LWW/NAQ NAQ-D-15-00019 September 3, 2015 20:16

Nurs Admin Q
Vol. 39, No. 4, pp. 304–310
Copyright c 2015 Wolters Kluwer Health, Inc. All rights reserved.

Nursing Knowledge
Big Data Science—Implications
for Nurse Leaders
Bonnie L. Westra, PhD, RN, FAAN, FACMI;
Thomas R. Clancy, PhD, MBA, RN, FAAN;
Joyce Sensmeier, MS, RN-BC, CPHIMS, FHIMSS, FAAN;
Judith J. Warren, PhD, RN, FAAN, FACMI;
Charlotte Weaver, PhD, RN, FAAN;
Connie W. Delaney, PhD, RN, FAAN, FACMI

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. Key words: Big Data, data analysis, informatics, knowledge engineering,
leadership, standardized data

T HE “Big Data”/“Data Science” messages

and initiatives permeate all aspects of the
nursing profession—practice, education, and
Author Affiliations: School of Nursing, University
of Minnesota, Minneapolis (Dr Westra); School of
Nursing, University of Minnesota, Minneapolis
(Dr Clancy); Health Information Management
Systems Society, Chicago, Illinois (Ms Sensmeier);
School of Nursing, The University of Kansas,
Lawrence, and Warren & Associates, LLC,
Plattsmouth, Nebraska (Dr Warren); School of
Nursing, University of Minnesota, Minneapolis (Dr
Delaney); and Healthcare Executive and Board
Member (Dr Weaver).
The authors declare no conflict of interest.
Correspondence: Bonnie L. Westra, PhD, RN, FAAN,
FACMI, School of Nursing, University of Minnesota, 308
Harvard St SE, WDH 5-140, Minneapolis, MN 55434
(westr006@umn.edu).
DOI: 10.1097/NAQ.0000000000000130
scholarship.1 Some professional may won-
der why there appears to be a considerable
amount of duplication of similar or identical
messages. Some individuals may be discover-
ing these messages for the first time; others
may be bored by the repetition. However, rep-
etition, or the truth effect, can be important
because people tend to believe information to
be correct when they are exposed to it multi-
ple times.2
The reality and import of the Big Data rev-
olution is a result of a mandate for transpar-
ent, knowledge supported practice, as well
as transparent, knowledge-driven education,
and discovery (scholarship). Both of these
are underpinnings of practice excellence. Big
Data revolution is driven by the availability
of technological capacity to support human
thought. It is essential because knowledge is

304

Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LWW/NAQ NAQ-D-15-00019 September 3, 2015 20:16
doubling every 12 months and is predicted to
soon double every 12 hours.3 The context for
our care, management of care, and ensuring
safety, quality, patient experience, and effi-
cient use of resources have transitioned from a
process depending on the linear growth of hu-
man knowledge to the exponential growth of
human knowledge.4 Big Data and Big Data sci-
ence have moved beyond the tipping point.5,6
Nursing has been preparing and contribut-
ing to this revolution for decades through
establishing nursing’s presence in national
standards through electronic health records
(EHRs). Nursing has been participating in a
plethora of regional and national networks
devoted to teaming together, data sharing,
and transparency of knowledge discovery.7-9
Nursing executive leadership is permeated
with “Big Data” messages and resources.1,10,11
Nursing leaders need to be knowledgeable,
proactive, and engaged in establishing effi-
cient ways to capture, integrate, and use Big
Data.
WHAT IS BIG DATA?
Big Data refers to high volume or complex
data that originates from a variety of sources.
When analyzed, it can lead to discovering new
knowledge.12,13 Typical examples of Big Data
sources in health care include EHRs; devices
such as intravenous pumps or electrocardio-
graphic monitors; the science of genomics;
and patient-generated data. Big Data includes
information about patients, the environment,
and administrative and claims data. The con-
tinuous integration of health systems provides
an increasing volume of data for nurse execu-
tives for support of decision making. As data
amass, newer methods of science are emerg-
ing to transform data into information and
knowledge.14 This can happen only if the data
are standardized and captured in consistent
ways to create decision support tools, such as
dashboards. It is critical for nursing leaders to
understand structured data and processes that
support analytic methods to control costs and
improve patient quality and safety.
The shift in care delivery from the hospi-
tal to the community increases the number of
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Nursing Knowledge 305
sources for data. It also increases the need to
create actionable information and knowledge
from the integration of traditional and non-
traditional data. In estimating needs for the
future workforce, the Department of Health
& Human Services estimated an oversupply of
nurses but quickly pointed out,
While not considered in this study, emerging care
delivery models, with a focus on managing health
status and preventing acute health issues, will likely
contribute to new growth in demand for nurses,
e.g., nurses taking on new and/or expanded roles
in preventive care and care coordination.15
This report, in part, highlights the ongoing
impact of mobile health on where patient care
is delivered. For example, although the total
number of nurses working in hospitals has
increased, the proportion of the total regis-
tered nurse workforce in acute care declined
from 67% in 1993 to 61% in 2014.16 A portion
of this redistribution has likely resulted from
the substitution of acute care with outpatient
clinic or home care. This has been and will be
further enabled by new mobile technology.
There has been a virtual explosion in mo-
bile health applications in the last 10 years.
These include implantable monitors (cardiac
and insulin), wearable technology (activity
and sleep monitors), augmented cognition
(symptom checkers), and the intranet of
things (smart homes and fall prevention car-
pets). Collectively, mobile health applications
will dramatically change where health care
will be delivered and how nurses will provide
it. In many cases, care provided in acute care
hospitals today will be safely administered in
the home due, in part, to the evolution of
mobile technology. The contribution of data
science, knowledge engineering, and knowl-
edge value to the success of these mobile
health applications and the integration of the
data with traditional health care data is often
overlooked.
NURSING KNOWLEDGE: BIG DATA
SCIENCE NATIONAL ACTION PLAN
Since 2013, the University of Minnesota
School of Nursing has partnered with diverse
LWW/NAQ NAQ-D-15-00019 September 3, 2015
306 NURSING ADMINISTRATION QUARTERLY/OCTOBER–DECEMBER 2015
stakeholders from practice, industry, educa-
tion, research, and professional organizations
through the “Nursing Knowledge: Big Data
Science” conferences to create and act on rec-
ommendations for inclusion of nursing data,
integrated with patient-generated and inter-
professional data.17 The intent of the national
action plan is to harmonize siloed and often
duplicative efforts to integrate nursing data
within Big Data initiatives and effectively use
it to transform health care while improving
quality and patient safety. In 2013, an invita-
tional conference was convened to begin this
effort. This was followed by a 2014 confer-
ence with expanded participation, where the
national agenda was enhanced with the for-
mation of 10 project teams to begin work for
the next year.18 These project teams focused
on education, practice, policy and incentives,
and research. In 2015, the emphasis shifted to-
ward identifying the value of Big Data, engag-
ing nursing leadership, and highlighting nurs-
ing informatics science. The foundation of ef-
fective implementation of nursing data within
the context of interprofessional and patient-
generated data was continued. There is ongo-
ing recognition that nursing leadership must
understand the value of Big Data and support
the effort needed to effectively capture and
use Big Data and emerging Big Data science
methods.
VALUE OF NURSING DATA
The collection and analysis of data is foun-
dational to the creation of information, knowl-
edge, and wisdom, as well as understanding
the impact of nursing care. There is little, if
any, relationship between nursing data and re-
imbursement. As a result, its value has been
ignored and devalued, although nurses spend
28% of their time documenting.19 Nurses are
closer to the patient than any other health care
provider and they value the patient’s stories.20
Patient stories describe how patients and
their families manage their health care issues.
While the capture of the story is part of the
art and caring of nursing, the information
collected and used to provide care is nurs-
ing science. Nursing documentation should
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
20:16
capture the essence of these patient stories
and nursing interventions to improve care
and enhance outcomes. Elements of patient
stories include (1) engagement in activities
of daily living and instrumental activities of
daily living; (2) availability of family, care-
givers, finances, and safe environment; (3)
knowledge, understanding, and strategies to
integrate therapies into unique lifestyles; and
(4) the mental and emotional state effects of
health and the management of therapy.
These elements are phenomena that
nurses address every day. Data collected
from thousands of patient stories could
provide information on the importance of
nursing to individual’s health, wellness, and
healing. Differences between organizations
that support the collection and analysis of
patient stories and those that do not would
be a valid area for health care research.
Documentation in the EHR needs to sup-
port the patient story in a way that the nurse
can apprehend and integrate it with interpro-
fessional and patient generated data. It’s im-
portant that this is done in an efficient way
that balances time spent on care and time
spent on documentation. The contribution of
nursing with unique patient stories enhances
the nurse’s ability to care for the patient in
what should be labeled “Personalized Nurs-
ing.” This would complement what Medicine
is already exploring: the use of Big Data, in-
cluding the analysis of genetic information, to
create personalized medicine.21
New questions for Big Data science are as
follows: Who gathers the data and makes it
available to the nurse? How can nurses be ed-
ucated to make sense of, and use, this enor-
mous amount of data?
STANDARDIZATION OF NURSING DATA
The phenomenon of “data rich and infor-
mation poor” (DRIP) in today’s EHRs and
other information systems is all too often
the reality for nursing. Despite the fact that
nursing documents more than any other
health professional in acute care organiza-
tions, nurses get back a negligible amount of
LWW/NAQ NAQ-D-15-00019 September 3, 2015 20:16
information to help inform their practices or
to know their patients’ quality outcomes.22
Data from EHRs should facilitate system-
atic learning and research at the point of
care from routine documentation for better
understanding of patient outcomes and costs
of care.23 The promise of creating informa-
tion and knowledge from electronic clinical,
financial, and administrative data require stan-
dardization of the processes and content of
nursing and interprofessional data. Big Data
science is not possible if every organization
collects the same data in different ways and
with different terminologies.
Syntactic and semantic harmonization
is needed. Syntactic harmonization is the
grammar of data—the rules, principles, and
processes that govern the structure of data.
Without syntax, it is hard to understand
the relationships between concepts. Are
they actions, descriptions, or modifiers?
Semantic harmonization describes the mean-
ing/interpretation of the concepts, or the
terminology, of what is being documented.
The field needs agreement on the relation-
ships and meaning of critical (to the patient,
not reimbursement) value sets (answers)
to be used in documentation. The value
sets must align with decision support rules,
eMeasures for quality reporting, regulatory
requirements, staffing decisions, and many
other important efforts. Also needed is agree-
ment on the best practices about workflow,
the relationship of workflow to data capture,
how to embed structured and standardized
terminology, examples of clinical decision
support embedded in the nurse’s workflow,
and how to do data aggregation in support of
sharing patient outcomes at a clinician, unit,
department, and organizational level.24
SCIENCE AND POTENTIAL OF BIG DATA
SCIENCE
The formation of large electronic reposito-
ries of health care data, often referred to in
the media as “Big Data,” has provided oppor-
tunities for data scientists to discover “knowl-
edge value.”25 Knowledge value is often rep-
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Nursing Knowledge 307
resented as patterns in the data that can be
translated into algorithms that can either de-
scribe or predict a health event. For example,
mobile symptom checker applications use al-
gorithms created from EHR data repositories
to classify specific disease conditions on the
basis of a combination of symptoms, diagnos-
tic tests, and a patient’s medical history. Pads
laced with optic fibers, and called “magic car-
pets” recognize patterns in a patient’s gait that
can predict the probability of a fall. Stream-
ing data from implantable cardiac sensors are
used to identify subtle patterns of approach-
ing heart failure. When these sensors and soft-
ware applications are used in combination,
they can predict a health event. They may
also be able to intervene and prevent it.
The use of advanced computational meth-
ods to create knowledge value is referred to
as knowledge engineering.25 Commonly used
methods include machine learning, decision
trees, association rules, artificial neural net-
works, support vector machines, clustering,
Bayesian networks, and genetic algorithms.
Although it is not necessary for nurse ad-
ministrators to know the details of these meth-
ods, it is important to know that knowledge
engineering and the creation of knowledge
value indirectly impact the delivery of nursing
care by advancing mobile technology. This in
turn is redistributing where care is delivered
by moving it out of the hospital and into out-
patient clinics and the home.
RECOMMENDATIONS FOR NURSING
LEADERS
There were a number of transformative rec-
ommendations from the Nursing Knowledge:
Big Data Science conference pertinent to the
goal of having “Big Data” available to nurs-
ing clinicians, managers, and executives. The
first is to leverage expertise in best practices
for nursing information systems by provid-
ing a mechanism for collecting, posting, and
housing clinical documentation workflows,
clinical decision system support tools, maps
of nursing documentation and terminologies
to national standards, and data queries and
LWW/NAQ NAQ-D-15-00019 September 3, 2015
308 NURSING ADMINISTRATION QUARTERLY/OCTOBER–DECEMBER 2015
reports (J. Moss, B. Weiner, R, Kennedy, and
C. A. Weaver, unpublished data, 2014). The
American Nurses Association26 recommends
use of any of its recognized terminologies, but
for exchange of data (and Big Data science), it
recommends 2 terminologies consistent with
meaningful use requirements: Logical Obser-
vation Identifiers Names and Codes for nurs-
ing assessments and the Systematized Nomen-
clature of Medicine—Clinical Terminology for
problems, and interventions.
The second recommendation for nursing
leaders is that they sponsor, support, and
require nursing informaticians doing clini-
cal system builds and maintenance to have
the knowledge and skills to integrate stan-
dard terminologies and to map to System-
atized Nomenclature of Medicine—Clinical
Terminology and Logical Observation Identi-
fiers Names and Codes.27 Together with the
first recommendation, this forms the building
blocks to allow current EHR systems to pro-
vide structured, standardized data in support
of aggregating, querying, and reporting back
on key nursing data for outcomes, while gen-
erating new best practice knowledge. As the
health care system moves toward reimburse-
ment on the basis of quality outcomes and
prevention, the value of nursing data in this
business proposition will become a key differ-
entiator for a health care organization’s eco-
nomic success.
RESOURCES IMPORTANT TO NURSE
LEADERS
A Big Data checklist for chief nurse
executives was developed by a work group
established during the 2014 Nursing Knowl-
edge: Big Data & Science for Transforming
Health Care Conference. Its purpose is to
help facilitate progress toward a learning
health system.18 Nurse executives should
understand how to extract meaningful
insights from Big Data in order to transform
health care, while improving clinical opera-
tions, care quality, cost-effectiveness, patient
safety, and outcomes. Big Data can support
improved decision making by offering a more
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
20:16
comprehensive and synthesized understand-
ing of health data across populations. It can
also help identify nursing and organizational-
related impacts. The Big Data Checklist
emphasizes the need to create a data culture
wherein nursing, clinical, and operational
decisions are based on data, and these data
are used consistently across the enterprise.
Competencies for nurse leaders in the use
of Big Data are needed to enhance strategic
decision making and support system agility.
In addition, the understanding and use of
analytical skills is a necessary competency for
nurse leaders in informatics-related roles.26
New strategies are being developed to
measure the value of nursing.28 Business
intelligence and analytics tools will uti-
lize the rich clinical, operational, financial,
and quality/safety outcome data currently
available to measure and compare nursing
value. Nursing financial models are emerg-
ing to bring transparency to support the risk-
sharing approach used within accountable
care organizations,10 value-based purchasing,
and pay-for-performance models. Value-based
metrics that can be leveraged include direct
and indirect nursing costs per patient per day,
average direct and indirect nursing intensity
costs per patient per case, patient-level qual-
ity metrics tied to actual care hours and costs,
individual nurse-/staff-/unit-level productivity,
and summary of patient-level data by unit or
cost center. One proposal is that a value-based
model will use analytics and metrics to assess
patient-level measures.
In response to recommendations by the
Health Information Management Systems So-
ciety CNO-CNIO Vendor Roundtable, the Big
Data Principles Workgroup was established.
This Workgroup developed the Guiding
Principles for Big Data in Nursing10 to
identify Big Data principles, barriers, and
challenges; develop a framework for uni-
versal requirements; identify differences in
the context of nursing outcomes; address
the impact of health information technology
system versions/configurations; analyze the
variation in quality measures; and discuss im-
plementation challenges. Through this effort,
LWW/NAQ NAQ-D-15-00019 September 3, 2015 20:16
4 key principles were identified that under-
score Big Data: privacy and security of health
information, data standards, interoperability,
and immutability. Recommendations to
advance these principles derive from the
following key areas: promotion of standards
and interoperability; advancement of quality
eMeasures; and leveraging of nursing infor-
matics experts. Each of these emergent efforts
accentuates that Big Data offers the potential
to accelerate the synthesis of new knowledge
to make a positive impact on nursing as
well as the individuals and populations we
serve.
CONCLUSION
The time is now for nurses to embrace
the notion of Big Data and Big Data science.
REFERENCES
1. Keenan G. Big data in health care: an urgent mandate
to CHANGE nursing EHRs. Online J Nurs In-
form. 2014;18(1). http://www.himss.org/Resource
Library/GenResourceDetail.aspx?ItemNumber=28968.
Accessed June 15, 2015.
2. Hasher L, Goldstein D, Toppino T. Frequency and
the conference of referential validity. J Verbal Learn
Verbal Behav. 1977;16:107-112.
3. Shilling DR. Knowledge doubling every 12
months, soon to be every 12 hours. Industry Tap.
http://www.industrytap.com/knowledge-doubling-
every-12-months-soon-to-be-every-12-hours/3950.
Published April 19, 2013. Accessed June 15, 2015.
4. Jellyvision Lab. Understanding the growth of
information. http://www.jellyvision.com/resources/
understanding-growth-information/. Updated 2015.
Accessed June 1, 2015.
5. Groves P, Kayyali B, Knott D, Van Kuiken S. The
big-data revolution in healthcare: accelerating value
and innovation, center for US health system reform:
business technology office, McKinsey&Company.
www.mckinsey.com/insights/health_systems_and_
services/the_big-data_revolution_in_us_health_care.
Updated 2013. Accessed June 1, 2015.
6. How big data impacts healthcare. Harvard Busi-
ness Review. https://hbr.org/resources/pdfs/comm/
sap/18826 HBR SAP Healthcare Aug 2014.pdf. Pub-
lished August 2014. Accessed June 15, 2015.
7. National Center for Advancing Translational Sci-
ences. Clinical and translational science awards. http:
//www.ncats.nih.gov/ctsa. Updated 2015. Accessed
June 1, 2015.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Nursing Knowledge 309
Nurses need to ensure that the right data are
collected in an interoperable format to sup-
port data analysis. They need to develop data
analytic skills to make meaning of the data
residing in these very large databases. These
data need to flow not only from EHRs but also
from the newer mobile applications, such as
smart phone applications. Armed with large
amounts of data from a variety of sources,
nurses will have the ability to demonstrate the
impact of nursing care on patient outcomes.
As we move from a fee-for-service to a value-
based system for reimbursement of patient
care (the long-term goal of meaningful use),
the information and knowledge from the anal-
ysis of nurse-generated data will make a differ-
ence. Nurses need to embrace a data gather-
ing and analyzing form of practice in this new
knowledge worker world.
8. Optum Labs. Driven by data, powered by people.
https://www.optum.com/optumlabs.html. Updated
2015. Accessed June 1, 2015.
9. National Institute of Nursing Research. NINR big data
in symptoms research boot camp. https://www.ninr
.nih.gov/training/trainingopportunitiesintramural/
bootcamp#.VWxnP5NUduJ. Updated 2015. Ac-
cessed June 1, 2015.
10. HIMSS. Guiding principles for big data in nursing:
Using big data to improve the quality of care and out-
comes. HIMSS CNO-CNIO vendor roundtable. http:
//www.himss.org/big10. Updated 2015. Accessed
June 1, 2015.
11. The TIGER Initiative Foundation. The leader-
ship imperative: TIGER’s recommendations for
integrating technology to transform practice
and education. http://thetigerinitiative.org/docs/
TIGERInitiatiaveFoundationReportTheLeadership
Imperative.pdf. Accessed June 1, 2015.
12. Bates DW, Saria S, Ohno-Machado L, Shah A, Esco-
bar G. Big data in health care: using analytics to
identify and manage high-risk and high-cost patients.
Health Aff (Millwood). 2014;33(7):1123-1131. doi:
10.1377/hlthaff.2014.0041.
13. Bates DW, Wells S. Personal health records and health
care utilization. JAMA. 2012;308(19):2034-2036. doi:
http://dx.doi.org/10.1001/jama.2012.68169.
14. Murdoch TB, Detsky AS. The inevitable application
of big data to health care. JAMA. 2013;309(13):1351-
1352. doi: 10.1001/jama.2013.393.
15. US Department of Health & Human Services, Health
Resources and Services Administration, National
LWW/NAQ NAQ-D-15-00019 September 3, 2015
310 NURSING ADMINISTRATION QUARTERLY/OCTOBER–DECEMBER 2015
Center for Health Workforce Analysis. The Future of
the Nursing Workforce: National- and State-Level
Projections, 2012-2025. Rockville, MD: 2014.
16. Bureau of Labor Statistics, US Department of La-
bor,. Occupational outlook handbook, 2014-15 edi-
tion, registered nurses. http://www.bls.gov/ooh/
healthcare/registered-nurses.htm. Updated 2014. Ac-
cessed May, 2015.
17. Westra BL, Latimer GE, Matney SA, et al. A national
action plan for sharable and comparable nursing data
to support practice and translational research for
transforming health care. J Am Med Inform Assoc.
2015;22:600-607.
18. University of Minnesota School of Nursing. Proceed-
ings of the Conference: Nursing Knowledge: Big Data
and Science for Transforming Health Care; June 5–6,
2014; Minneapolis, MN. http://www.nursing.umn.
edu/prod/groups/nurs/@pub/@nurs/documents/
content/nurs content 482402.pdf. Accessed June
15, 2015.
19. Hendrich A, Chow MP, Skierczynski BA, Lu
ZA. 36-hosptial time and motion study: how do
medical-surgical nurses spend their time? Perm J.
2008;12(3):25-34.
20. Hull S. Enhance patient engagement through sharing.
Am Nurs Today Suppl. 2015:6-7.
21. Personalized Medicine Coalition. The age of per-
sonalized medicine. http://www.ageofpersonalized
medicine.org/what_is_personalized_medicine/. Ac-
cessed June 1, 2015.
22. Yee T, Needleman J, Pearson M, Parkerton P, Park-
erton M, Wolstein J. The influence of integrated
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
20:16
electronic medical records and computerized nurs-
ing notes on nurses’ time spent in documenta-
tion. Comput Inform Nurs. 2012;30(6):287-292. doi:
10.1097/NXN.0b013e31824af835.
23. Payne TH, Corley S, Cullen TA, et al. Report of the
AMIA EHR 2020 task force on the status and future
direction of EHRs. J Am Med Inform Assoc. [pub-
lished online ahead of print May 29, 2015]. doi:
10.1093/jamia/ocv066.
24. Bowles KH, Potashnik S, Ratcliffe SJ, et al.
Conducting research using the electronic health
record across multi-hospital systems: seman-
tic harmonization implications for administra-
tors. J Nurs Adm. 2013;43(6):355-360. doi:
10.1097/NNA.0b013e3182942c3c.
25. Canton J. Future Smart: Managing the Game
Changing Trends That Will Transform Your World.
Philadelphia, PA: De Capo Press; 2015.
26. American Nurses Association. Nursing Infor-
matics: Scope and Standards of Practice. 2nd
ed. Silver Spring, MD: Nursesbooks.org; 2015.
http://www.nursesbooks.org/Main-Menu/eBooks/
eStandards/ebook-Nursing-Informatics-2nd-Ed.aspx.
Accessed June 15, 2015.
27. Byrne MD, Lang N. Examination of nurs-
ing data elements from evidence-based recom-
mendations for clinical decision support. Com-
put Inform Nurs. 2013;31(12):605-614. doi:
10.1097/CIN.0000000000000013.
28. Welton JM, Harper EM. Nursing value-based fi-
nancial models. Nurs Economic$. 2015;33(1):
14-19.