tools to
break down the barriers that keep information
from be-ing shared (Table 1). Strategic planning
is es-sential for effective application of technol-
ogy to implement standardized language systems
developed to facilitate information sharing.
Overcoming Information
Barriers
The ANA has taken a proactive role by creat-ing
the Nursing Information and Data Set
Evaluation Center (NIDSEC). The NIDSEC has
identified 12 languages uniquely devel-oped to
document nursing care (Table 2).7 Information
system vendors can submit their products for
evaluation based on NIDSEC standards to show
the extent to which their information system
integrates one or more ANA-recognized nursing
languages. These languages include classification
systems spe-
284 CHARTERS AACN Clinical Issues

TABLE 1 Where to Find Data Reflecting the Problem-solving Process of

Delivering Healthcare or for Evaluation of Healthcare
Standardized Languages Containing Diagnosis or Defining and Describing Patient Problems
Nursing Healthcare

National—Problem Specific
North American Nursing Diagnosis Association Code on Dental Procedures and Nomenclature
(NANDA) / Nursing Diagnosis Extension and (CDT-4)
Classification (NDEC)
Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV)

National—Integrated
Home Health Care Classification (HHCC)*
Omaha System*
Patient Care Data Set (PCDS)*
Perioperative Nursing Data Set*

International—Problem Specific
International Classification of Diseases, Ninth
Revision, Clinical Modification (ICD-9-CM)
International Statistical Classification of Diseases
(ICD 10)
International Classification of Functioning, Disability
and Health (ICIDH-2)

International—Integrated
International Classification for Nursing Practice
(ICNP) (phenomena)

Standardized Languages Containing Implementation or Intervention Terms or Procedures

Used to Treat Patients
Nursing Healthcare

National—Intervention Specific
Nursing Interventions Classification (NIC) Alternative Billing Codes (ABC)
Sexual Assault Nurse Examiner (SANE) Code on Dental Procedures and Nomenclature (CDT-4)
Current Procedural Terminology (CPT-4)

National—Integrated
Home Health Care Classification (HHCC)*
Omaha System*
Patient Care Data Set (PCDS)*
Perioperative Nursing Data Set*

International—Integrated
International Classification for Nursing Practice
(ICNP) (actions)

Standardized Languages Containing Outcomes or Goals or the Results of Care Interventions

Nursing Healthcare Domains

National—Outcome Specific
Nursing Outcomes Classification (NOC)
(continues)
Vol. 14, No. 3 August 2003 INFORMATICS, OUTCOMES, AND QI 285

TABLE 1 Where to Find Data Reflecting the Problem-solving Process of

Delivering Healthcare or for Evaluation of Healthcare (Continued)
National—Integrated
Home Health Care Classification (HHCC)* Outcomes and Assessment Information Set (OASIS)
Omaha System*
Patient Care Data Set (PCDS)*
Perioperative Nursing Data Set*

International—Integrated
International Classification for Nursing Practice
(ICNP)

Standardized Nursing Languages Useful for Evaluation

Language Systems That Address One or Two Integrated Language Systems
Components but Link With Other Languages

National
North American Nursing Diagnosis Association Home Health Care Classification (HHCC)*
(NANDA) / Nursing Diagnosis Extension
and Classification (NDEC)
Nursing Interventions Classification (NIC) Omaha System*
Nursing Outcomes Classification (NOC) Patient Care Data Set (PCDS)*
Perioperative Nursing Data Set*

International
International Classification for Nursing Practice (ICNP)

* Language systems containing assessment, diagnosis, planning, interventions, outcomes.

cific to the problem-solving process used by to the effects of nursing interventions.9 An

nursing, integrated classification systems, and
minimum data sets. A challenge for the specific
classification systems is to find ways to connect
the discrete steps of the nursing process:
assessment, diagnosis, planning, in-terventions,
and outcomes.
annual conference is devoted to developing and
linking these and other classification systems,
including international nursing classification and
international nursing min-imum data set efforts.

Specific Classification Systems
One NI initiative involves linking nursing
process classification systems.8 The Nursing
Diagnosis Extension and Classification (NDEC)
is a collaborative effort to refine and extend the
North American Nursing Di-agnosis Association
(NANDA) taxonomy. It provides a standard for
describing human responses to health
problems/life process. The Nursing
Interventions Classification (NIC) describes
treatments nurses perform, and the Nursing
Outcomes Classification (NOC) describes patient
outcomes sensitive
Healthcare Intervention
Classifications
For describing interventions, there is no in-
ternational equivalent to the American Med-ical
Association’s Current Procedural Termi-nology (CPT).
The current version (fourth edition) is used for
reporting medical ser-vices and procedures to
facilitate reimburse-ment of claims for
physicians. It does not capture many healthcare
delivery activities. Nursing interventions are
missing. Health-care professionals are calling for
major CPT revisions in the fifth edition to
incorporate many more interventions, including
nursing.
286 CHARTERS
TABLE 2 The 12 American Nurses Association Recognized Languages for
Nursing
ANA NIDSEC Recognized Systems for Collecting Nursing Data
Minimum Data Sets
Nursing Minimum Data Set (NMDS)
Nursing Management Minimum Data Set (NMMDS)
The CPT-5 will be developed over the next few
years.9
Approximately 800 nursing procedures are
represented in the Alternative Billing Codes
developed by Alternative Link, Inc. These codes
are used to process claims re-quiring a code for
an alternative medicine procedure, service, or
supply. The nursing procedures were drawn from
the Nursing In-terventions Classification, the
Home Health-care Classification System
(HHCC), the Om-aha Community Health
System (Omaha System), and the Sexual Assault
Nurse Exam-iner.9
Integrated Classification
Systems
The HHCC and the Omaha System are used to
document home healthcare.10,11 The Pa-tient
Care Data Set and the Perioperative Nursing
Data Set include codes for nursing interventions.
The Sexual Assault Nurse Ex-aminer is a new
terminology system.9 These standard terms with
definitions and indica-tors facilitate
documentation in an elec-tronic clinical
information system and pro-vide visibility of the
activities of nursing. The electronic data then are
used to answer questions about healthcare quality
and ef-fectiveness.
AACN Clinical Issues
Standardized Terminology Systems
Alternative Billing Codes (ABC)
Home Health Care Classification (HHCC)
International Classification for Nursing Practice (ICNP)
North American Nursing Diagnosis Association
(NANDA) / Nursing Diagnosis Extension and
Classification (NDEC)
Nursing Interventions Classification (NIC)
Nursing Outcomes Classification (NOC)
Omaha System
Patient Care Data Set (PCDS)
Perioperative Nursing Data Set
Systematized Nomenclature of Medicine (SNOMED)
Clinical Terms (CT) / Reference Terminology (RT)
International Integrated
Classification Systems
Nursing has developed many languages that
overlap and conflict. There is agreement that
consolidation needs to occur. The Vanderbilt
Nursing Languages Summit recommends an
international perspective, proposing specific
nursing language initiatives in the interna-tional
standards environment. The Interna-tional
Council of Nurses has partnered with the
International Medical Informatics Associ-ation’s
NI Special Interest Group to prepare a series of
nursing language proposals. These proposals will
be presented to the In-ternational Organization
for Standards.9
Nurses from around the world also are
collaborating to develop the International
Classification for Nursing Practice (ICNP), es-
tablishing an international language to de-scribe
nursing. The ICNP is a combination terminology
for nursing practice, allowing description of
nursing phenomena (nursing diagnosis), nursing
actions (nursing inter-ventions), and nursing
outcomes by combin-ing terms from eight axes.
The benefits of a worldwide standardized
taxonomy include improved communication
among nurses and between nurses and others;
ability to com-pare nursing data over time and
across client populations, settings, and
geographic areas; and ability to project trends in
patient needs,
Vol. 14, No. 3 August 2003
nursing interventions, resource utilization, and
outcomes.12
Sources of Data Describing
Outcomes
Individual languages that link with other
languages and integrated language systems that
contain assessment, intervention, and outcome
data support evaluation of health-care. The
Nursing Outcomes Classification, a nursing
specific outcome classification system that links
with other languages, con-tains outcome data
that nurses find useful for evaluation.13 The
HHCC, Omaha Sys-tem, Patient Care Data Set,
and Preopera-tive Nursing Data Set are
integrated lan-guages with data describing
nursing outcomes. Nurses also use an integrated
healthcare standardized language, Outcome and
Assessment Information Set (OASIS), to
evaluate outcomes.
Minimum Data Sets
Organizing data so that collected informa-tion
can be compared across healthcare organizations
is essential for meeting the needs of healthcare
professionals, admin-istrators, and regulatory
bodies. According to Hunter,14 “A data set is a
collection of data elements organized for a
specific purpose.”(p.221) To make the work of
nurses visible, nursing-sensitive data should be
part of healthcare minimum data sets. Nursing
care then can be described and compared across
settings and geographic areas.
TABLE 3 Nursing and Healthcare Minimum Data Sets
Minimum Data Sets
Nursing
Nursing Minimum Data Set (NMDS)
Nursing Management Minimum Data Set (NMMDS)
INFORMATICS, OUTCOMES, AND QI 287
There are two minimum data sets specific to
nursing: the Nursing Minimum Data Set
(NMDS) and the Nursing Management Mini-
mum Data Set (NMMDS).9 The NMDS cap-
tures nursing practice with 16 data elements,
including five patient or client demographic
elements, seven service elements, and four
nursing care elements (nursing diagnosis, nursing
intervention, nursing outcome, and intensity of
nursing care).15 The NMMDS builds on the
foundation of the NMDS, but adds contextual
data elements. The NMMDS consists of 17 data
elements organized by environment elements,
nurse resources ele-ments, and financial
resources elements. This allows description of
the healthcare and nursing environment
associated with nursing diagnosis, nursing
intervention, and nursing outcome.
There are several healthcare minimum data
sets (Table 3), including the Minimum Data Set
for Long-Term Care, Version 2 (MDS-2), the
Minimum Data Set—Post Acute Care (MDS-
PAC), and the Mental Health Minimum Data Set
(MHMDS). Uniform healthcare data sets include
the Uniform Ambulatory Care Data Set
(UACDS), the Uniform Hospital Dis-charge
Data Set (UHDDS), and the Uniform Health
Minimum Data Set (UMHDS). The NMDS was
modeled after the UMHDS, but in-cludes six
additional data elements.16
Standard Data Sets for Clinical
Reporting and Quality
Improvement
Regulatory and accreditation reporting re-
quirements also use standard data sets to
Healthcare
Minimum Data Set for Long-term Care Version 2 (MDS-2)
Minimum Data Set—Post Acute Care (MDS-PAC)
Mental Health Minimum Data Set (MHMDS)
Uniform Ambulatory Care Data Set (UACDS)
Uniform Hospital Discharge Data Set (UHDDS)
Uniform Health Minimum Data Set (UMHDS)
288 CHARTERS AACN Clinical Issues

compare quality of care delivered by health-care
organizations over time. The Joint Commission
on Accreditation of Healthcare Organizations
(JCAHO) uses ORYX, the JCAHO initiative for
measuring quality indi-cators, to integrate
performance measures in the accreditation
process. Medicare reim-bursement to healthcare
organizations is tied into JCAHO accreditation
and to participa-tion in the Centers for Medicare
and Medic-aid Services (CMS) (formerly known
as the Healthcare Financing Administration)
Healthcare Quality Improvement Program,
which has extensive data reporting require-
ments.9
The CMS program requires home health
agencies requesting Medicare reimburse-ment to
report the OASIS data set for partici-pation in
the Outcome-Based Quality Im-provement
Program. Managed care or-ganizations seeking
Medicare reimburse-ment must be accredited by
the National Committee on Quality Assurance,
which uses the Health Plan Employer Data and
In-formation Set. They also must participate in
the Quality Improvement System for Man-aged
Care. Long-term care facilities seeking Medicare
reimbursement must report the Medicare
Minimum Data Set. Manual data entry to meet
these reporting requirements is too costly, so
institutions use information systems to enter and
retrieve the data.17
Standard Clinical Data Sets for
National Comparison
The Logical Observation Identifiers Names and
Codes (LOINC) database provides a standard set
of universal names and codes to identify
individual laboratory results, clinical
observations, and diagnostic study observa-tions
(Table 4). The purpose of LOINC is to facilitate
the exchange and pooling of results for clinical
care, outcomes management, and research. The
Regenstrief Institute is extend-ing the clinical
terms portion of the LOINC database, and has
solicited nursing language for inclusion.18
Standard Clinical Data for
International Comparison
The need for electronic data that can be
compared across organizations extends be-yond
the boundaries of the United States. There is
great interest in creating a common language to
facilitate worldwide communi-cation of
healthcare information. On the in-ternational
front, the Systematized Nomen-clature of
Medicine (SNOMED) provides a vocabulary
organized in a hierarchical, sys-tematized
structure. There are two forms of SNOMED:
one focused on clinical terms (SNOMED CT)
linking nursing taxonomies to other healthcare
disciplines and one fo-cused on specialty
medicine reference termi-nology (SNOMED
RT). This is an interna-tional approach to
electronic automation of terms that physicians,
nurses, and other health professionals use in
communicating healthcare information.11
International efforts to classify diagnosis led
to the creation of the International Classi-fication
of Diseases. The CMS uses the Inter-national
Classification of Diseases, 9th Revi-sion, Clinical
Modification (ICD-9-CM) to facilitate statistical
reporting of related dis-ease entities and
procedures. This classifica-tion system lacks
terms that make nursing visible. The World
Health Organization and

TABLE 4 Useful Languages for Clinical Information

Other Clinically Relevant Languages

National International

Human Genome Project Read Version 3

Logical Observation Identifiers Names and Systematized Nomenclature of Medicine Clinical Terms
Codes (LOINC) (SNOMED CT)
Unified Medical Language System (UMLS) Systematized Nomenclature of Medicine Reference
Terminology (SNOMED RT)
Vol. 14, No. 3 August 2003
other nations have moved on to the Interna-
tional Statistical Classification of Diseases and
Related Health Problems, 10th Revision (ICD-
10), the latest version in the series. This update
extends beyond diseases and injuries to facilitate
general epidemiologic studies and evaluation of
healthcare.9
To provide an even richer description, the
World Health Organization created a com-
plementary classification system, the Interna-
tional Classification of Functioning Disability
and Health (ICIDH-2). The ICIDH-2 provides a
unified and standard language and frame-work
for description of human functioning and
disability. This framework uses three di-
mensions: body functions and structure, ac-
tivities at the individual level, and participa-tion
in society. The classification covers any
disturbance in functional states associated with
health conditions at body, individual, and society
levels.9 This approach comes closer to capturing
the phenomena of inter-est to nursing.
How to Find Information When
Terminology Differs
The Unified Medical Language System (UMLS)
began in 1986 as a National Library of Medicine
project to develop systems that can help health
professionals and re-searchers retrieve and
integrate electronic biomedical information from
a variety of sources.19 The UMLS provides a
standardized way to access healthcare literature
and makes it easy for users to link disparate in-
formation systems such as computer-based
patient records, expert systems, factual data-
bases, and bibliographic databases. The UMLS
knowledge sources link many differ-ent names
for the same concepts from about 60 biomedical
vocabularies and classifica-tions, assign types or
categories to concepts, and provide permissible
relations among these types.9 This allows
retrieval of related information, regardless of the
different ways data were organized originally.
Quality Improvement
Nursing informatics provides a means for
making changes. Change management is a
INFORMATICS, OUTCOMES, AND QI 289
key component of the informatics nurse spe-
cialist role.1 Nursing informatics focuses on
managing and processing data to form infor-
mation and build knowledge. It plays an es-
sential role in supporting changes in nursing
practice. Evidenced-based decision making and
outcome-focused care depend on infor-mation.4
Manual documentation is inadequate for
supporting the information needs of a man-aged
care environment. One way to change
documentation is through continu-ous quality
improvement.20 Nurse execu-tives find
“integrated hospital information systems very
useful in the retrieving, sum-marizing, and
comparing of large volumes of data necessary for
quality improvement initiatives”21(p289) Electronic
automation of nursing documentation achieved
through the quality improvement process reduces
the burden of data collection and analysis while
improving completeness, accuracy,22 and
timeliness of access to data, and enabling the use
of automated reminders. Another benefit is the
elimination of redundant data collec-tion.
Systematic comparative analysis of the linkages
among assessments, interventions, and outcomes
builds nursing knowledge and results in
improved healthcare delivery.4 The evidence
shows where quality improve-ment efforts
should be focused.
Sources of Data for Nursing
Evaluation
Nursing evaluation activities are supported by
specific classification systems (NANDA/
NDEC, NIC, and NOC) and integrated clas-
sification systems (HHCC, Omaha System,
Patient Care Data Set, and Perioperative Nursing
Data Set), as well as by the NMDS and the
NMMDS.9 On the international front, the ICNP
supports nursing evaluation activities.
The ANA Safety and Quality Initiative ad-
dresses the issues of patient safety and qual-ity of
care. Nursing has a social and profes-sional
responsibility to provide evidence or data that
help to guide and improve care. The ANA has
developed and defined 10 spe-cific quality
indicators of nursing, which were instituted in
the Nursing Care Report Card for Acute Care.23
Under this initiative
290 CHARTERS
the National Database of Nursing Quality In-
dicators promotes the development of stan-
dardized information on nursing quality and
patient outcomes. This instrument is used to
quantify the relationship between nursing and
patient outcomes.24
Nursing Informatics Tools and
Practice Guidelines
The translation of knowledge gained through
analysis of electronic clinical infor-mation into
practice starts with the creation of clinical
practice guidelines.25 On the ba-sis of evidence
gathered and analyzed us-ing NI tools, guidelines
promoting effective and efficient care are
developed. Then NI tools assist in disseminating
and imple-menting the guidelines. Finally, NI
tools are used to evaluate the association between
guideline use and patient outcomes. The findings
provide a focus for quality im-provement
activities.
Information technology provides a vari-ety of
quality implementation tools. Mc-Queen and
McCormick25 recommended a three-pronged
approach in considering au-tomated tools for
guideline implementa-tion. A theory-based
approach fosters ra-tional and scientific decisions
regarding the choice of automated tools. An
active approach to change management is more
effective than passive dissemination of in-
formation. An active approach engages key figures
in the decision-making process. A multipronged
approach uses several diverse guideline
implementation tools simultaneously, with
support from both top-down leaders and
bottom-up champions. Examples of tools useful
in the implementation of guidelines include deci-
sion support systems, automated reminder
systems, profiling or auditing with feed-back to
providers, online communication for information
dissemination and ex-change, electronic patient
record guideline flow sheets, and interactive
computer-as-sisted instruction for education
outreach to providers.25
Once the analysis is complete, findings are
disseminated through a Web site, online journals,
ListServs, chat sessions, e-mail, or the use of
presentation software such as
AACN Clinical Issues
PowerPoint. Word processing and graphics
programs are used to disseminate the find-ings.
Reports to agencies may be submitted online.
Publications end up in bibliographic databases.26
In any event, the research process provides
feedback for use in devel-oping and refining
clinical guidelines.
Translating Research Findings
Into Practice
There is a known gap between the develop-ment
of research-based knowledge and its use in
practice. Increasing accessibility to re-search
reports through computer technology increases
nurses’ use of research findings, enhancing the
diffusion process whereby a new idea is
communicated to members of a community over
time.27 Electronic communi-cation networks
provide a dissemination method that reaches
both researchers and clinicians quickly,
overcomes geographic isolation, provides
relevant literature in one place, presents both
ongoing and completed research in accessible
terminology, and facil-itates dialogue between
researchers and clin-icians and between
researchers and other re-searchers.
As nurses become familiar with Internet
resources and develop skill in navigating the
World Wide Web, they may discover ways to use
this communication tool to enhance their own
work. Rapid dissemination of re-search findings
to a large audience increases the potential for
building mutual beneficial relationships. The
ability to link pages with others gives the work a
broader context. Adaptations of clinical
guidelines for specific settings can be shared,
creating extended in-formation resources.28
Facilitating Collaboration
A new paradigm for supporting patient out-
comes research is a “collaboratory,” which is a
virtual administrative meta-laboratory con-
necting several sites and tools with team
members.29 Team members communicate
electronically using the Internet and the World
Wide Web. The collaboratory pro-vides an
opportunity for nurse administra-tors to
communicate and collaborate in
Vol. 14, No. 3 August 2003
strategic planning, problem solving, and out-
comes research without regard to geo-graphic
location. Virtual cooperative work is based on
trust, which must be developed between team
members. The benefits of a collaboratory include
improving ties be-tween team members,
promoting diversity, enabling collaboration
between administra-tors and researchers in
diverse areas, and de-veloping and disseminating
new knowledge. Building a collaboratory is a
social and tech-nological event as well as a
scientific en-deavor. The process of building a
collabora-tory is a quality improvement
initiative.30
Support for Healthcare
Consumers
Information resources used to collect, process,
and disseminate healthcare infor-mation
encompass clinical information sys-tems,
knowledge acquisition tools, knowl-edge bases,
decision support systems, and education systems
for both providers and healthcare consumers.31
One evolving infor-matics branch is Consumer
Health Informat-ics, which focuses on health
information sys-tems specifically designed for use
by the public.32 For example, an online support
group for head injury victims and their care-
givers, moderated by a nurse, provides health
information to healthcare consumers.
Evaluating the Effect of
Technology on Healthcare
Information technology used to improve
healthcare also requires evaluation. Technol-ogy
assessment is one way to evaluate out-comes.
The most comprehensive technology
assessments directly evaluate health and eco-
nomic outcomes. For example, evaluation of an
electronic reminder system used to screen for a
specific disease may examine the mor-tality and
morbidity rates for that disease as well as the cost
of the system. In assessing the outcomes of an
intervention, the impor-tance of patients’
preferences may be consid-ered as part of a
third-stage technology assessment. A third-stage
technology assess-ment demonstrates both the
efficacy and the cost effectiveness of a system.
Outcome mea-
INFORMATICS, OUTCOMES, AND QI 291
sures may include the number of lives saved, life-
years saved, quality-adjusted life years saved,
cases of disease prevented, and cases of disease
averted. The goal is to demon-strate that a
beneficial change in the process of healthcare led
to improved health out-comes.33 Advanced
practice nurses are most effective in creating
change to improve health outcomes when the
change is made in alignment with the enterprise
strategic plan.
Strategic Planning
Strategic planning allows an organization to align
its mission, vision, goals, and objec-tives with the
use of resources and expendi-ture of effort.
Information systems are tools for helping
healthcare organizations to achieve their goals
and objectives. Without an information system
plan that guides the information system and
helps the organiza-tion to use the information
system to achieve its business strategies, “the
organization will not be able to effectively meet
its overall goals.”34(p103) It is essential that
information system strategies be congruent and
synergis-tic with the overall strategies of an
organiza-tion. Investment in infrastructure
support should be according to priorities set by
the strategic plan.35 In the dynamic environment
of healthcare, integration that maximizes in-
formation flow is the challenging but critical
factor in the designing of information infra-
structure. Strategic planning identifies the need
for standards to achieve the desired in-formation
flow.36,37 Nursing informatics has a role in
defining strategies, both as a voice for the needs
of those using these systems and as a
technologically knowledgeable evalua-tor of
potential solutions.
As healthcare organizations evolve into
integrated delivery networks, they become
knowledge based. An integrated delivery network
must be able rapidly to gather, com-municate,
analyze, and act on enterprise-wide information.
Clinical integration is the extent to which patient
care services are co-ordinated across the
enterprise. “[C]linical in-tegration is the key to
providing seamless care across the continuum
and the basis of all integrated delivery system
efforts.”38(p199) Coordinated clinical efforts result
in the total integration of illness and wellness
services.
292 CHARTERS
“Efforts to reengineer and redesign work-flow
must occur concurrently with the devel-opment
and implementation of new infor-mation
systems.”38(p73) Douglas38 depicted the similarities
between the nursing process and the classic
systems development life cy-cle. Both the nursing
process and healthcare information systems use a
problem-solving approach to achieve the goal of
improving healthcare delivery.
Case Study
An organization decides to move from pa-per-
based clinical documentation to an elec-tronic
clinical information system. A commit-tee is
appointed to determine the functional
requirements for the new system. The com-
mittee has both information technology staff and
healthcare providers as members. Great care is
taken to have a representative from each group
that will use or support the new system. An
advanced practice nurse volun-teers to be on the
committee to influence the selection process.
The advanced practice nurse wants to improve
healthcare quality, but is hampered when doing
chart reviews by the incomplete documentation.
The advanced practice nurse advises the
committee to add a requirement that the vendor
must provide the NIDSEC evaluation of the
clinical information system under con-sideration.
This is congruent with the enter-prise strategic
plan, which aims to improve documentation of
patient status to aid in pre-dictive modeling for
staffing. The nursing shortage has greatly
affected the organiza-tion, and the strategic plan
seeks to mitigate the limitation by understanding
the relation between quality of care and patient
out-comes. The advance practice nurse wants to
show the unique contribution of nurses to
healthcare outcomes. However, there is not
enough data to support this because of in-
consistent or incomplete documentation by some
nurses.
The committee completes the require-ments
analysis and does a cost-benefit study. This study
finds that the clinical information system will
help the organization fulfill its mission and will
pay for itself in 3 years. The Board of Directors
gives approval for the committee to proceed with
a request for pro-
AACN Clinical Issues
posals. The advanced practice nurse helps to
write the evaluation and acceptance criteria,
making sure that the nursing process docu-
mentation capability is heavily weighted.
When vendors respond to the request for
proposals, the selection committee narrows the
choice down to two finalists. The ad-vanced
practice nurse, as a member of the evaluation
team, takes part in the vendor demonstrations
and visits two sites using the systems under
consideration. The advance practice nurse
assesses the ability of each clinical information
system to document pa-tient problems, nursing
interventions, and patient outcomes. Then the
advance practice nurse asks the staff at each site
using the clinical information system to show
how the system at the site reports and aggregates
that data. Both clinical information systems pro-
vide documentation capability, but clearly only
one has the capability of exporting the data in a
useful way. The clinical information system with
the best reporting capability is selected as the
best fit with the functional re-quirements.
The advance practice nurse helps to plan the
implementation, taking an active role in designing
the training the nursing staff will receive in the
use of the new system. The system’s capability to
document does not mean that the nursing staff
will use that ca-pability. Educating the nursing
staff about the value of timely, accurate,
complete doc-umentation must be part of the
training. For-tunately, because this is essential for
the strategic plan to succeed, there is high-level
support for this training.
The implementation team does a baseline
study investigating the completeness of doc-
umentation. The study is repeated 6 months after
implementation of the system. The ad-mission
assessments were 2% complete be-fore
implementation of the clinical informa-tion
system. The study 6 months after
implementation of the clinical information
system shows that the admission assess-ments
are 98% complete. Because patient problems are
well documented, it is possible to analyze the
associated nursing interven-tions and patient
outcomes.
The advance practice nurse discovers that
when the staffing ratio is one nurse to four
surgical patients, the rate of postoperative
complications is significantly lower. The or-
Vol. 14, No. 3 August 2003
ganization adjusts the staffing pattern to achieve
this ratio, and finds that nurses are attracted to
working for the organization. The clinical
information system allowed the nursing staff to
document the difference they made in patient
outcomes, and this informa-tion was used to
change the staffing pattern. The change
improved the quality of care, and the high level
of quality attracted nurses at a time when other
organizations were ex-periencing a significant
shortage. This met the enterprise strategic plan
goal to improve documentation of patient status,
to aid in predictive modeling for staffing, and to
help the organization cope with the nursing
shortage.
Summary
Nursing informatics provides tools for im-
proving healthcare. Standard classification
systems and terminologies capture relevant data
and identify outcomes as a by-product of nursing
documentation. The use of stan-dard
classification systems and vocabularies allows
comparison both within and across healthcare
delivery systems, nationally and internationally.
Electronically linking out-comes to interventions
to assessments facili-tates planning and
evaluation of healthcare. This, in turn, identifies
opportunities for quality improvement. Nursing
informatics supports changes in nursing practice
by pro-viding data, information, and knowledge
about cost effectiveness, outcome-focused care,
and evidence-based decision making.
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