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 Essentials of
Nursing
Informatics

FM.indd 1 27-10-2020 14:03:57

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 Essentials of
Nursing
Informatics
SEVENTH EDITION

Virginia K. Saba, EdD, RN, FAAN, FACMI

CEO and President
SabaCare, Inc.
Arlington, Virginia
Distinguished Scholar, Emeritus
Georgetown University
Washington, District of Columbia
Professor, Adjunct
Uniformed Services University
Bethesda, Maryland

Kathleen A. McCormick, PhD, RN, FAAN, FACMI, FHIMSS

Principal/Owner
SciMind, LLC
North Potomac, Maryland

New York • Chicago • San Francisco • Athens • London • Madrid • Mexico City
Milan • New Delhi • Singapore • Sydney • Toronto

FM.indd 3 27-10-2020 14:03:58

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 CONTENTS

Contributors ix 9 Human–Computer Interaction • 153

Foreword xix
Preface xxi
Acknowledgments xxiii
Part 1 — Nursing Informatics
Technologies 1
Carol J. Bickford and Marisa L. Wilson
1 Historical Perspectives of Nursing
Informatics • 3
Virginia K. Saba / Bonnie L. Westra / Juliana J. Brixey
2 Computer Systems Basics—Hardware • 29
Mary L. McHugh
3 Advanced Hardware and mHealth • 45
David J. Whitten / Kathleen G. Charters
4 Computer Systems Basics—Software • 57
Mary L. McHugh
5 Open Source and Free Software • 69
David J. Whitten
6 Data and Data Processing • 101
Irene Joos / Cristina Robles Bahm / Ramona Nelson
Part 2 — System Standards 119
Virginia K. Saba and Joyce Sensmeier
7 Health Data Standards: Development,
Harmonization, and Interoperability • 121
Joyce Sensmeier
8 Standardized Nursing Terminologies • 137
Jane Englebright / Nicholas R. Hardiker / Tae
Youn Kim
Gregory L. Alexander
10 Trustworthy Systems for Safe and Private
Healthcare • 163
Dixie B. Baker
11 Social Determinants of Health, Electronic
Health Records, and Health Outcomes • 181
Marisa L. Wilson / Paula M. Procter
Part 3 — System Life Cycle 193
Denise D. Tyler
12 System Design Life Cycle: A Framework • 195
Susan K. Newbold
13 System and Functional Testing • 219
Theresa (Tess) Settergren / Denise D. Tyler
14 System Life Cycle Tools • 235
Denise D. Tyler
Part 4 — Informatics Theory
Standards 251
Virginia K. Saba
15 Healthcare Project Management • 253
Barbara Van de Castle / Patricia C. Dykes
16 The Practice Specialty of Nursing
Informatics • 265
Carolyn Sipes / Carol J. Bickford
17 Foundations of Nursing Informatics • 287
Sarah Collins Rossetti / Susan C. Hull / Suzanne
Bakken

FM.indd 5 27-10-2020 14:03:59

 vi C ontents
Part 5 — Policies and Quality Measures
in Healthcare 317
Kathleen Smith
18 Establishing Nursing Informatics
in Public Policy • 319
Rebecca Freeman / Allison Viola
19 Quality Measurement and the Importance
of Nursing Informatics • 329
Jean D. Moody-Williams
20 Using Six Sigma and Lean for Measuring
Quality • 341
Evelyn J. S. Hovenga / Lois M. Hazelton / Sally R. Britnell
21 Informatics Applications to Support Rural
and Remote Health • 355
Amy J. Barton
22 Communication Skills in Health IT,
Building Strong Teams for Successful Health
IT Outcomes • 363
Elizabeth (Liz) Johnson / Karen M. Marhefka
23 Nurse Scheduling and Credentialing
Systems • 381
Karlene M. Kerfoot / Kathleen Smith
24 Mastering Skills that Support Nursing
Practice • 393
Melissa Barthold †
Part 6 — Nursing Practice Applications 403
Heather Carter-Templeton
25 Translation of Evidence into Nursing Practice • 405
Heather Carter-Templeton
26 Improving Healthcare Quality and Patient
Outcomes Through the Integration of
Evidence-Based Practice and Informatics • 423
Lynda R. Hardy / Bernadette Mazurek Melnyk
27 Nursing Plan of Care Framework for HIT • 441
Luann Whittenburg / Avaretta Davis
Author deceased
†
FM.indd 6
28 Structuring Advanced Practice Knowledge:
Curricular, Practice, and Internet
Resource Use • 455
Mary Ann Lavin
29 Beyond EMR Implementation: Optimize and
Enhance • 481
Ellen Pollack
30 Federal Healthcare Sector Nursing
Informatics • 493
Stephanie J. Raps / Margaret S. Beaubien / Christine Boltz /
Michael E. Ludwig / Chris E. Nichols / Gerald N. Taylor /
Susy Postal
31 Monitoring Interoperability, Device Interface,
and Security • 507
R. Renee Johnson-Smith / Jillanna C. Firth
32 Population Health Informatics • 521
Karen A. Monsen
33 Informatics Solutions for Emergency Planning
and Response • 535
Elizabeth (Betsy) Weiner / Lynn A. (Slepski) Nash
34 Health Information Technology: Striving
to Improve Patient Safety • 553
Patricia P. Sengstack
35 Consumer Patient Engagement and
Connectivity in Patients with Chronic Disease
in the Community and at Home • 567
Hyeoun-Ae Park / Naoki Nakashima / Hu Yuandong /
Yu-Chuan (Jack) Li
Part 7 — Advanced Applications for the
Fourth Nursing IT Revolution 583
Kathleen A. McCormick
36 New Models of Healthcare Delivery
and Retailers Producing Big Data • 587
Susan C. Hull
37 Artificial Intelligence in Healthcare • 605
Eileen Koski / Judy Murphy
27-10-2020 14:03:59

38 Telehealth: Healthcare Evolution
in the Technology Age • 615
Teresa A. Rincon / Mark D. Sugrue
39 Nursing’s Role in Genomics and Information
Technology for Precision Health • 635
Kathleen A. McCormick / Kathleen A. Calzone
40 Big Data Analysis of Electronic
Health Record (EHR) Data • 653
Roy L. Simpson
41 Nursing Data Science and Quality
Clinical Outcomes • 663
Lynn M. Nagle / Margaret A. Kennedy / Peggy A. White
42 Nursing Informatics Innovations to Improve
Quality Patient Care on Many Continents • 677
Kaija Saranto / Ulla-Mari Kinnunen / Virpi Jylhä /
Pia Liljamo / Eija Kivekäs
43 Global eHealth and Informatics • 693
Hyeoun-Ae Park / Heimar F. Marin
Part 8 — Educational Applications
Diane J. Skiba
44 Nursing Curriculum Reform and Healthcare
Information Technology • 709
Eun-Shim Nahm / Mary Etta Mills / Marisa L. Wilson
FM.indd 7
Contents vii
45 The Evolution of the TIGER Initiative • 725
Toria Shaw Morawski / Joyce Sensmeier
46 Initiation and Management of Accessible,
Effective Online Learning • 739
Patricia E. Allen / Khadija Bakrim / Darlene Lacy
47 Social Media Tools in the Connected Age • 757
Diane J. Skiba / Sarah Mattice / Chanmi Lee
48 A Paradigm Shift in Simulation: Experiential
Learning in Virtual Worlds and Future Use
of Virtual Reality, Robotics, and Drones • 769
E. LaVerne Manos / Nellie Modaress
Part 9 — Research Applications 791
Veronica D. Feeg
49 Computer Use in Nursing Research • 793
Veronica D. Feeg / Theresa A. Rienzo / Marcia T. Caton /
Olga S. Kagan
50 Information Literacy and Computerized
Information Resources • 825
707 Diane S. Pravikoff / June Levy
Appendix Clinical Care Classification (CCC) System:
Overview, Applications, and Analyses • 843
Virginia K. Saba / Luann Whittenburg
Index • 873
27-10-2020 14:03:59
 This page intentionally left blank

FM.indd 8 27-10-2020 14:03:59

 CONTRIBUTORS

Gregory L. Alexander, PhD, RN, FACMI, FAAN Cristina Robles Bahm, PhD, MSIS
Helen Young CUPHSONAA Professor Assistant Professor
Columbia University Program Coordinator
School of Nursing Chair Computer Science
New York, New York La Roche University
Chapter 9: Human–Computer Interaction Pittsburgh, Pennsylvania
Chapter 6: Data and Data Processing
Patricia E. Allen, EdD, RN, CNE, ANEF, FAAN
Professor Emeritus, Texas Tech University–Health Melissa Barthold,† DNP, MSN, RN-BC, CPHIMSS,
Science Center FHIMSS
School of Nursing Principal
Lubbock, Texas Nursing Informatics Consulting
Chapter 46: Initiation and Management of Cape Coral, Florida
Accessible, Effective Online Learning Chapter 24: Mastering Skills that Support Nursing

Dixie B. Baker, PhD, MS, MS, BS, FHIMSS Amy J. Barton, PhD, RN, FAAN, ANEF
Senior Partner, Martin, Blanck and Associates Professor Daniel & Janet Mordecai Rural Health
Alexandria, Virginia Nursing Endowed Chair
Chapter 10: Trustworthy Systems for Safe College of Nursing
and Private Healthcare University of Colorado Anschutz Medical Campus
Aurora, Colorado
Suzanne Bakken, PhD, RN, FACMI, FIAHSI, Chapter 21: Informatics Applications to Support
FAAN Rural and Remote Health
The Alumni Professor of Nursing and Professor
of Biomedical Informatics Margaret S. Beaubien, MS, MSN, RN, CPHIMS
Columbia University Captain, NC, USN (Retired)
New York, New York Napa, California
Chapter 17: Foundations of Nursing Informatics Chapter 30: Federal Healthcare Sector Nursing
Informatics
Khadija Bakrim, EdD
Educational Technologist Carol J. Bickford, PhD, RN-BC, CPHIMS, FAMIA,
Texas Tech University Health Science Center FHIMSS, FAAN
School of Nursing Senior Policy Advisor
Lubbock, Texas American Nurses Association
Chapter 46: Initiation and Management of Accessible, Silver Spring, Maryland
Effective Online Learning Section Editor—Part 1: Nursing Informatics Technologies
Chapter 16: The Practice Specialty of Nursing Informatics
Author deceased
†

ix

FM.indd 9 27-10-2020 14:03:59

 x C ontributors

Christine Boltz, MA, MS, RN-BC, CPHIMS Marcia T. Caton, PhD, RN

Captain, NC, USN (Retired)/Online Instructor Professor
Excelsior College, School of Nursing Barbara H. Hagan School of Nursing and Health
Alexandria, Virginia Sciences
Chapter 30: Federal Healthcare Sector Nursing Malloy College
Informatics School of Nursing
Rockville Centre, New York
Sally R. Britnell, PhD, RN Chapter 49: Computer Use in Nursing Research
Lecturer
Auckland University of Technology Kathleen G. Charters, PhD, RN
Nursing Department Retired Nursing Informatics Consultant
School of Clinical Sciences Department of Defense
Auckland, New Zealand Sequim, Washington
Chapter 20: Using Six Sigma and Lean for Measuring Chapter 3: Advanced Hardware and mHealth
Quality
Avaretta Davis, DNP, MHS, RN
Juliana J. Brixey, PhD, MPH, RN Deputy Chief Nursing Informatics Officer
Associate Professor Veterans Affairs, Veterans Health Administration
University of Texas Health Science Center Washington, District of Columbia
at Houston Chapter 27: Nursing Plan of Care Framework for HIT
School of Biomedical Informatics
Cizik School of Nursing Patricia C. Dykes, PhD, RN, FACMI, FAAN
Houston, Texas Program Director Research, Center for Patient
Chapter 1: Historical Perspectives of Nursing Safety, Research, and Practice
Informatics Brigham and Women’s Hospital
Associate Professor of Medicine, Harvard Medical
Kathleen A. Calzone, PhD, RN, AGN-BC, School
FAAN Chair, American Medical Informatics Association
Research Geneticist (AMIA), Board of Directors
National Institutes of Health, National Cancer Boston, Massachusetts
Institute, Center for Cancer Research, Genetics Chapter15: Healthcare Project Management
Branch
Bethesda, Maryland Jane Englebright, PhD, RN, CENP, FAAN
Chapter 39: Nursing’s Role in Genomics and Senior Vice President & Chief Nurse Executive
Information Technology for Precision Health HCA Healthcare
Nashville, Tennessee
Heather Carter-Templeton, PhD, RN-BC, FAAN Chapter 8: Standardized Nursing Terminologies
The University of Alabama
Capstone College of Nursing Jillanna C. Firth, RN, BSN
Tuscaloosa, Alabama Roudebush VA Medical Center
Section Editor—Part 6: Nursing Practice Applications CIS/ARK/BCMA Coordinator
Chapter 25: Translation of Evidence into Nursing Indianapolis, Indiana
Practice Chapter 31: Monitoring Interoperability, Device
Interface, and Security

FM.indd 10 27-10-2020 14:03:59

 Contributors xi

Veronica D. Feeg, PhD, RN, FAAN Evelyn J. S. Hovenga, PhD, RN, FACHI, FACS,
Professor, Associate Dean FACN, FIAHSI
Barbara H. Hagan School of Nursing CEO, Professor & Director, eHealth Education PTY Ltd
Molloy College Director, Global eHealth Collaborative (GEHCO)
Rockville Centre, New York East Melbourne, Victoria
Section Editor—Part 9: Research Applications Australia
Chapter 49: Computer Use in Nursing Research Chapter 20: Using Six Sigma and Lean for Measuring
Quality
Rebecca Freeman, PhD, RN, FAAN, FNAP
University of Vermont Susan C. Hull, MSN, RN-BC, NEA, FAMIA
Vice President of Health Informatics Chief Health Information Officer
Burlington, Vermont CareLoop, Inc.
Chapter 18: Establishing Nursing Informatics Boulder, Colorado
in Public Policy Co-chair, Alliance for Nursing Informatics
Chapter 17: Foundations of Nursing Informatics
Nicholas R. Hardiker, PhD, RN, FACMI Chapter 36: New Models of Healthcare Delivery and
Professor of Nursing and Health Informatics and Retailers Producing Big Data
Associate Dean (Research & Enterprise)
School of Human and Health Sciences Elizabeth (Liz) Johnson, MS, FAAN, LCHIME,
University of Huddersfield FCHIME, CHCIO, FHIMSS, RN
Huddersfield, United Kingdom Retired Chief Innovation Officer
Chapter 8: Standardized Nursing Terminologies Tenet Health
Dallas, Texas
Lynda R. Hardy, PhD, RN, FAAN Chapter 22: Communication Skills in Health IT, Building
Director, Data Science & Discovery Strong Teams for Successful Health IT Outcomes
Associate Professor, Clinical
R. Renee Johnson-Smith, RN, MBA
The Ohio State University
Roudebush VA Medical Center
College of Nursing
Risk Manager
Columbus, Ohio
Indianapolis, Indiana
Chapter 26: Improving Healthcare Quality and Patient
Chapter 31: Monitoring Interoperability, Device
Outcomes Through the Integration of Evidence-Based
Interface, and Security
Practice and Informatics
Irene Joos, PhD, RN, MSIS
Lois M. Hazelton, RN, Dip App Sci (Nurs), B App Professor, IST
Sci (Ad Nurs), PhD (Entrepreneurship), FACN Adjunct Professor, Nursing
Independent Consultant and Researcher La Roche University
Nerrina, Victoria Pittsburgh, Pennsylvania
Australia Chapter 6: Data and Data Processing
Chapter 20: Using Six Sigma and Lean for Measuring
Quality

FM.indd 11 27-10-2020 14:03:59

 xii C ontributors

Virpi Jylhä, PhD, PT Ulla-Mari Kinnunen, PhD, RN

Senior Lecturer, Health and Human Services Adjunct Professor
Informatics Senior Lecturer, Health and Human Services
Department of Health and Social Management Informatics
University of Eastern Finland Department of Health and Social
Kuopio, Finland Management
Chapter 42: Nursing Informatics Innovations to University of Eastern Finland
Improve Quality Patient Care on Many Continents Kuopio, Finland
Chapter 42: Nursing Informatics Innovations
Olga S. Kagan, PhD, RN to Improve Quality Patient Care on Many
Adjunct Professor Continents
Barbara H. Hagan School of Nursing and Health
Sciences Eija Kivekäs, PhD, RN
Molloy College PostDoc Researcher, Health and Human Services
School of Nursing Informatics
Rockville Centre, New York Department of Health and Social Management
Chapter 49: Computer Use in Nursing Research University of Eastern Finland
Kuopio, Finland
Margaret A. Kennedy, PhD, MS, BScN, RN,
Chapter 42: Nursing Informatics Innovations
CPHIMS-CA, PMP
to Improve Quality Patient Care on Many
Chief Nursing Informatics Officer and
Continents
Managing Partner
Grevity Consulting Inc
Vancouver, British Columbia Eileen Koski, MPhil, FAMIA
Canada Program Director, Health Data & Insights, Center
Chapter 41: Nursing Data Science and Quality Clinical for Computational Health
Outcomes IBM T. J. Watson Research Center
Yorktown Heights, New York
Karlene M. Kerfoot, PhD, RN, FAAN Chapter 37: Artificial Intelligence in Healthcare
Chief Nursing Officer
API Healthcare/Symplr Darlene Lacy, PhD, RNC, CNE
Hartford, Wisconsin Associate Professor
Chapter 23: Nurse Scheduling and Credentialing Texas Tech University Health Sciences Center
Systems School of Nursing
Lubbock, Texas
Tae Youn Kim, PhD, RN Chapter 46: Initiation and Management of Accessible,
Associate Professor Effective Online Teaching
University of California Davis
Betty Irene Moore School of Nursing
Sacramento, California
Chapter 8: Standardized Nursing
Terminologies

FM.indd 12 27-10-2020 14:03:59

 Contributors xiii

Mary Ann Lavin, DSc, RN, ANP-BC (Retired), Michael E. Ludwig, MSN, RN-BC, CPHIMS
FNI, FAAN U.S. Army
Multidimensional Search and Design Consultant Chapter 30: Federal Healthcare Sector Nursing
Founder and President, TIIKO, LLC Informatics
Associate Professor Emerita
Saint Louis University E. LaVerne Manos, DNP, RN-BC, FAMIA
Trudy Busch Valentine School of Nursing Program Director
Saint Louis, Missouri Interprofessional Master of Science in Health
Chapter 28: Structuring Advanced Practice Knowledge: Informatics & Post-Master’s Certificate in Health
Curricular, Practice, and Internet Resource Use Informatics
Director, Informatics
Chanmi Lee, BSN, RN, FNP-C Director, Center for Health Informatics
Family Nurse Practitioner Clinical Associate Professor
Stride Community Health Center Kansas University Center for Health Informatics
Aurora, Colorado Kansas University School of Nursing
Chapter 47: Social Media Tools in the Connected Age Kansas City, Kansas
Chapter 48: A Paradigm Shift in Simulation:
June Levy, MLS Experiential Learning in Virtual Worlds and Future Use
Vice President of Virtual Reality, Robotics, and Drones
CINAHL Information Systems
Glendale, California Karen M. Marhefka, DHA, MHA, RHIA
Chapter 50: Information Literacy and Computerized Principal, Impacts Advisors
Information Resources Naperville, Illinois
Chapter 22: Communication Skills in Health IT,
Yu-Chuan (Jack) Li, MD, PhD, FACMI, FACHI, Building Strong Teams for Successful Health IT Outcomes
FIAHSI
Distinguished Professor and Dean, Graduate Heimar F. Marin, RN, MS, PhD, FACMI
Institute of Biomedical Informatics Alumni Professor, Nursing and Health
College of Medical Science and Technology Informatics
Taipei Medical University Federal University of São Paulo
Taipei, Taiwan Fellow, American College of Medical
Chapter 35: Consumer Patient Engagement and Informatics
Connectivity in Patients with Chronic Disease in the Editor-in-Chief, International Journal of
Community and at Home Medical Informatics
São Paulo, São Paulo
Pia Liljamo, PhD, RN Brazil
Development Manager Chapter 43: Global eHealth and Informatics
Oulu University Hospital Administrative Centre
Oulu, Finland Sarah Mattice, MS, RN
Chapter 42: Nursing Informatics Innovations Adjunct Instructor
to Improve Quality Patient Care on Many University of Colorado
Continents College of Nursing
Aurora, Colorado
Chapter 47: Social Media Tools in the Connected Age

FM.indd 13 27-10-2020 14:03:59

 xiv C ontributors
Kathleen A. McCormick, PhD, RN, FAAN, FACMI,
FHIMSS
Principal/Owner
SciMind, LLC
North Potomac, Maryland
Book Editor and Section Editor—Part 7: Advanced
Applications for the Fourth Nursing IT Revolution
Chapter 39: Nursing’s Role in Genomics and
Information Technology for Precision Health
Mary L. McHugh
Retired Dean of Nursing
Los Angeles, California
Chapter 2: Computer Systems Basics—Hardware
Chapter 4: Computer Systems Basics—Software
Bernadette Mazurek Melnyk, PhD, APRN-CNP,
FAANP, FNAP, FAAN
Vice President for Health Promotion
University Chief Wellness Officer
Dean and Professor, College of Nursing
Professor of Pediatrics & Psychiatry, College of
Medicine
Executive Director, The Helene Fuld Health Trust
National Institute for The Ohio State University
Columbus, Ohio
Editor, Worldviews on Evidence-Based Nursing
Chapter 26: Improving Healthcare Quality and Patient
Outcomes Through the Integration of Evidence-Based
Practice and Informatics
Mary Etta Mills, ScD, RN, NEA, BC, FAAN
Professor
Organizational Systems and Adult Health
University of Maryland
School of Nursing
Baltimore, Maryland
Chapter 44: Nursing Curriculum Reform and
Healthcare Information Technology
FM.indd 14
Nellie Modaress, MS
Assistant to Online Learning
Liaison to School of Nursing
University of Kansas Center for Health
Informatics
Kansas City, Kansas
Chapter 48: A Paradigm Shift in Simulation:
Experiential Learning in Virtual Worlds and Future Use
of Virtual Reality, Robotics, and Drones
Karen A. Monsen, PhD, RN, FAMIA, FAAN
Professor and Chair, Population Health and Systems
Cooperative
University of Minnesota
School of Nursing
Minneapolis, Minnesota
Chapter 32: Population Health Informatics
Jean D. Moody-Williams, RN, MPP
Principal, Transitions, Trust and Triumph: Quality
Improvement and Patient Engagement
Fulton, Maryland
Chapter 19: Quality Measurement and the Importance
of Nursing Informatics
Toria Shaw Morawski, MSW
Sr. Manager, Professional Development
Health Information Management Society System
(HIMSS)
Chicago, Illinois
Chapter 45: The Evolution of the TIGER Initiative
Judy Murphy, RN, FACMI, LFHIMSS, FAAN
Chief Nursing Officer
IBM Global Healthcare
Minneapolis, Minnesota
Chapter 37: Artificial Intelligence in Healthcare
27-10-2020 14:03:59
 Contributors xv

Lynn M. Nagle, PhD, RN, FAAN Susan K. Newbold, PhD, RN-BC, FHIMSS, FAMIA,
Director, Digital Health and Virtual Learning FAAN
Adjunct Professor Owner
Faculty of Nursing Nursing Informatics Boot Camp
University of New Brunswick Franklin, Tennessee
Adjunct Professor Chapter 12: System Design Life Cycle: A Framework
University of Toronto
Western University Chris E. Nichols, MHA, RN
Editor-in-Chief, Canadian Journal of Nursing Leadership LSSBB Program Manager
President Enterprise Intelligence & Data Solutions PMO
Nagle & Associates Inc. Defense Healthcare Management Systems PEO
Health Informatics Consulting Falls Church, Virginia
New Brunswick/Toronto, Canada Chapter 30: Federal Healthcare Sector
Chapter 41: Nursing Data Science and Quality Nursing Informatics
Clinical Outcomes Hyeoun-Ae Park, PhD, RN, FACMI, FAAN, FIAHSI
Eun-Shim Nahm, PhD, RN, FAAN Professor
Professor Seoul National University
Organizational Systems and Adult Health School of Nursing and Medical Informatics
University of Maryland Interdisciplinary Program
School of Nursing Seoul, Republic of Korea
Baltimore, Maryland Chapter 35: Consumer Patient Engagement and
Chapter 44: Nursing Curriculum Reform and Connectivity in Patients with Chronic Disease in the
Healthcare Information Technology Community and at Home
Chapter 43: Global eHealth and Informatics
Naoki Nakashima, MD, PhD
Professor/Director, Medical Information Center Ellen Pollack, MSN, RN-BC
Kyushu University Hospital, Japan Chief Nursing Informatics Officer
Fukuoka City, Japan UCLA Health
Chapter 35: Consumer Patient Engagement and Los Angeles, California
Connectivity in Patient with Chronic Disease in the Chapter 29: Beyond EMR Implementation: Optimize
Community and at Home and Enhance

Lynn A. (Slepski) Nash, PhD, RN, PHCNS-BC, FAAN Susy Postal, DNP, RN-BC
Captain (Retired), U.S. Public Health Service Chief Health Informatics Officer
Gaithersburg, Maryland Indian Health Service
Chapter 33: Informatics Solutions for Emergency Rockville, Maryland
Planning and Response Chapter 30: Federal Healthcare Sector Nursing
Informatics
Ramona Nelson, PhD, RN, BC, FAAN
Professor Emerita Diane S. Pravikoff, RN, PhD, FAAN
Slippery Rock University Vice President, Research (Retired)
President CINAHL Information Systems
Ramona Nelson Consulting Glendale, California
Pittsburgh, Pennsylvania Chapter 50: Information Literacy and Computerized
Chapter 6: Data and Data Processing Information Resources

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 xvi C ontributors
Paula M. Procter, RN, CertED (FE), MSc, SFHEA,
FBCS, CITP, FIMIANI, IAHSI
Professor of Nursing Informatics
Department of Nursing and Midwifery
Sheffield Hallam University
Sheffield, United Kingdom
Chapter 11: Social Determinants of Health, Electronic
Health Records, and Health Outcomes
Stephanie J. Raps, MSN, RN-BC
Doctoral Candidate
Daniel K. Inouye Graduate School of Nursing
Uniformed Services University of the Health Sciences
Major, U.S. Air Force
Bethesda, Maryland
Chapter 30: Federal Healthcare Sector Nursing
Informatics
Theresa A. Rienzo, BSN, RN, MS, MLIS, AHIP
Associate Librarian Health Sciences
James E. Tobin Library
Molloy College
Rockville Centre, New York
Chapter 49: Computer Use in Nursing Research
Teresa A. Rincon, RN, PhD, CCRN-K, FCCM
Director of Clinical Ops & Innovation, Virtual Med
UMass Memorial Healthcare
Assistant Professor, Graduate School of Nursing
University of Massachusetts Medical School
Worcester, Massachusetts
Chapter 38: Telehealth: Healthcare Evolution in the
Technology Age
Sarah Collins Rossetti, RN, PhD, FACMI, FAMIA
Assistant Professor of Biomedical Informatics and
Nursing
Columbia University Medical Center
New York, New York
Chapter 17: Foundations of Nursing Informatics
FM.indd 16
Virginia K. Saba, EdD, RN, FACMI, FAAN, LL
CEO & President
Sabacare.com
Arlington, Virginia
Distinguished Scholar, Adjunct
Georgetown University
Washington, District of Columbia
Professor, Adjunct
Uniformed Services University
Bethesda, Maryland
Book Editor and Section Editor—Part 1: Nursing
Informatics Technologies
Part 4: Informatics Theory Standards
Chapter 1: Historical Perspectives of Nursing
Informatics
Appendix: Clinical Care Classification (CCC) System:
Overview, Applications, and Analyses
Kaija Saranto, PhD, RN, FACMI, FAAN, FIAHSI
Professor, Health and Human Services
Informatics
Department of Health and Social Management
University of Eastern Finland
Kuopio, Finland
Chapter 42: Nursing Informatics Innovations to
Improve Quality Patient Care on Many Continents
Patricia P. Sengstack, DNP, RN-BC, FAAN
Associate Professor, Vanderbilt University School of
Nursing
Nursing Informatics Executive, Vanderbilt University
Medical Center
Nashville, Tennessee
Chapter 34: Health Information Technology: Striving
to Improve Patient Safety
Joyce Sensmeier, MS, RN-BC, FHIMSS, FAAN
Senior Advisor, Informatics
Health Information Management Society System
(HIMSS)
Chicago, Illinois
Section Editor—Part 2: System Standards
Chapter 7: Health Data Standards: Development,
Harmonization, and Interoperability
27-10-2020 14:04:00
 Contributors xvii

Theresa (Tess) Settergren, MHA, MA, RN-BC Mark D. Sugrue, RN-BC, MSN, FHIMSS
Director, Nursing Informatics (Retired) Managing Director, Clinical Delivery & Informatics
University of Minnesota Solutions
Minneapolis, Minnesota Commonwealth Medicine
Chapter 13: System and Functional Testing University of Massachusetts Medical School
Member, HIMSS North America Board of Directors
Roy L. Simpson, DNP, RN, DPNAP, FAAN, FACMI (2019–2020)
Assistant Dean, Technology Management and Chair, HIMSS North America Board of Directors
Clinical Professor (6/2020–2021)
Doctoral Program: Doctorate Nursing Shrewsbury, Massachusetts
Practice Chapter 38: Telehealth: Healthcare Evolution in the
Nell Hodgson Woodruff School of Nursing Technology Age
Emory University
Atlanta, Georgia Gerald N. Taylor, MD, MPH
Chapter 40: Big Data Analysis of Electronic Health Flight Surgeon, Diplomate American Board of
Record (EHR) Data Preventive Medicine
Captain, USPHS
Diane J. Skiba, PhD, FACMI
Coast Guard Chief Medical Informatics Officer
Professor Emeritus
Washington, District of Columbia
University of Colorado
Chapter 30: Federal Healthcare Sector
Aurora, Colorado
Nursing Informatics
Media Editor
Chapter 47: Social Media Tools in the Connected Age
Denise D. Tyler, DNP, MSN/MBA, RN-BC
Carolyn Sipes, PhD, CNS, APRN, PMP, RN-BC, Clinical Specialist
NEA-BC, FAAN Visalia, California
Professor, Core Faculty, PhD Program Section Editor—Part 3: System Life Cycle
Walden University Chapter 13: System and Functional Testing
Minneapolis, Minnesota Chapter 14: System Life Cycle Tools
Chapter 16: The Practice Specialty of Nursing
Informatics Barbara Van de Castle, DNP, APRN-CNS, OCN,
RN-BC
Kathleen Smith, MScEd, RN-BC, FHIMSS
Assistant Professor
Managing Partner
University of Maryland School of Nursing
Informatics Consulting and Continuing
Baltimore, Maryland
Education, LLC
Nurse Educator
Weeki Wachee, Florida
Sidney Kimmel Comprehensive Cancer Center
Section Editor—Part 5: Policies and Quality
Johns Hopkins University
Measurement in Health Care
Baltimore, Maryland
Chapter 23: Nurse Scheduling and Credentialing
Chapter 15: Healthcare Project Management
Systems

FM.indd 17 27-10-2020 14:04:00

 xviii C ontributors

Allison Viola, MBA, RHIA Luann Whittenburg, PhD, RN-BC, FNP-BC,

Director, Guidehouse CPHIMS, FHIMSS, FAAN
Washington, District of Columbia Consultant, Health Informatics
Chapter 18: Establishing Nursing Informatics Fairfax, Virginia
Chapter 27: Nursing Plan of Care Framework for HIT
Elizabeth (Betsy) Weiner, PhD, RN-BC, FACMI, Appendix: Clinical Care Classification (CCC) System:
FAAN Overview, Applications, and Analyses
Senior Associate Dean for Informatics
Centennial Independence Foundation Professor of Marisa L. Wilson, DNSc, MHSc, RN-BC, CPHIMS,
Nursing FAMIA, FAAN
Vanderbilt University School of Nursing Associate Professor
Nashville, Tennessee Interim Department Chair: Family, Community and
Chapter 33: Informatics Solutions for Emergency Health Systems
Planning and Response Health Systems Leadership Pathway Director
The University of Alabama at Birmingham
Bonnie L. Westra, PhD, RN, FAAN, FACMI School of Nursing
Associate Professor Emerita Birmingham, Alabama
University of Minnesota Section Editor—Part 1: Nursing Informatics
School of Nursing Technologies
Minneapolis, Minnesota Chapter 11: Social Determinants of Health, Electronic
Chapter 1: Historical Perspectives of Nursing Health Records, and Health Outcomes
Chapter 44: Nursing Curriculum Reform and
Peggy A. White, RN, BA, MN Healthcare Information Technology
Consultant, Canadian Nurses Association—
Canadian Health Outcomes for Better Information Hu Yuandong, MD
and Care Initiative Deputy Chief
Co-Lead, National Nursing Data Standards Initiative Physician Institute of Chronic Disease
Thornbury, Ontario Guizhou Provincial Center for Disease Control
Canada Guizhou, China
Chapter 41: Nursing Data Science and Quality Clinical Chapter 35: Consumer Patient Engagement and
Outcomes Connectivity in Patients with Chronic Disease in the
Community and at Home
David J. Whitten, MSC
Medical Informatics
Central Regional Hospital
Department of Health and Human Services (DHHS)
Butner, North Carolina
Chapter 3: Advanced Hardware and mHealth
Chapter 5: Open Source and Free Software

FM.indd 18 27-10-2020 14:04:00


In the years since the previous edition of Essentials in
Nursing Informatics was published, U.S. hospitals have
achieved nearly universal adoption of electronic health
record (EHR) systems. Physician offices are only slightly
behind in joining the digital ranks, and health profession-
als across the nation now utilize EHR systems in daily
practice. The “HITECH Act” has forever changed health
informatics, and we now face new challenges in improv-
ing usability, interoperability, and learning capability of
these systems. With the rise of artificial intelligence and
a need to reduce documentation burden required by cur-
rent EHR systems, we see significant opportunity and
responsibility for healthcare providers to address these
challenges. Nurse informaticists are at the center of this
transformational opportunity.
Historically, care teams communicated primarily
through written notes in the patient chart. Paper repre-
sented a technical barrier, as the best patient care is depen-
dent on data availability over time, across locations, and
among healthcare team members—including the patient.
Access to the most accurate and complete information
remains vital, and nursing informaticists are leading much
of the work being done to improve the speed, accuracy,
and utility of clinical information.
We have made progress in gaining nearly instant access
to patient data and evidence-based decision support that
enables nurses, physicians, and other clinicians to make
better decisions about patient care. These technologies,
however, require continued optimization of the tech-
nology, the interoperability, and the workflow to drive
improvement in user experience, reduce documentation
burden, and improve patient outcomes.
The accelerating demands for gathering and using
data to improve patient care and clinical operations have
increased awareness of informatics as a core skill, inten-
sifying the need for clinicians to better understand these
increasingly ubiquitous technologies. This edition incor-
porates updated teaching aids to help educators develop
more sophisticated users of technology, who are equipped
to improve processes and workflows that result in safer,
more effective, and efficient patient care.
As the specialty that integrates nursing science, com-
puter science, and information science to manage and
communicate data, information, and knowledge—and
FM.indd 19
FOREWORD
ultimately, build wisdom—into nursing practice, nursing
informatics is uniquely positioned to help lead the opti-
mization journey that will simplify data capture, promote
sharing of data in a mobile environment, and create high-
performing, patient-centric clinical information systems.
The vision for a better future of healthcare is tightly
associated with the future of health information technol-
ogy, and data are the fuel for this journey. Thus, nurse
informaticists are critical healthcare leaders for the 21st
century, experts in the right place at the right time, bring-
ing the clinical, technical, and leadership skills together to
create effective partnerships among their numerous con-
stituencies—leadership teams, clinicians, data scientists,
information technologists, and more. Their role is central
in advancing value and science-driven healthcare, and so
their work in moving healthcare informatics from data
management to decision support is essential.
In the 15 years since the call for EHRs was made in
the 2004 Presidential State of the Union message, we have
witnessed rapid evolution of health information technol-
ogy and its use in healthcare systems. The next 15 years
will bring the increasing convergence of data from myr-
iad sources outside of the formal healthcare setting into
the context of clinical care. We will move up the analytic
hierarchy from descriptive to diagnostic, predictive, and
ultimately prescriptive and autonomous systems. Thus,
the future of this field promises both challenge and oppor-
tunity for prepared participants.
Just as the field has evolved, so has nursing informat-
ics. Its practitioners have already provided tremendous
energy, insight, and leadership in helping to establish the
necessary infrastructure and in driving gains in healthcare
technology competency, information literacy, and better
healthcare outcomes. Now more than ever, we believe
nursing informatics holds great promise to enhance the
quality, continuity, value, and experience of healthcare.
Jonathan B. Perlin, MD, PhD, MSHA, FACP, FACMI
President, Clinical Services Group and Chief Medical
Officer
HCA Healthcare
Jane D. Englebright, PhD, RN, CENP, FAAN
Senior Vice President and Chief Nurse Executive
HCA Healthcare
xix
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FM.indd 20 27-10-2020 14:04:00


This seventh edition of Essentials of Nursing Informatics
was initiated in response to requests by educators to pro-
vide a digital as well as an online version for faculty to use
in the development of their course work and by nurses
and other users of the sixth edition. We expanded the
content to stay current, since the publisher does not plan
to generate a Study Guide for this version. To do so, we
have added Questions and Answers in each chapter as
well as added a Summary in each of the nine parts and
one Appendix of the text. Further with the updated ANA
Certification Examination, we returned the basic, detailed
Fundamental Chapters to update so that the chapters
completely address their focus and scope.
Each of the nine parts of this edition has had a Section
Editor to assist the authors with their content: Part 1:
Nursing Informatics Technologies—Carol J. Bickford
and Marisa L. Wilson; Part 2: System Standards—
Virginia K. Saba and Joyce Sensmeier; Part 3: System
Life Cycle—Denise D. Tyler; Part 4: Informatics Theory
Standards—Virginia K. Saba; Part 5: Policies and Quality
Measures in Healthcare—Kathleen Smith; Part 6: Nursing
Practice Applications—Heather Carter-Templeton; Part
7: Advanced Applications for the Fourth Nursing IT
Revolution—Kathleen A. McCormick; Part 8: Educational
Applications—Diane J. Skiba; and Part 9: Research
Applications—Veronica D. Feeg. For this edition, faculty
recommended that we write a part summary introducing
important concepts in each part.
This book was written by experts in nursing and infor-
matics, but when we were editing this book, the most
unusual circumstances occurred. The COVID-19 pan-
demic swept across continents. Nurses in practice were
stretched by large volumes of critical care to a large cohort
of patients. Unique digital concepts were developed on
site, implemented to large groups of healthcare profes-
sionals in the ICU, the hospital, nearby local pop-up hospi-
tals, primary care offices, networks of specialty healthcare
workers, and skilled nursing facilities and nursing homes.
The mandate for interconnected healthcare, telehealth,
and digital education quickly became an adopted norm.
Several new chapters were added in Part 7: Advanced
Applications for the Fourth Nursing IT Revolution
(Kathleen McCormick—Section Editor). This part has the
following chapters: New Models of Healthcare Delivery
FM.indd 21
PREFACE
(Chap. 36), Artificial Intelligence in Healthcare (Chap. 37),
Telehealth: Healthcare Evolution in the Technology Age
(Chap. 38), Nursing’s Role in Genomics and Information
Technology for Precision Health (Chap. 39), Big Data
Analysis of Electronic Health Record (EHR) Data (Chap.
40), Nursing Data Science and Quality Clinical Outcomes
(Chap. 41), Nursing Informatics Innovations to Improve
Quality Patient Care on Many Continents (Chap. 42), and
Global eHealth and Informatics (Chap. 43). We requested
authors to include updates on the digital health require-
ments, policies, and regulations as a result of the COVID-19
pandemic.
The updates in chapters include new references, poli-
cies, and skills required by nurses in the field. A complete
update and an overview of the Federal Health Care Sector
Nursing Informatics are described by experts represent-
ing all the federal sectors. The Veteran’s Administration
Nursing Plan of Care Framework is described. Instead
of an International Section, the nurse authors from
Australia, South Korea, Finland, South America, Canada,
the United Kingdom, and North America have described
their expertise in Six Sigma, Measuring and Evaluating
Quality, describing Consumer Patient Engagement and
Connectivity in Patients with Chronic Diseases in the
Community and in their Home, and Global eHealth ini-
tiatives in Nursing Informatics. Their chapters represent
the expertise that they bring to Essentials of Nursing
Informatics, seventh edition.
Our new Media Editor, Diane J. Skiba, is considering
including a website for slides, abstracts, and any other
materials of interest that the authors determined would
support the faculty and/or enhance the educational pro-
cess. We feel that this new edition will provide the new
theories, federal policies, and new content that have
impacted the field of Nursing Informatics that are con-
tinually changing.
Virginia and Kathleen have felt that they have, dur-
ing the past 20+ years, and their six editions, with their
specialist authors in the field, provided the most current
and reliable information as this new Nursing Specialty
advanced, grew, and changed with the technological
advancements that impacted on the changing healthcare
processes. We feel honored that this text has been used by
the key administrative leaders, educators, and researchers
xxi
27-10-2020 14:04:00
 xxii P reface

in the field. We feel that this text has helped keep Nursing teach the content, assist nurses with the certification
Informatics in the forefront of our discipline. We hope you requirements, and help us advance Nursing Informatics in
will be as pleased with this seventh edition as you have the 21st century.
been with the past editions. We hope it will help faculty
Dr. Virginia K. Saba
Dr. Kathleen A. McCormick

FM.indd 22 27-10-2020 14:04:00

 ACKNOWLEDGMENTS
This seventh edition of Essentials of Nursing Informatics is
dedicated to all the section editors, chapter authors, and
their co-authors. Each of these prestigious contributors
are experts in their respective positions, implementing
systems, policies, research, and educational programs to
support and advance Nursing Informatics in this country
and abroad.
We acknowledge our international colleagues in
Nursing Informatics. We also acknowledge the McGraw
Hill staff Susan Barnes Oldenburg, Richard Ruzycka, and
Christina Thomas and their contractors Touseen Qadri
from MPS Limited who contributed to the editing of this
book, completing the production of this book, as well as
supporting the expansion of the book with new resources.
FM.indd 23
We also want to especially remember those authors and
other supporters of Nursing Informatics who have left us
last year: Helen Connors, Kathleen (Milholland) Hunter,
Margaret Ross Kraft, Melissa Barthold, Julie McAfoos,
Andrew McLaughlin, Dr. Donald, Lindberg, and others
who have left their mark on the field.
The authors also acknowledge their families because
without their encouragement and help this book would
not be a reality. We thank the Lord for giving us the oppor-
tunity to embark on a seventh edition and for the help we
received in completing it.
Dr. Virginia K. Saba
Dr. Kathleen A. McCormick
xxiii
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FM.indd 24 27-10-2020 14:04:00

 part 1
Nursing Informatics
Technologies
Carol J. Bickford and Marisa L. Wilson

A new feature of the seventh edition of Essentials in Nursing Informatics is a part summary that provides an overview
for each of the nine parts of this edition. Each part represents a specific focus on this Nursing Informatics specialty and
provides appropriate information in separate chapters. The coronavirus pandemic that occurred during the publishing
process also allowed some authors to address its impact on specific practice areas.
The informatics nurse uses data to create information and knowledge to support best care practices. The informatics
nurse engages the data to information to knowledge process using technology to support patient care, increase effi-
ciency, ensure quality, and improve outcomes. In order to do this, the informatics nurse needs to understand the founda-
tions of computer hardware and software as well as the processes for managing data and information. Understanding
how computer hardware and software works is core to fulfilling the tenets of nursing informatics as outlined in the
American Nurses Association (ANA) Nursing Informatics: Scope and Standards of Practice, Second Edition. Part 1 content
description follows.
Chapter 1, entitled Historical Perspectives in Nursing Informatics, authored by Dr. Virginia K. Saba, Dr. Bonnie L. Westra,
and Dr. Julie J. Brixey, provides a historical overview of Nursing Informatics (NI) during 10-year period starting in the 1960s
with the introduction of computer technology in healthcare. The chapter provides landmark events that influenced the
growth of NI as a new nursing specialty. It provides an update on new activities since the previous edition, including
new information on where and who were involved in advancing this specialty. It includes the new criteria, established
by the NI pioneers, that addressed nursing practice standards, educational content, certification requirements, etc. It also
updated the Landmark Events and Pioneers in Computers and Nursing, and Nursing Informatics table with the name of
the major NI pioneer involved.
Chapter 2, Computer Systems Basics—Hardware, authored by Dr. Mary L. McHugh, provides a helpful overview of basic
computer hardware components, their characteristics, and functions. Because computers are ubiquitous in everyone’s
personal life and the healthcare industry, an understanding of the operations of such an infrastructure is foundational for
the informatics nurse. The five basic types of computers and the associated internal components and diverse peripherals
are described, as is the critical connectivity provided by network hardware.

ch01.indd 1 22-10-2020 03:11:52

 Chapter 3, developed by Dr. David J. Whitten who updated Dr. Kathleen Charters’ earlier description of Advanced
Hardware and mHealth supports innovative mobile healthcare models. This chapter informs the readers of the use of
increasingly sophisticated mechanical devices and electronic systems that will allow providers to provide care, con-
sultation, and communications in and across a multitude of settings. This chapter reviews the use of advanced tablets,
smartphones, wearables, and implantable or injectable devices made possible by the acceleration of increasingly sophis-
ticated and powerful hardware within an infrastructure that supports these activities.
Chapter 4, Computer Systems Basics—Software, authored by Dr. Mary L. McHugh, clarifies the differences and com-
plementary interrelationships of the three basic types of software: system software, utility programs, and applications
software. Discussion of the evolution of the generations and levels of programming languages promotes appreciation
of the complexity of today’s information systems’ environments and the value of expert programmers, colleagues, and
specialists partnering with the informatics nurse to ensure continuity of operations and services.
In Chapter 5, Drs. David J. Whitten expanded the previous authors’—Drs. Peter Murray and W. Scott Erdley—focus on
an important topic Open Source and Free Software or Free/Libre Open Source Software (FLOSS). Most informatics nurses
will work with vendor software products. However, they need to be aware of the resources available for use that are free
and open source. The informatics nurse needs to be familiar with the risks and rewards of using this software and the
differences between this and proprietary software when making choices. The authors provide a history of FLOSS, along
with development models, that dates back to the 1950s. They describe the benefits and issues related to the choice
to use FLOSS versus proprietary software. Whitten also provided detailed steps that one would consider when choos-
ing software, whether FLOSS or proprietary. The authors also cover the topic of licensing, which with the FLOSS model
encourages sharing of the software to facilitate dissemination.
Chapter 6 covers Data and Data Processing. Drs. Irene Joos, Cristina Bahm, and Ramona Nelson offer a broad presenta-
tion of this topic. Nelson’s Data to Information to Knowledge to Wisdom Model’s megastructures and concepts underline
NI, as well as processes for creating and using knowledge that the data care providers collect. In this chapter, the authors
describe important concepts in generating data. They introduce information on big data, data repositories, database
management systems, database models, and processes for curating data. The function and processes of interoperability
are described. Auditing data, information creation, and interpretation in the form of analytics are explained. Clinical
decision support and expert systems are presented as examples of processes using data to support value-based care.

ch01.indd 2 22-10-2020 03:11:52

 1
Historical Perspectives
of Nursing Informatics
Virginia K. Saba / Bonnie L. Westra / Juliana J. Brixey

• OBJECTIVES
1. Identify a brief historical perspective of nursing informatics.
2. Explore lessons learned from the pioneers in nursing informatics.
3. List the major landmark events and milestones of nursing informatics.

• KEY WORDS
Computers
Computer Literacy
Computer Systems
Data Standards
Electronic Health Records (EHR)
Healthcare Information Technology (HIT)
Information Systems
Internet
Nursing Informatics (NI)

referring to technology that captures, processes, and gen-

OVERVIEW
Nursing Informatics is a phrase that evolved from the
French word “informatique” which referred to the field
of applied computer science concerned with the pro-
cessing of information such as nursing information. The
computer was seen as a tool that could be used in many
environments.
In the early 1960s, the computer was introduced into
healthcare facilities for the processing of basic adminis-
trative tasks. Thus the computer revolution in healthcare
began and led to today’s healthcare information technol-
ogy (HIT) and/or electronic health record (EHR) systems.
The importance of the computer as an essential tool
in HIT systems and the delivery of contemporary health-
care is indisputable. HIT is an all-encompassing term
erates healthcare information. Computerization and/or
electronic processing affect all aspects of healthcare deliv-
ery including (a) provision and documentation of patient
care, (b) education of healthcare providers, (c) scientific
research for advancing healthcare delivery, (d) administra-
tion of healthcare delivery services, (e) reimbursement for
patient care, (f ) legal and ethical implications, as well as
(g) safety and quality issues.
Since the inception of the computer, there has been
a shift from the use of mainframe, mini, or microcom-
puters (PCs) to integrating multiple technologies and
telecommunication devices such as wireless, handheld,
mobile computers, and smart (cell) phones designed to
support the continuity of care across healthcare settings
and HIT systems. There has also been a shift from storage

ch01.indd 3 22-10-2020 03:11:52

 4 P art 1 • N ursing I nformatics T echnologies
devices to cloud storage. Furthermore, there is less need
to develop written instructions for software programs
as today’s applications are icon-based, user-friendly, and
menu-driven. Additionally, video tutorials are available for
many programs. Touch-screen devices are replacing the
need for a mouse.
Today, computers in nursing are used to manage
patient care information, monitor quality, and evaluate
outcomes. Computers and networks are also being used
for communicating (sending and receiving) data and mes-
sages via the Internet, accessing resources, and interacting
with patients on the Web. Nurses are increasingly using
systems for planning, budgeting, and policy-making for
patient care services. Computers are also used to docu-
ment and process real-time plans of care, support nursing
research, test new systems, design new knowledge data-
bases, develop data warehouses, and advance the role of
nursing in the healthcare industry and nursing science.
Moreover, computers are enhancing nursing education
and distance learning with new media modalities.
This chapter is an updated and revised version of the
chapter “Historical Perspectives of Nursing Informatics”
(Saba & Westra, 2015) published in the 6th edition of the
Essentials of Nursing Informatics (Saba & McCormick,
2015). In this chapter the significant events influencing
the growth of nursing informatics (NI) as a nursing spe-
cialty are analyzed according to (1) seven time periods,
(2) a view of the newest technological innovations used by
nurses, (3) a description of Nursing Informatics Pioneers
including a synthesis of lessons learned from videotaped
interviews with NI pioneers, (4) electronic health records
from a historical perspective, and (5) landmark events in
nursing and computers, with Table 1-1 listing those events
that influenced the introduction of computers into the
nursing profession including key “computer/informatics”
nurse that directed the activity. Also, Table 1-2 lists cur-
rent organizations supporting nursing informatics.
MAJOR HISTORICAL PERSPECTIVES
OF NURSING AND COMPUTERS
Seven Time Periods
Computers were introduced into the nursing profession
over 40 years ago. Major milestones of nursing are inter-
woven with the advancement of computer and informa-
tion technologies, the increased need for nursing data,
development of nursing applications, and changes mak-
ing the nursing profession an autonomous discipline. The
key activities and events for each decade are presented
to provide a background and the sequence of events to
ch01.indd 4
demonstrate nursing’s commitment to Computers and
Nursing including Information Technology.
Prior to 1960s Computers were first developed in the
late 1930s to early 1940s. As computers have evolved,
computing power has increased. This was attributed to
the increasing number of transistors or chips placed in
an integrated circuit. In the mid-1960s Gordon Moore
noted that the number doubled approximately every two
years. This argument has become known as Moore’s law
(Techopedia, 2019).
Use of computers in the healthcare industry did not
occur until the 1950s and 1960s. During this time, there
were only a few experts nationally and internationally
who formed a cadre of pioneers that adapted computers
to healthcare and nursing which was undergoing major
changes. Several professional advances provided the impe-
tus for the profession to embrace computers—a new tech-
nological tool. Computers were initially used in healthcare
facilities for basic office, administrative, and financial
accounting functions. These early computers used punch
cards to store data and card readers to read computer pro-
grams, sort, and prepare data for processing. Computers
were linked together and operated by paper tape using
teletypewriters to print their output. As computer technol-
ogy advanced, healthcare technologies also advanced. The
major advances are listed chronologically in Table 1-1.
1960s During the 1960s the uses of computer technology
in healthcare settings began to be explored. Questions such
as “Why use computers?” and “What should be comput-
erized?” were discussed. Nursing practice standards were
reviewed, and nursing resources were analyzed. Studies
were conducted to determine how computer technology
could be utilized effectively in the healthcare industry and
what areas of nursing should be automated. The nurses’ sta-
tion in the hospital was viewed as the hub of information
exchange; therefore, numerous initial computer applica-
tions were developed and implemented in this location.
By the mid-1960s, clinical practice presented nurses
with new opportunities for computer use. Increasingly
complex patient care requirements and the prolifera-
tion of intensive care units (ICUs) required that nurses
become super users of computer technology as nurses
monitored patients’ status via cardiac monitors and insti-
tuted treatment regimens through ventilators and other
computerized devices such as infusion pumps. A signifi-
cant increase in time spent by nurses documenting patient
care, in some cases estimated at 40%, as well as a noted rise
in medication administration errors prompted the need to
investigate emerging hospital computer-based informa-
tion systems (Sherman, 1965; Wolkodoff, 1963).
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ch01.indd 5

TABLE 1.1 Landmark Events and Pioneers in Computers and Nursing, and Nursing Informatics
Year(s) Title/Event Sponsor(s) Coordinator/Chair/NI Representative(s)

1973 First Invitational Conference: Management National League for Nursing (NLN) and Goldie Levenson (NLN)
Information Systems (MISs) for Public and Division of Nursing, Public Health Virginia K. Saba (DN/PHS)
Community Health Agencies Service (DN/PHS), Arlington, VA
1974 to 1975 Five Workshops in USA on MISs for Public and NLN and DN/PHS, selected US Cities Goldie Levenson (NLN)
Community Health Agencies Virginia K. Saba (DN/PHS)
1976 State-of-the-Art Conference on Management for NLN and DN/PHS, Washington, DC Goldie Levenson (NLN)
Public and Community Health Agencies Virginia K. Saba (DN/PHS)
1977 First Research: State-of-the-Art Conference on University of Illinois College of Nursing, Harriet H. Werley (UIL)
Nursing Information Systems Chicago, IL Margaret Grier (UIL)
1977 First undergraduate academic course: Computers The State University of New York at Judith Ronald (SUNY, Buffalo)
and Nursing Buffalo, Buffalo, NY
1979 First Military Conference on Computers in Nursing TRIMIS Army Nurse Consultant Team, Dorothy Pocklington (TRIMIS Army)
Walter Reed Hospital, Washington, DC Linda Guttman (ANC)
1980 First Workshop: Computer Usage in Healthcare University of Akron, School of Nursing, Virginia Newbern (UA/SON)

Chapter 1 • Historical Perspectives of Nursing Informatics

Continuing Education Department, Dorothy Pocklington (TRIMIS Army)
Akron, OH
Virginia K. Saba (DN/PHS)
1980 First Computer Textbook: Computers in Nursing Nursing Resources, Boston, MA Rita Zielstorff, Editor
1981 First Special Interest Group Meeting on Computers in Annual SCAMC Conference Event, Virginia K. Saba, Chair (DN/PHS)
Nursing at SCAMC Washington, DC
1981 to 1991 First Nursing Papers at Fifth Annual Symposium on Annual SCAMC Conference Sessions, Virginia K. Saba (DN/PHS)
Computer Applications in Medical Care (SCAMC) Washington, DC Coralee Farlee (NCHSR)
1981 to 1984 Four National Conferences: Computer Technology NIH Clinical Center, TRIMIS Army Nurse Virginia K. Saba (DN/PHS)
and Nursing Consultant Team, and DN/PHS NIH Ruth Carlson and Carol Romano (CC/NIH)
Campus, Bethesda, MD
Dorothy Pocklington and Carolyn Tindal
(TRIMIS Army) Transport Research and
Innovation Monitoring and Information
System Army
1981 Early academic course on Computers in Nursing Foundation for Advanced Education in Virginia K. Saba (DN/PHS)
(NIH/CC) Sciences (FAES) at NIH, Bethesda, MD Kathleen A. McCormick (NIH/PHS)
1982 Study Group on Nursing Information Systems University Hospitals of Cleveland, Case Mary Kiley (CWS)
Western Reserve University, and Gerry Weston (NCHSR)
National Center for Health Services
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Research (NCHSR/PHS), Cleveland, OH

(continued)

5
ch01.indd 6

6
TABLE 1.1 Landmark Events and Pioneers in Computers and Nursing, and Nursing Informatics (continued)
Year(s) Title/Event Sponsor(s) Coordinator/Chair/NI Representative(s)

P art 1 • N ursing I nformatics T echnologies

1982 to 2013 Initiated Annual International Nursing Rutgers, State University of New Jersey, College of Gayle Pearson (Rutgers)
Computer Technology Conference Nursing, CE Department, selected cities Jean Arnold (Rutgers)
Mary Anne Rizzolo
1982 First International Workshop: The Impact of London Hospital, UK and IFIP-IMIA, Harrogate, UK Maureen Scholes (UK)
Computers on Nursing Barry Barber (UK)
1982 First Newsletter: Computers in Nursing School of Nursing, University of Texas at Austin, Gary Hales (UT)
Austin, TX
1982/1984 Two Boston University (BU) Workshops on Boston University School of Nursing, Boston, MA Diane Skiba (BU)
Computers and Nursing
1982 PLATO IV CAI Educational Network System University of Illinois School of Nursing, Chicago, IL Pat Tymchyshyn (UIL)
1982 Capital Area Roundtable in Informatics in Greater Washington, DC Founding Members:
Nursing (CARING) Founded Susan McDermott
P.J. Hallberg
Susan Newbold
1983 to Present Initiated nursing papers at MEDINFO 1983—Amsterdam, NL Elly Pluyter-Wenting, First Nursing Chair
(Every 3 Years) World Congress on Medical Informatics, 1986—Washington, DC, USA
International Medical Informatics
1989—Singapore, Malaysia
Association (IMIA)
1992—Geneva, Switzerland
1995—Vancouver, Canada
1998—Seoul, South Korea
2001—London, United Kingdom
2004—San Francisco, CA, United States
2007—Brisbane, Australia
2010—Capetown, South Africa
2013—Copenhagen, Denmark
2015—São Paulo, Brazil
2017—Hangzhou, China
2019—Lyon, France
2021—Sydney, Australia
1983 Second Annual Joint SCAMC Congress and SCAMC and IMIA, San Francisco, CA and Virginia K. Saba, Nursing Chair
IMIA Conference Baltimore, MD
1983 Early Workshop: Computers in Nursing University of Texas at Austin, Austin, TX Susan Grobe (UT—Austin)
1983 First Hospital Workshop: Computers in St. Agnes Hospital for HEC, Baltimore, MD Susan Newbold
Nursing Practice
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1983 First: Nursing Model for Patient Care and TRIMIS Program Office, Washington, DC Karen Rieder (NNC)
Acuity System Dena Nortan (NNC)
ch01.indd 7

1983 to 2012 Initiated International Symposium:
Nursing Use of Computers and
Information Science, International
Medical Informatics Association
(IMIA) Working Group 8 on Nursing
Informatics (NI).
2008 to 2014 Renamed: IMIA Nursing Informatics,
2014 to Present Special Interest Group (IMIA/NI-SIG)
(Q 2 Years)
1983—Amsterdam, Netherlands 1983—Maureen Scholes, First Chair
1985—Calgary, Canada 1985—Kathryn J. Hannah and Evelyn J.
Guillemin
1988—Dublin, Ireland Noel Daley and Maureen Scholes
1991—Melbourne, Australia Evelyn S. Hovenga and Joan Edgecumbe
1994—San Antonio, TX, USA Susan Grobe and Virginia K. Saba
1997—Stockholm, Sweden Ulla Gerdin and Marianne Tallberg
2000—Auckland, New Zealand Robyn Carr and Paula Rocha
2003—Rio de Janeiro, Brazil Heimar Marin and Eduardo Marques
2006—Seoul, Korea Hyeoun-Ae Park
2009—Helsinki, Finland Anneli Ensio and Kaija Saranto
2012—Montreal, Canada Patricia Abbott (JHU)
2014—Taipei, Taiwan Polun Chang
2016—Geneva, Switzerland Patrick Weber

Chapter 1 • Historical Perspectives of Nursing Informatics

2018—Guadlajara, Mexico Diane Skiba.
2021—Sidney, Australia Judy Murphy
1984 American Nursing Association (ANA) ANA Harriet Werley, Chair
Initiated First Council on Computer First Exec. Board:
Applications in Nursing (CCAN) Ivo Abraham
Kathleen McCormick
Virginia K. Saba
Rita Zielstorff
1984 First Seminar: Microcomputers for Nurses University of California at San Francisco, College William Holzemer, Chair
of Nursing, San Francisco, CA
1984 First Nursing Computer Journal: JB Lippincott, Philadelphia, PA Gary Hales (UT Austin)
Computers in Nursing CIN, Renamed First Editorial Board:
Computers, Informatics, Nursing Patricia Schwirian (OSU)
Virginia K. Saba (GT)
Susan Grobe ( UT)
Rita Zielstorff (MGH Lab)
1984 to 1995 First Annual Directory of Educational Software Christine Bolwell and National League for Nursing Christine Bolwell
for Nursing (NLN)

(continued)
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7
ch01.indd 8

8
P art 1 • N ursing I nformatics T echnologies
TABLE 1.1 Landmark Events and Pioneers in Computers and Nursing, and Nursing Informatics (continued)
Year(s) Title/Event Sponsor(s) Coordinator/Chair/NI Representative(s)

1985 NLN initiated First National Forum: National League for Nursing, New York City, NY Susan Grobe, Chair
Computers in Healthcare and Nursing First Exec. Board:
Diane Skiba
Judy Ronald
Bill Holzemer
Roy Simpson
Pat Tymchyshyn
1985 First Annual Seminar on Computers and NYU Medical Center, NY, NY Patsy Marr New York University (NYU)
Nursing Practice Janet Kelly (NYU)
1985 First Invitational Nursing Minimum Data University of Illinois School of Nursing, Chicago, IL Harriet Werley (UIL)
Set (NMDS) Conference Norma Lang (UM)
1985 Early academic course: Essentials of Georgetown University School of Nursing, Virginia K. Saba (GU)
Computers, in Undergraduate and Washington, DC
Graduate Programs
1985 to 1990 Early 5-year Project: Continuing Nursing Southern Regional Education Board (SREB), Eula Aiken (SREB)
Education: Computer Technology, Focus: Atlanta, GA
Nursing Faculty
1985 First Test Authoring Program (TAP) Addison-Wesley Publishing, New York, NY William Holzemer (UCSF)
1985 First Artificial Intelligence System for Creighton On-line Multiple Medical Education Sheila Ryan, Dean and Faculty Professor,
Nursing Services (COMMES), Creighton University Steven Evans, Developer
1986 Two early Microcomputer Institutes for Georgetown University, School of Nursing, Virginia K. Saba (GU)
Nurses Washington, DC Dorothy Pocklington (USL)
University of Southwest Louisiana Nursing Diane Skiba (BU)
Department, Lafayette, LA
1986 Established first nurse educator’s newslet- Christine Bolwell and Stewart Publishing, Christine Bolwell, Editor
ter: Micro World Alexandria, VA
1986 CIN First Indexed in MEDLINE and CINAHL J. B. Lippincott Publisher, Philadelphia, PA Gary Hales, Editor
1986 First NI Pyramid—NI Research Model Published in CIN Indexed in MEDLINE and CINAHL Patricia Schwirian (OSU)
1987 Initiated and Created Interactive Videodisc American Journal of Nursing, New York, NY Mary Ann Rizzolo (AJN)
Software Programs
1987 International Working Group Task Force on IMIA/NI Working Group 8 and Swedish Ulla Gerdin (NI)
Education Federation, Stockholm, Sweden Kristina Janson Jelger and Hans Peterson
(Swedish Federation)
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ch01.indd 9

1987 Videodisc for Health Conference:
Interactive Healthcare Conference
1988 Recommendation #3: Support Automated
Information Systems.
1988 Priority Expert Panel E: Nursing Informatics
Task Force
1988 First Set of Criteria for Vendors
1989 Invitational Conference: Nursing
Information Systems, Washington, DC
1989 to Present Initiated First Graduate Programs with
Specialty in Nursing Informatics,
Master’s and Doctorate
1989 to 2009 Virtual Learning Resources
Stewart Publishing, Alexandria, VA Scott Stewart, Publisher
National Commission on Nursing Implementation Vivian DeBack, Chair
Project (NCNIP), Secretary’s Commission on
Nursing Shortage
National Center for Nursing Research, National Judy Ozbolt, Chair
Institutes of Health, Bethesda, MD
ANA (American Nurses Association/Council on Mary McHugh
Nursing Science)/CANS Chair
Rita Zielstorff
Jacqueline Clinton
National Commission on Nursing Implementation Vivian DeBack, Chair
Project (NCNIP), ANA, NLN, and NIS Industry
University of Maryland School of Nursing, Barbara Heller, Dean
Baltimore, MD Program Chairs: Carol Gassert, Patricia
Abbott, Kathleen Charters, Judy Ozbolt,
and Eun-Shim Nahm
Fuld Institute for Technology in Nursing Julie McAfoos, Pioneer Software Developer.
Education (FITNE)

Chapter 1 • Historical Perspectives of Nursing Informatics

1989 ICN Resolution Initiated Project: International Council of Nurses Conference, Fadwa Affra (ICN)
International Classification of Nursing Seoul, Korea
Practice (ICNP)
1990 to 1995 Annual Nurse Scholars Program (HBO) Healthcare Technology Company and Roy Simpson (HBO)
HealthQuest Corporation Diane Skiba (BU)
Judith Ronald (SUNY Buffalo)
1990 ANA House of Delegates Endorsed: ANA House of Delegates Harriet Werley (UM)
Nursing Minimum Data Set (NMDS) to
Define Costs and Quality of Care
1990 Invitational Conference: State-of-the-Art of NCNIP, Orlando, FL Vivian DeBack, Chair
Information Systems
1990 Renamed ANA: Steering Committee on ANA, Washington, DC Norma Lang, Chair
Databases to Support Nursing Practice Kathy Milholland Hunter (ANA)
1990 Task Force: Nursing Information Systems NCNIP, ANA, NLN, NIS Industry Task Force, Project Vivian DeBack, Chair
Hope, VA
1991 to 2001 First Annual European Summer Institute International Nursing Informatics Experts Jos Aarts and Diane Skiba (USA)
1991 First Nursing Informatics Listserv University of Massachusetts, Amherst, MA Gordon Larrivee
1991 Formation of Combined Annual SCAMC AMIA/SCAMC Sponsors, Washington, DC Judy Ozbolt, First Chair
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Special Nursing Informatics Working

Group and AMIA NIWG
(continued)

9
ch01.indd 10
TABLE 1.1 Landmark Events and Pioneers in Computers and Nursing, and Nursing Informatics (continued)
Year(s) Title/Event
1991/1992 Two WHO Workshops: Nursing Informatics
1991 to Present Initiated Annual Summer Institute in
Nursing Informatics (SINI)
1992 ANA Approved Nursing Informatics as a
New Nursing Specialty
1992 Formation of Virginia Henderson
International Nursing Library (INL)
1991/1992 ANA “Recognized” Four Nursing
Terminologies: Clinical Care
Classification (CCC) System, OMAHA
System, NANDA (North American
Nursing Diagnosis Association)
and (NIC) Nursing Intervention
Classification
1992 Read Clinical Thesaurus Added Nursing
Terms in UMLS/NLM
1992 Canadian Nurses Association: Nursing
Minimum Data Set Conference
1992 American Nursing Informatics Association
(ANIA) Founded
1993 Four ANA “Recognized” Nursing
Terminologies Integrated into UMLS
1993 Initiated Virginia Henderson Electronic
Library Online via Internet
1993 Initiated AJN Network Online via Internet
1993 ANC Postgraduate Course: Computer
Applications for Nursing
1993 Formation: Nursing Informatics Fellowship
Program
1993 Alpha Version: Working Paper of (ICNP)
International Classification of Nursing
Practice
22-10-2020 03:11:53
10
Sponsor(s) Coordinator/Chair/NI Representative(s)
P art 1 • N ursing I nformatics T echnologies
World Health Organization and US PHS, Marian Hirschfield (WHO)
Washington, DC, and Geneva, Switzerland Carol Romano (PHS)
University of Maryland School of Nursing (SON), Program Chairs: Carol Gassert,
Baltimore, MD Mary Etta Mills,
Judy Ozbolt, and Marisa Wilson
ANA Database Steering Committee, Washington, Norma Lang, Chair
DC
Sigma Theta Tau International Honor Society, Judith Graves, Director
Indianapolis, IN
ANA Database Steering Committee, Washington, Norma Lang, Chair
DC
Read Codes Clinical Terms, Version 3 Ann Casey (UK)
Canadian Nurses Association, Edmonton, Alberta, Phyllis Giovannetti, Chair
Canada
Southern, CA Melodie Kaltenbaugh
Constance Berg
ANA Database Steering Committee and NLM Norma Lang, Chair
Betsy Humphreys (NLM)
Sigma Theta Tau International Honor Society, Carol Hudgings, Director
Indianapolis, IN
American Journal of Nursing Company, New York, Mary Ann Rizzolo, Director
NY
Army Nurse Corps, Washington, DC Army Nurse Corps (ANC)
Partners Healthcare Systems, Wellesley, MA Rita Zielstorff, Director
International Council of Nurses, Geneva, Fadwa Affara (ICN)
Switzerland
ch01.indd 11

1993 Formed: Denver Free-Net University of Colorado Health Sciences Center, Diane Skiba (UC), Developer
Denver, CO
1993 Priority Expert Panel E: Nursing Informatics National Center for Nursing Research (NCNR/NIH), Judy Ozbolt, Chair
Report: Nursing Informatics: Enhancing Bethesda, MD
Patient Care
1994 ANA-NET Online American Nurses Association, Washington, DC Kathy Milholland (ANA)
1994 Four Nursing Educators Workshops on Southern Council on Collegiate Regional Eula Aiken (SREB)
Computers in Education Education and University of Maryland, Mary Etta Mills (UMD)
Washington, DC; Baltimore, MD; Atlanta, GA;
Augusta, GA
1994 Next Generation: Clinical Information Tri-Council for Nursing and Kellogg Foundation, Sheila Ryan, Chair
Systems Conference Washington, DC
1994, 2008, and First Nursing: Scope and Standards of ANA Database Steering Committee Kathy Milholland (ANA), Carol Bickford (ANA)
2014 Nursing Informatics Practice
1995 First International NI Teleconference: Three International NI Experts: Sue Sparks (USA)
Countries Linked Together Nursing Informatics, USA Evelyn Hovenga (AU)
Health Information System, Australia Robyn Carr (NZ)

Chapter 1 • Historical Perspectives of Nursing Informatics

Nursing informatics, New Zealand
1995 First Combined NYU Hospital and NYU NYU School of Nursing and NYU Medical Center, Barbara Carty, Chair
SON: Programs on Nursing Informatics New York, NY Janet Kelly, Co-Chair
and Patient Care: A New Era
1995 First Weekend Immersion in NI (WINI) CARING Group, Warrenton, VA Susan Newbold (CARING)
Carol Bickford (ANA)
Kathleen Smith (USN Retired)
1995 First CPRI Davies Recognition Awards of Computer-Based Patient Record Institute, Los Intermountain Healthcare, Salt Lake City, UT
Excellence Symposium Angeles, CA Columbia Presbyterian MC, New York, NY
Department of Veterans Affairs, Washington,
DC
1995 Initiated CARING Web site CARING Susan Newbold (CARING)
Marina Douglas
1995 First ANA Certification in Nursing ANA Credentialing Center (ANCC) Rita Zielstorff (Chair)
Informatics
1996 ANA Established Nursing Information and ANA Database Steering Committee, Rita Zielstorff, Chair
Data Set Evaluation Center (NIDSEC) Washington, DC Carol Bickford
Connie Delaney, Co-Chair
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(continued)

11
ch01.indd 12

12
TABLE 1.1 Landmark Events and Pioneers in Computers and Nursing, and Nursing Informatics (continued)
Year(s) Title/Event Sponsor(s) Coordinator/Chair/NI Representative(s)

P art 1 • N ursing I nformatics T echnologies

1996 First Online Nursing Wichita State University, Wichita, KS Mary McHugh
Informatics Course Associate Professor
1996–1997 Nightingale Project—Health Telematics University of Athens, Greece, and European Union John Mantas, Chair (Greece)
Education, Three Workshops and Two Arie Hasman, Co-Chair (Netherlands)
International Conferences
Consultants:
Virginia K. Saba (USA)
Evelyn Hovenga (AU)
1996 Initiated TELENURSE Project Danish Institute for Health and Nursing Research Randi Mortensen, Director
and European Union Gunnar Nielsen, Co-Director
1996 First Harriet Werley Award for Best Nursing AMIA-NI Working Group (NIWG), Washington, DC Rita Zielstorff (MGH Computer Lab) First
Informatics Paper at AMIA Awardee
1997 Invitational National Nursing Informatics National Advisory Council on Nurse Education Carol Gassert, Chair
Workgroup and Practice and DN/PHS
1997 ANA Published NIDSEC Standards and ANA Database Steering Committee Rita Zielstorff, Chair
Scoring Guidelines Connie Delaney, Co-Chair
1997 National Database of Nursing Quality American Nurses Association Nancy Dunton, PI
Indicators (NDNQI®)
1997 Initiated Nursing Informatics Archival NLM—History Collection Virginia K. Saba, Chair (GT)
Collection
1998 Initiated NursingCenter.com Web site JB Lippincott, New York, NY Maryanne Rizzalo, Director
1999 Beta Version: ICNP Published International Council of Nurses, Geneva, Fadwa Affara (ICN)
Switzerland
1999 to 2008 Annual Summer Nursing Terminology Vanderbilt University, Nashville, TN Judy Oxbolt, Chair
Summit Suzanne Bakken, Program Chair
1999 Convergent Terminology Group for Nursing SNOMED/RT International, Northbrook, IL Suzanne Bakken, Chair (NYU), and Debra
Konicek (CAP)
1999 and 2004 United States Health Information Department of Defense (Health Affairs), CMS, Luann Whittenburg (OASD/HA)
Knowledgebase (USHIK) Integrated CDC, AHRQ Glenn Sperle (CMS)
Nursing Data
M. Fitzmaurice (AHRQ)

1999 Inaugural Virtual Graduation: Online Post- GSN, Uniformed Services University Faye Abdellah (USU)
Masters: ANP Certificate Program VA Tele-Conference Network, Bethesda, MD Virginia K. Saba (USU)
Eight Nationwide VA MCs Charlotte Beason (VA)
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ch01.indd 13

1999 First Meeting: Nursing Data Standards Project Pan American Health Organization (PAHO), Roberto Rodriquez (PAHO)
for Central Organization (PAHO) and Brazil Washington, DC Heimar Marin (Brazil)
2000 First, Director of Professional Services Healthcare Information Management System Joyce Sensmeier
Society (HIMSS)
2000 ICNP Programme Office Established International Council of Nurses, Geneva, Amy Coenen, First Nursing Director
Switzerland
2000 Computer-Based Patient Record Institute CPRI, Los Angeles, CA Virginia K. Saba, Nursing Chair
(CPRI) 2000 Conference
2001 AMIA’s Nursing Informatics Leaders University of Wisconsin, Madison, WI Pattie Brennan, President
Columbia University, New York, NY Suzanne Bakken, Program Chair
2002 ICNP Strategic Advisory Group Established ICN, Geneva, Switzerland Amy Coenen, Director
2002 Conference: Strategy for Health IT and Medical Records Institute (MRI), Boston, MA Peter Waegemann, President
eHealth Vendors
2002 AAN Conference: Using Innovative American Academy of Nursing, Washington, DC Margaret McClure, Chair
Technology Linda Bolton, Co-Chair
Nellie O’Gara, Co-Chair
2002 Initiated AAN Expert Panel on Nursing American Academy of Nursing Annual Virginia K. Saba, Co-Chair
Informatics Conference, Naples, FL Ida Androwich, Co-Chair

Chapter 1 • Historical Perspectives of Nursing Informatics

2003 Finnish Nursing Informatics Symposium
2003 First ISO-Approved Nursing Standard:
Integrated Reference Terminology Model
for Nursing
2004 First ICN Research and Development
Centre
2004 to Present Initiated Annual Nursing Informatics
Symposium at (HIMSS) Health
Information Management Systems
Society Conference and Exhibition
2004 Initial Formation of Alliance for Nursing
Informatics (ANI)
2004 to 2012 First Nurse on (NCHVS) National Center
for Vital Health Statistics Standards
22-10-2020 03:11:53
Finnish Nurses Association (FNA) and Siemens
Medical Solutions, Helsinki, Finland
IMIA/NI-SIG and ICN, Oslo, Norway
Deutschsprachige ICNP, Freiburg, Germany
HIMSS Annual Conference, Orlando, FL
AMIA/HIMSS
NCVHS, Washington, DC
Kaija Saranto (FN)
Anneli Ensio (FN)
Rosemary Kennedy (Siemens)
Virginia K. Saba, Chair (NI/SIG)
Kathleen McCormick, Co-Chair (NIWG)
Amy Coenen, Co-Chair (ICN)
Evelyn Hovenga, Co-Chair (NI/SIG)
Susanne Bakken, Chair, Tech. Group
Peter Koenig, Director
Joyce Sensmeier, First Chair
Connie Delaney, Chair
Joyce Sensmeier, Co-Chair
Judy Warren, KUMC

Subcommittee
(continued)

13
ch01.indd 14

14
TABLE 1.1 Landmark Events and Pioneers in Computers and Nursing, and Nursing Informatics (continued)

P art 1 • N ursing I nformatics T echnologies

Year(s) Title/Event Sponsor(s) Coordinator/Chair/NI Representative(s)

2004 Office of the National Coordinator for National Coordinators First Coordinator:
Health Information Technology (ONC) Dr. David Brailer
Established
Dr. Robert Kolodner
Dr. David Blumenthal
Dr. Farzad Mostashari
Dr. Karen DeSalvo,
Nominated Directors.
2004 Technology Informatics Guiding Education National Members Marion Ball, Chair
Reform (TIGER)—Phase I Online Teleconferences Diane Skiba, Co-Chair
2006 First TIGER Summit 100 Invited Representatives from 70 Healthcare Marion Ball, Chair
Organizations; Summit Held at USU, Bethesda, Diane Skiba, Co-Chair
MD
2006 Revitalized NI Archival Collection—Initiated AMIA/NIWG Executive Committee Kathleen McCormick, Chair
Solicitation of Pioneer NI Documents Bonnie Westra, Co-Chair
Virginia K. Saba, Consultant
2005/2008/2009 ICNP Version 1.0, Version 1.1, and Version 2 ICN, Geneva, Switzerland Amy Coenen, Director
2006/2008 Symposium on Nursing Informatics Brazil Medical Informatics Society Heimar Marin, Chair
2007/2008 First National Nursing Terminology (ANSI-HITSP)American National Standards Virginia K. Saba and Colleagues, HITSP
Standard: Clinical Care Classification Institute’ and ‘Healthcare Information Committee Developers
(CCC) System Technology System Panel: Bio-surveillance
Committee HITSP Recommended and HHS
Secretary Approved
2007 to Present ANIA/CARING Joint Conferences Las Vegas, Washington, DC Victoria Bradley, Initial Chair
2009 to Present American Recovery and Reinvestment Act ONC National Health Information Technology Focus on Hospital HIT/EHR (Healthcare
of 2009—Health Information Technology Committee: Information Technology/Electronic
for Economic and Clinical Health (HITECH Healthcare Records) Systems Integrated
Act of 2009); ONC Formed Two National and Interoperable Terminology Standards
Committees, Each with One Nurse Health Policy Committee Judy Murphy, (Aurora Health Systems, MI)
Health Standards Committee Connie Delaney (UMN):
2009 ICNP recognized by WHO as First ICN and WHO, Geneva, Switzerland Amy Coenen, Director
International Nursing Terminology
2010 to Present Nursing Informatics Boot Camp Hospitals, Schools of Nursing, Vendors, Healthcare Susan K. Newbold, President
Member Organization
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ch01.indd 15

2010 Initiated: Doctor of Nursing Practice
Specialty in Informatics
2010 American Nursing Informatics Association
(ANIA and CARING) Merged
2011 Tiger Initiative Foundation Incorporated
2011 First Nurse as Deputy National
Coordinator for Programs & Policy at the
Office of the National Coordinator for
Health IT (ONC)
2012 to Present ANIA New Re-Named and First Annual
ANIA Conference
2013 First NI Nurse to be President of IMIA
2013 to 2019 Clinical Care Classification (CCC) System
(Q2 years) User Meetings
2013 to Present Nursing Knowledge Big Data Science
Initiative Annual Conferences
University of Minnesota, Minneapolis, MN
ANIA and CARING
TIGER Initiative
Office of the National Coordinator (ONC)
ANIA with merged CARING
IMIA
Hospital Corp of America (HCA) Nashville, TN
University of Minnesota School of Nursing
Connie Delaney, Dean SON, UMN
Bonnie Westra, Chair
Victoria Bradley, First President
Patricia Hinton Walker, Chair
Judy Murphy
Victoria Bradley, President
Patricia Sengstack, President (2013/2014)
Hyeoun-Ae Park
Seoul National University, Seoul, Korea
Virginia K. Saba Chair Jane Englebright
Co-Chair
Connie Delaney, Chair
Bonnie Westra

Chapter 1 • Historical Perspectives of Nursing Informatics

Co-Chair
2014 Collection of NI Artifacts Donated to University of Texas School of Biomedical Juliana and Jack Brixey
McGovern Historic Center Informatics
2016 First NI Nurse Director of National Library National Library of Medicine Patricia Brennen
of Medicine (NLM)
2016-2020 IMIA/NI-SIG Chair NI Expert - UC Diane Skiba, Chair
2019 Transfer CCC System to Hospital Corp of Nashville, TN Virginia K. Saba, CCC CNO & President ‘to’
America (HCA) Jane Englbright Senior VP & Chief Nursing
Executive , HCA
Jane Englebright, Senior VP & Chief Nursing
Executive, HCA
2020 7th Edition: Essentials of Nursing McGraw-Hill Publishing Virginia K. Saba, Co-Author
Informatics Kathleen McCormick, Co-Author
2021 MEDINFO / Combined IMIA and IMIA/ Sidney, Australia Australian NI
NI-SIG)
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15
 16 P art 1 • N ursing I nformatics T echnologies

TABLE 1.2 Nursing Knowledge Big Data Science Workgroups

Trendw Explanation/Example

Care Coordination Identify shareable and comparable data across settings to support care
coordination activities and improve patient outcomes.
Clinical Data Analytics Demonstrate the value of sharable and comparable nurse-sensitive data
to support practice and translational research for transforming health
care and improving patient quality and safety.
Context of Care Develop the test Big Data set using the Kruchten 4+1 Model and Unified
Modeling Language (UML) to introduce an integrating and harmonizing
framework for sharable and comparable nurse data across the care con-
tinuum that incorporates the Nursing Minimum Management Data Set
(NMMDS) and links key Workgroup activities.
Education Strengthen informatics education at the graduate and specialty levels and
the ability of educators who teach informatics to nursing student so
that we can achieve the outcomes of shareable and comparable nursing
data through the work of nurses at the point of care.
Encoding and Modeling Develop and disseminate LOINC and SNOMED Clinical Terms for electronic
health record nursing assessments, and incorporate them into a frame-
work and repository for dissemination.
Engage and Equip All Nurses in Health IT Policy Equip nurses with education, tools, and resources and engage them as
knowledgeable advocates for health IT policy efforts important to
nursing.
E-Repository Develop and implement a repository designed to collect nursing infor-
matics best evidence in the form of documents, surveys, instruments,
algorithms, for example.
Mobile Health Explore the use of mobile health tools and data for nurses including both
nursing-generated data and patient-generated data. Identify and sup-
port activities and resources to address unmet needs and create oppor-
tunities to utilize mHealth data within nursing workflows.
Nursing Value Measure the value of nursing care as well as the contribution of individual
nurses to clinical outcomes and cost. Develop big data techniques for
secondary data analysis that will provide metrics to monitor quality,
costs, performance, effectiveness, and efficiency of nursing care.
Social Determinants of Health Support the inclusion, interoperability, and data exchange of Social
Determinants of Health (SDOH) data in electronic health records, per-
sonal and m-health tools, and community and public health portals
across care settings. Empower nurses (practice, education, research, pol-
icy) to use SDOH data as context for planning care. Develop a roadmap
to engage nurses to improve population health through large-scale
adoption of SDOH.
Transforming Documentation Explore ways to decrease the nursing documentation burden and serve
up the information already in the electronic health record at the right
time in the workflow to support evidence-based and personalized care.
Elevate purpose-driven, role-based, patient-centric, evidence-informed
documentation transformation to capture nurse observations and inter-
ventions, and drive purposeful secondary-use and precision nursing.

ch01.indd 16 22-10-2020 03:11:54

 Chapter 1 • Historical Perspectives of Nursing Informatics
1970s During the late 1960s through the 1970s, hospitals
began developing computer-based information systems
which initially focused on computerized physician order
entry (CPOE) and results reporting; pharmacy, labora-
tory, and radiology reports; information for financial and
managerial purposes; and physiologic monitoring systems
in the intensive care units; and a few systems started to
include care planning, decision support, and interdisci-
plinary problem lists. While the content contained in early
hospital information systems frequently was not specific to
nursing practice, a few systems did provide a few pioneer
nurses with a foundation on which to base future nurs-
ing information systems (Blackmon et al., 1982; Collen,
1995; Ozbolt & Bakken, 2003; Romano, McCormick, &
McNeely, 1982). Regardless of the focus, which remained
primarily on medical practice, nurses often were involved
in implementing health information technology (HIT)
systems.
Interest in computers and nursing began to emerge
in public health, home health, and education during the
1960s to 1970s. Automation in public health agencies
began as a result of pressure to standardize data collec-
tion procedures and provide state-wide reports on the
activities and health of the public (Parker, Ausman, &
Ovedovitz, 1965). In the 1970s, conferences sponsored
by the Division of Nursing (DN), Public Health Service
(PHS), and the National League for Nursing (NLN) helped
public health and home health nurses understand the
importance of nursing data and their relationship to new
Medicare and Medicaid legislation requirements passed
in 1966. The conferences provided information on the
usefulness of computers for capturing and aggregating
home health and public health information. Additional
government-sponsored conferences focused on educa-
tional uses of computers for nurses (Public Health Service,
1976). Simultaneously, hospitals and public health agen-
cies embarked on investigating computers and nursing;
the opportunity to improve education using computer
technology commenced. Bitzer (1966) reported on one
of the first uses of a computerized teaching system called
PLATO, which was implemented to teach classes in off-
campus sites as an alternative to traditional classroom
education.
The early nursing networks, which were conceived
at health informatics organizational meetings, helped to
expand nursing awareness of computers and the impact
HIT could have on practice. The state of technology ini-
tially limited opportunities for nurses to contribute to the
HIT design, but as technology evolved toward the later part
of the 1970s and as nurses provided workshops nationally,
nurses gained confidence that they could use computers
to improve practice. The national nursing organization’s
ch01.indd 17
17
federal agencies (Public Health Service, Army Nurse
Corps) and several university schools of nursing provided
educational conferences and workshops on the state-of-
the-art regarding computer technology and its influence
on nursing. During this time, the Clinical Center at the
National Institutes of Health implemented the Technicon
Data System (TDS) system; one of the earliest clinical
information systems (called Eclipsys & Allscripts) was the
first system to include nursing practice protocols.
In addition to the use of computers, advancement was
underway for other technologies and/or devices used by
nurses. For example, the first point-of-care blood glucose
monitor became available for use in the clinical setting in
1970 (Clarke & Foster, 2012). The devices became smaller
and more widespread in the 1980s.
1980s In the 1980s, the field of nursing informatics
exploded and became visible in the healthcare industry
and nursing. Technology challenged creative profession-
als in the use of computers in nursing. As computer sys-
tems were implemented, the needs of nursing took on a
cause-and-effect modality; that is, as new computer tech-
nologies emerged and as computer architecture advanced,
the need for nursing software evolved. It became apparent
that the nursing profession needed to update its practice
standards and determine specific data standards, vocabu-
laries, and classification schemes that could be used for
the computer-based patient record systems.
In the 1980s, the microcomputer or personal computer
(PC) emerged. This revolutionary technology made com-
puters more accessible, affordable, and usable by nurses
and other healthcare providers. The PC brought comput-
ing power to the workplace and, more importantly, to the
point of care. Also, the PCs served as dumb terminals
linked to the mainframe computers and as stand-alone
systems (workstations). The PCs were user-friendly and
allowed nurses to design and program their own applica-
tions. The influence of computer technology extended to
the introduction of devices to improve patient safety. For
example, the automated dispensing cabinets (ADCs) were
introduced in the 1980s (Grissinger, 2012). The computer-
controlled ADCs replaced medication carts and drug floor
stock. Tracking of medications occurred at the point of
care. The use of ADCs in the clinical setting has resulted
in the reduction of medication errors.
Starting in 1981, national and international confer-
ences and workshops were conducted by an increasing
number of nursing pioneers to help nurses understand
and get involved in this new emerging nursing specialty.
Also during the 1980s, invitational conferences were
conducted to develop nursing data sets and vocabular-
ies as well as numerous workshops were conducted at
22-10-2020 03:11:54
 18 P art 1 • N ursing I nformatics T echnologies
universities to introduce this new specialty into nursing
education. During this period, many mainframe health-
care information systems (HISs) emerged with nursing
subsystems. These systems documented several aspects
of the patient record, namely, provider order entry and
results reporting, the Kardex reporting, vital signs, and
other systems-documented narrative nursing notes using
word-processing software packages. Discharge planning
systems were developed and used as referrals to commu-
nity, public, and home healthcare facilities for the contin-
uum of care.
Nurses began presenting at multidisciplinary confer-
ences and formed their own working groups within HIT
organizations, such as the first Nursing Special Interest
Group on Computers which met for the first time dur-
ing SCAMC (Symposium on Computer Applications in
Medical Care) in 1981. As medical informatics evolved,
nursing began focusing on what was unique about nursing
within the context of informatics. Resolutions were passed
by the American Nurses Association (ANA) regarding
computer use in nursing and in 1985, the ANA approved
the formation of the Council on Computer Applications in
Nursing (CCAN). One of the first activities the CCAN exec-
utive board initiated was to solicit several early pioneers to
develop monographs on the status of computers in nursing
practice, education, research, and management. The CCAN
board developed a yearly Computer Nurse Directory on the
known nurses involved in the field, conducted computer
applications demonstrations at the ANA annual confer-
ences, and shared information with their growing members
in the first CCAN newsletter Input-Output. During this
time NI newsletters, journals, and several books, such as the
first edition of this book Essentials of Computers for Nurses
published in 1986, were used for educational courses intro-
duced in the academic nursing programs, and workshops
conducted on computers and nursing. The CCAN became
a very powerful force in integrating computer applications
into the nursing profession. In 1988, the CCAN commis-
sioned three NI experts to prepare a set of criteria on the
integration of nursing practice for EHR vendors to fol-
low (Zielstorff, McHugh, & Clinton, 1988). In 1989, the
ANA renamed the CCAN to the Steering Committee on
Databases to Support Clinical Nursing Practice, which later
became the Committee for Nursing Practice Information
Infrastructure (CNPII). The purpose of the CNPII was to
support development and recognition of national health
data standards (Coenen et al., 2001).
1990s By the 1990s, large integrated healthcare delivery
systems evolved, further creating the need for informa-
tion across healthcare facilities within these large systems
to standardize processes, control costs, and assure the
ch01.indd 18
quality of care (Shortliffe, Perreault, Wiederhold, & Pagan,
2003). Advances in relational databases, client-server
architectures, and new programming methods created the
opportunity for better application development at lower
costs. Legislative activity in the mid-1990s paved the way
for EHRs through the Health Insurance Portability and
Accountability Act (HIPAA) of 1996 (public-law 104-191),
emphasizing standardized transactions, and privacy and
security of patient-identifiable information (Gallagher,
2010). The complexity of technology, workflow analysis,
and regulations shaped new roles for nursing.
In 1992, the ANA recognized nursing informatics as
a new nursing specialty with a separate Scope of Nursing
Informatics Practice Standards, and also established a
specific credentialing examination for it (ANA, 2008).
Numerous local, national, and international organiza-
tions provided a forum for networking and continuing
education for nurses involved with informatics (Sackett &
Erdley, 2002). The demand for NI expertise increased in
the healthcare industry and other settings where nurses
functioned, and the technology revolution continued to
impact the nursing profession.
The need for computer-based nursing practice stan-
dards, data standards, nursing minimum data sets, and
national databases emerged concurrently with the need
for a unified nursing language, including nomenclatures,
vocabularies, taxonomies, and classification schemes
(Westra, Delaney, Konicek, & Keenan, 2008). Nurse
administrators started to demand that the HITs include
nursing care protocols and nurse educators continued to
require the use of innovative technologies for all levels
and types of nursing and patient education. Also, nurse
researchers required knowledge representation, deci-
sion support, and expert systems based on standards that
allowed for aggregated data (Bakken, 2006).
In 1997, the ANA developed the Nursing Information
and Data Set Evaluation Center (NIDSEC) to evaluate and
recognize nursing information systems (ANA, 1997). The
purpose was to guide the development and selection of
nursing systems that included standardized nursing ter-
minologies integrated throughout the system whenever
it was appropriate. There were four high-level standards:
(a) inclusion of ANA-recognized terminologies; (b) link-
ages among concepts represented by the terminologies
retained in a logical and reusable manner; (c) data included
in a clinical data repository; and (d) general system char-
acteristics. The Certification Commission for Health
Information Technology (CCHIT) had similar criteria
for the EHR certification, which was later adopted by the
Office of the National Coordinator for Health Information
Technology (ONC); however, nursing data was no longer
included. ANA was ahead of its time in its thinking and
22-10-2020 03:11:54
 Chapter 1 • Historical Perspectives of Nursing Informatics
development. The criteria are now under revision by the
ANA to support nurses to advocate their requirements for
the emerging HIT systems.
Technology rapidly changed in the 1990s, increasing
its use within and across nursing units as well as across
healthcare facilities. Computer hardware—PCs—con-
tinued to get smaller and computer notebooks were
becoming affordable, increasing the types of computer
technology available for nurses to use. Linking computers
through networks both within hospitals and health sys-
tems as well as across systems facilitated the flow of patient
information to provide better care. By 1995, the Internet
began providing access to information and knowledge
databases to be integrated into desktop computer systems.
It revolutionized information technologies. The Internet
moved into the mainstream social milieu with electronic
mail (e-mail), file transfer protocol (FTP), Gopher, and
Telnet, and World Wide Web (WWW) protocols greatly
enhanced its usability and user-friendliness (Saba, 1996;
Sparks, 1996). The Internet was used for high-performance
computing and communication (HPCC) or the “informa-
tion superhighway” and facilitated data exchange between
computerized patient record systems across facilities and
settings over time. The Internet led to improvements in
networks, and a browser, WWW, allowed organizations
to communicate more effectively and increased access to
information that supported nursing practice. The WWW
also became an integral part of the HIT systems and the
means for nurses to browse the Internet and search world-
wide resources (Nicoll, 1998; Saba, 1995).
2000s A change occurred in the new millennium as more
and more healthcare information became digitalized and
newer technologies emerged. In 2004 an executive order
13335 established the ONC and issued a recommendation
calling for all healthcare providers to adopt interoperable
EHRs by at least 2014 or 2015 (http://healthhit.gocv/topic/
about-onc). This challenged nurses to get involved in the
design of systems to support their workflow as well as in
the integration of information from multiple sources to
support nurses’ knowledge of technology. In the late 2000s,
as hospitals became “paperless,” they began employing
new nurses who had never charted on paper.
Technological developments that influenced health-
care and nursing included data capture and data sharing
technological tools. Wireless, point of care, regional data-
base projects, and increased IT solutions proliferated in
healthcare environments, but predominately in hospitals
and large healthcare systems. The use of bar coding and
radiofrequency identification (RFID) emerged as a useful
technology to match the “right patient with the right med-
ication” to improve patient safety. A barcode medication
ch01.indd 19
19
administration (BCMA) system was first implemented
in 2000 in an acute care hospital to electronically cap-
ture medication management (Wideman, Whittler, &
Anderson, 2005). The RFID also emerged to help nurses
find equipment or scan patients to assure that all surgical
equipment is removed from inside patients before surgi-
cal sites are closed (Westra, 2009). Smaller mobile devices
with wireless or Internet access such as notebooks, tablet
PCs, personal digital assistants (PDAs), and smart cellu-
lar telephones increased access to information for nurses
within hospitals and in the community. The development
and subsequent refinement of voice over Internet protocol
(VoIP) provided voice cost-effective communication for
healthcare organizations.
The Internet which appeared in 1995 provided a
means for the development of clinical applications. Also,
databases for EHRs could be hosted remotely on the
Internet, decreasing costs of implementing EHRs. Remote
monitoring of multiple critical care units from a single
site increased access for safe and effective cardiac care
(Rajecki, 2008). Home healthcare increasingly partnered
with information technology for the provision of patient
care. Telehealth applications, a recognized specialty for
nursing since the late 1990s, provided a means for nurses
to monitor patients at home and support specialty con-
sultation in rural and underserved areas. The NI research
agenda promoted the integration of nursing care data in
HIT systems that would also generate data for analysis,
reuse, and aggregation.
A historical analysis of the impact of the Nursing
Minimum Data Set (NMDS) demonstrated that contin-
ued consensus and effort was needed to bring to fruition
the vision and implementation of minimum nursing data
into clinical practice (Hobbs, 2011). The NMDS continues
to be the underlining focus in the newer HIT systems. A
new NI research agenda for 2008–2018 (Bakken, Stone, &
Larson, 2012) emerged as critical for this specialty. The
new agenda is built on the agenda originally developed and
published by the National Institute for Nursing Research
(NINR) in 1993 (NINR, 1993). The authors focused on
the new NI research agenda on “3 aspects of context—
genomic health care, shifting research paradigms and
social (Web2.0) technologies” (p. 280).
A combination of the economic recession along with
the escalating cost of healthcare resulted in the American
Recovery and Reinvestment Act (ARRA) of 2009 and
the Health Information Technology for Economic and
Clinical Health (HITECH) Act of 2009 with funding to
implement HIT and/or EHR systems, support health-
care information exchange, enhance community and
university-based informatics education, and support lead-
ing edge research to improve the use of HIT (Gallagher,
22-10-2020 03:11:54
 20 P art 1 • N ursing I nformatics T echnologies
2010). One of the first ONC initiatives was the Healthcare
Information Technology Standards Panel (HITSP) which
was designed to determine what coding systems were used
to process patient care data from admission to discharge.
It was found that the nursing care data was missing in the
existing EHRs. Initially, in 2005–2007, the Clinical Care
Classification (CCC) System met the established stan-
dards as interoperable and was accepted and approved as
the free, coded, nursing taxonomies that could be used for
assessing and documenting nursing care to generate qual-
ity outcomes (Saba & Whittenburg, 2015). This project
ended in 2009 when the HITECH Act of 2009 emerged.
2010s During 2010, the ONC convened two national
committees, (a) National Committee on Health Policy and
(b) National Committee on Health Standards, which out-
lined and designed to address the HITECH Act of 2009.
The committees designed the “Meaningful Use” (MU)
program which was to be implemented in three stages of
legislation consisting of regulations which built onto each
other with the ultimate goal of implementing a complete
and interoperable EHR and/or HIT system in all U.S. hos-
pitals. For each stage, regulations were proposed by the
national committees, developed and reviewed by the pub-
lic before they were finalized, and submitted to Centers for
Medicare and Medicaid (CMS) and the healthcare facili-
ties for implementation.
In 2011–2012, MU Stage 1 was initiated focusing pri-
marily on the CPOE initiative for physicians. Hospitals
that implemented this MU regulation successfully received
federal funds for their HIT systems. In 2013–2015, MU
Stage 2 was introduced focusing primarily on the imple-
mentation of quality indicators that required electronic
data to be collected as an integral component in the HIT
systems. The quality indicators would be used to guide
hospitals in patient safety and if not implemented used
as indicators subject to financial penalties. The proposed
MU Stage 3 that focused on care quality outcome mea-
sures was not implemented but replaced by the Medicare
Access and CHIP Reauthorization Act (MACRA) of
2015. The MACRA legislation created a new Medicare
Quality Payment Program that prioritized the value of
healthcare received by Medicare beneficiaries and revised
Medicare’s reimbursement to eligible providers. The legis-
lation consolidated components of the Physician Quality
Reporting System (PQRS), Value-Based Payment Modifier
(VBM), and the Medicare Electronic Health Record
(EHR) Incentive program into the Merit-Based Incentive
Payment System (MIPS). The purpose of the MIPS pro-
gram, initiated in 2017, was to establish Medicare pay-
ment to healthcare professional’s performance score
based on a value-based healthcare model. As a result, the
ch01.indd 20
CMS began to focus reimbursement on a quality payment
program that addressed quality outcome measures (MIPS,
2019). It is anticipated that this initiative will also mini-
mize the payment burden on the clinicians by aggregating
their patients’ health information from multiple providers
into a single electronic application.
As of 2018, the CMS proposed policies to strengthen
Interoperability. The ONC and CMS rebranded MU to
Promoting Interoperability. It is anticipated that the initia-
tive will make use of new technologies and for patients to
aggregate their health information from multiple provid-
ers into a single electronic application. In 2019, the ONC
continued to implement the latest legislation as well as
Interoperability through summits, webinars, and public
comment.
Nurses have always been involved with all phases of
MU as well as all other legislation, from the implemen-
tation of systems to assuring usage and adaptation to the
evolving health policy affecting the HIT and/or EHR sys-
tems. Thus, the field of nursing informatics (NI) contin-
ues to grow due to the MU regulations which continue to
impact on every inpatient hospital in the country. To date,
the majority of hospitals in the country has established
HIT departments and has employed at least one nurse to
serve as a NI expert to assist with the implementation of
MU requirements. As the MU requirements changed they
also impacted on the role of the NI experts in hospitals
and ultimately on the roles of all nurses in the inpatient
and outpatient facilities making NI an integral component
of all professional nursing services. An example of nurs-
ing involvement is the implementation of the CCC System
nursing terminologies for documenting nursing practice
in the Hospital Corp of American (HCA) healthcare facili-
ties (Saba & Whittenburg, 2015).
Electronic Health Record Systems from a
Historical Perspective
In 1989, the Institute of Medicine (IOM) of the National
Academy of Sciences convened a committee and asked
the question, “Why is healthcare still predominantly
using paper-based records when so many new computer-
based information technologies are emerging?” (Dick &
Steen, 1991). The IOM invited representatives of major
stakeholders in healthcare and asked them to define the
problem, identify issues, and outline a path forward. Two
major conclusions resulted from the committee’s delib-
erations. First, computerized patient record (CPR) is an
essential technology for healthcare and is an integral tool
for all professionals. Second, the committee after hear-
ing from numerous stakeholders recognized that there
22-10-2020 03:11:54
Another random document with
no related content on Scribd:
 "Mutta hän tekee minulle pahaa", kirkui poika. "Hän tekee pahaa
minulle juuri nyt."

"No niin, varro vaan, kunnes saan hänet maalle kanssani", sanoi
Jem.
"Oma muijansakaan ei ole tunteva häntä, kun lasken hänet
kynsistäni."

Pojan vastaus oli virta hävyttömyyksiä, pääasiallisesti tarkoittaen

Jemin ruumiillisia puutteellisuuksia.

"Kas niin, älkää olko epäkohtelias, sanoi merimies tirskuten.

"Kierosilmäinen linnunpelätti", kirkui Ralph villisti.

"Jahka olet lopettanut tuon nuoren herran kanssa, Dobbs", sanoi

Jem valitulla kohteliaisuudella, "tahtoisin minä lainata häntä
vähäsen, opettaakseni säädyllisyyttä."

"Hän ei tahdo erota minusta", virnisteli Dobbs. "Huomaahan poika

kuka hänelle hyvää tahtoo."

"Varroppas vaan…", nyyhki Ralph, kun Jem repäsi hänet Dobbsin

polvilta.

"Hellalletta", ihmetteli Jem. "Luulempa hänen itkevän. Monta

merirosvoa olen eläissäni nähnyt, mutta tämä tosiaankin on
ensimäinen laatuaan."

"Antakaa pojan olla rauhassa", sanoi kokki, lihava hyvänluontoisen

näkönen mies. "Kas niin, tule tänne, poikaseni. Eivät he niin pahaa
tarkoita, miltä näyttää."
 Iloisena päästyään kiusaajistaan, riensi Ralph kokin luokse, mutta
puri hammasta häpeästä, kun tämä kunnon mies otti hänet polviensa
väliin ja kuivasi hänen silmänsä johonkin, jota hän kutsui
nenäliinaksi.

"Teistä kyllä tulee hyvää", sanoi hän ystävällisesti. "Teistä kyllä

tulee yhtä hyvä merirosvo, kuin mekin olemme, jahka vaan valmiiksi
tulette."

"Niin, odottakaa vaan ensimäistä yhteentörmäystä", nyyhkytti

poika.
"Ellei silloin eräs henkilö saa kuulaa selkäänsä, on se minun vikani."

Molemmat matruusit katsahtivat toisiinsa.

"Vai se se kova olikin, jonka tunsin", sanoi Dobbs. "Ja minä kun
luulin sitä tuppipuukoksi."

Enempää kursailematta, tarttui hän poikaa kaulukseen ja kaivoi

hänen taskustaan pienen, halvan revolverin. "Katsoppas tätä, Jem!"

"Kyllä, jahka ensin otat sormesi liipasimesta", sanoi Jem vähän

happamen imelästi.

"Minä heitän sen yli syrjän", sanoi Dobbs.

"Älä hulluttele, Bill", huudahti Smithers ja pisti aseen taskuunsa.

"Joku lasi olutta sillä aina heltiää. Pois tieltä, Bill, merirosvojen
kuningas haluaa kannelle."

Bill astui syrjään ja laskettuaan pojan rauhassa muutaman

rappusen, sysäsi hän yht'äkkiä hartioillaan pojan takapuoleen, jotta
Ralph syöksyi kannelle mahalleen. Kiireesti oli poika kuitenkin taas
pystyssä ja otettuaan arvokkaamman asennon, nojautui hän laivan
syrjään ja katseli halveksivasti ahertavia "työmuurahaisia" laiturilla ja
joella.

Yöllä nostettiin purjeet ja päivän koittaessa ankkuroitiin

Longreachin ulkosatamaan, jossa tynnöreillä lastattu lotja pian tuli
kuunarin sivulle. Poika vainusi seikkailuja, kuullessaan astioiden
sisältävän ruutia. Lastattiin kymmenen tonnia, lotja irroitettiin,
kansiluukut asetettiin paikoilleen ja Susan Jane jätti sataman.

Tämä oli pojan ensimäinen matka ja hän katseli uteliaasti merellä

purjehtivia laivoja. Matruusien kanssa oli rauha jo solmittu ja nämä
koettivat turhaan pelottaa poikaa verta jähmetyttävillä jutuilla
seikkailuistaan.

"Hän on koko kirottu nulikka, totta totisesti, se hän on", sanoi Bill,
joka itsekin oli ihmetellyt kertomistaitoaan. "Ajatelkaas, hän nauroi
vaan, kun kerroin heittäneeni rintalapsen haikaloille."

"Aivan samantapainen, kuin muutkin pojat, Bill", sanoi kokki.

"Odottakaa nyt, kunnes itsekin saatte niitä seitsemän, kahdeksan
kappaletta."

"Mitä siellä teet poika?" kysyi laivuri, kun Ralph, jota merimiesten
jutut eivät enää huvittaneet, asteli kädet housuntaskuissa ympäri
peräkantta.

"En mitään", vastasi poika.

"Pysyttele sitten toisessa päässä laivaa", sanoi laivuri, "ja mene

auttamaan kokkia perunain kuorimisessa."
 Ralph epäili, mutta perämiehen huulilla näyttäytyvä iva-hymy, sai
hänet pian tekemään päätöksensä.

"Minä en ole tullut tänne perunoita kuorimaan", sanoi hän ylpeästi.

"Vai niin", sanoi laivuri kohteliaasti. "Ja minkätähden tänne sitten

olet tullut, ellei ole epäkohteliasta kysyä?"

"Taistellakseni vihollisen kanssa", sanoi Ralph.

"Tule tänne", käski laivuri.

Poika totteli hitaasti.

"Kuuleppas", sanoi laivuri. "Minä aion rutistaa vähän järkeä

tyhmään kalloosi. Olen kuullut järjettömistä leikeistäsi maalla ja kun
isäsi kertoi, ettei sinua voi pitää aisoissa, päätin minä ottaa sen
tehdäkseni. Ja sen saatkin nähdä, ettei kanssani ole yhtä helppo
leikitellä kuin hänen. Miten lapsellista ajatellakin! Tämäkö
merirosvojen laiva! Sinun ikäisesi pojan pitäisi jo tietää, ettei sellaisia
enää löydy."

"Tehän sanoitte olevanne merirosvo", sanoi poika. "Muuten en

mukaanne olisi lähtenytkään."

"Senpä tähden niin sanoinkin", sanoi laivuri.

"Mutta koskaan en voinut sinua luulla sellaiseksi pässinpääksi,

että todeksi sitä ottaisit. Merirosvo! Jopa nyt peräti! Näytänkö minä
sitten merirosvolta?"

"Ette, — ette todellakaan", vastasi poika pilkallisesti nauraen.

"Paremmin näytätte…"
 "Miltä näytän?" kysyi laivuri ja astui askeleen lähemmäksi. "Miltä?"

"Olen unohtanut sen", sanoi Ralph varovasti.

"Elä valehtele", sanoi laivuri ja punastui, kuullessaan perämiehen

tirskuvan. "No laula ulos vaan! Annan kaksi minuuttia aikaa sinulle."

"Kadunlakasija", esitteli perämies, tullen avuksi. "Ämmä,

nokikolari, lumpunkokooja, taskuvaras, linnan vanki, pesumuija…"

"Jos olisitte hyvä ja hoitaisitte omat toimenne, George, ettekä

sekaantuisi asioihin, jotka teihin eivät koske, niin olisin erinomaisen
kiitollinen", sanoi laivuri puoleksi tukahtuneella äänellä. "No poika,
minkä näköiseksi aioit sanoa minua?

"Kuten perämieskin", sanoi Ralph pitkäveteisesti.

"Älä valehtele!" ärjäsi laivuri raivoissaan. "Et sinä sitä ole voinut
unohtaa."

"En olekaan", sanoi Ralph, "mutta en tietänyt, mitä te siitä

pitäisitte."

Laivuri katsoi epäilevästi poikaa, työnsi hattunsa takaraivolle ja

raappi hermostuneesti päätään.

Enkä myöskään tietänyt mitä perämies "siitä pitäisi", jatkoi poika.

Hän vapautti laivurin kiusallisesta kohtauksesta, juoksemalla

keittiöön. Susan Janen päällikkö katseli hetkisen tyhmistyneenä
ympärilleen ja kääntyi sitten perämieheensä.

"Hänestä ette hevillä ota selvää", sanoi tämä viimeksimainittu ja

nyökkäsi. "Todellinen pieni saatana."
 Laivuri ei vastannut, mutta kun perunat olivat valmiita, sai nuori
merimiehen alku ryhtyä kiillottamaan messinkejä, senjälkeen siivota
kajuutan ja lopuksi auttaa kokkia pannujen ja patojen
puhdistuksessa. Perämies sillä aikaa piti tarkastuksen hänen
arkussaan.

"Näistä hän saa hullutuksensa", sanoi hän kajuuttaan palattuaan,

kainalossaan paksu pinkka pieniä kirjoja. "Kuulkaas nimiä vaan: —
'Tyynen meren leijona', 'Yksikätinen merirosvo', 'Kapteeni Kiddin
viimeinen matka'…"

Hän istuutui lähelle kajuutan ikkunaa ja alkoi selailla kirjoja, lukien

laivurillekin tuon tuostakin jonkun kultamurusen. Viimemainittu
kuunteli alussa halveksien, vaan lopulta oikealla jännityksellä.

"En todellakaan saa mitään kokonaisuutta luvustanne, George",

sanoi hän harmistuneena. "Kuka oli Rudolph? Lukekaa enemmän."

Perämies luki taukoamatta kolme ensimäistä vihkoa ja kolmas

loppui juuri kuin Rudolph ui kilpaa kahden haikalan ja
veneenlastillisen ihmissyöjäin kanssa. Mutta tähän vihot
loppuivatkin, vaikka perämies uudestaan tarkasti pojan arkun.

"Muuta ei häneltä voinut odottaakaan", sanoi laivuri suuttuneena.

"Vaan minäpä opetan hänelle järjestystä, totta totisesti! Nuo kirjat
lukitsette arkkuunne, George, ettekä anna niitä pojalle."

Aavalle merelle saapuminen alkoi nyt tuntua kuunarilla.

Edessäpäin näkyi vaan sininen meri, jolla valkeat purjeet ja savuavat
sauhupiiput kiidättivät Englannin tavaroita mailman markkinoille.
 Seuraavat päivät oli poika joko merikipeä, tai työssä; tätä
viimemainittua käytti laivuri hyvänä lääkkeenä merirosvohoureita
vastaan ja edelliseen neuvoi kokki parhaaksi suolaista sianlihaa. Kun
vihdoin viidentenä aamuna päästiin Fairhaveniin, oli poika
seitsemännessä taivaassa, nähdessään taas maata ja rakennuksia.

Fairhaveniin jätettiin vaan osa lastista ja Ralph hommasi, toisten

mukana, housut ja paidanhihat kiverrettyinä. Kun työ oli valmis,
nostettiin uudestaan ankkuri ja purjehdittiin noin 30 penikulman
päässä olevaan Lawportiin, johon ruutilasti oli jätettävä.

Perille päästyä oli ilta ja pakoveden aika, joten ankkuroitiin

kaupungin lävitse juoksevan joen suuhun.

"Purjehdimme neljän tienoilla sisään", sanoi laivuri perämiehelle.

"No Ralph? Tuntuuko ollenkaan paremmalta, kun vähän olen
naputellut tyhmyyksiä päästäsi?"

"Paljonkin paremmalta, sir", vastasi poika kunnioittavasti.

"Ole kiltti poika", sanoi laivuri ja pysähtyi kajuutan rappusille, "niin

saat jäädä, jos sinua haluttaa, pitemmällekin laivaan. Nyt saat
mennä kojuusi, sillä huomen aamulla on aikaisin oltava pystyssä."

Poika jäi yksin kannelle. Miehistö istui kanssissa ja poltteli, paitsi

kokkia, joka hääräili jotakin omaan laskuunsa keittiössä.

Tunti senjälkeen hiipi hänkin lepäämään. Molemmat matruusit

nukkuivat jo ja kokki aikoi juuri ryömiä kojuunsa, kun samassa
huomasi pojan vuoteen tyhjäksi. Ihmetellen hieroi hän nenäänsä,
nousi kannelle ja katseli ympärilleen, vaan kuin ei mitään näkynyt,
palasi hän takaisin.
 "Missä poika on?" kysyi hän ja ravisteli Jemiä käsivarresta.

"Mitä?" mörisi Jem ja nousi istumaan. "Kenen poika?"

"Meidän, — Ralph?" sanoi kokki. "Minä en löydä häntä mistään.

Ettei hän vaan olisi mennyt yli syrjän, varpusraukka."

Kun Jem kieltäytyi neuvottelemasta asiasta, herätti kokki Dobbsin.

Dobbs murisi muutamia kirouksia ja nukkui uudestaan. Kokki nousi
taas kannelle, etsi kaikista mahdollisista paikoista, kiipesi kappaleen
matkaa mastoonkin, missä ei eläissään ollut käynyt, ja kun ei
jälkeäkään näkynyt pojasta, tyytyi hän, joskin vastenmielisesti
johtopäätökseen, että poika oli pudonnut mereen.

"Varpusraukka", sanoi hän surkutellen ja katseli, ympärilleen.

Hitaasti asteli hän peräkannelle ja pudisti päätään, mutta
vilkaistuaan perän taakse, pelästyi hän, päästi tahtomattaan huudon
ja hieroi silmiään. Laivavene oli myöskin kadonnut.

"Mitä?" kysyivät molemmat merimiehet, kun kokki törmäsi kanssiin

ja ilmoitti uutisen. "Jos se on poissa, niin se on poissa."

"Eiköhän liene parasta mennä ilmoittamaan asia laivurille?" sanoi

kokki.

"Anna hänen itse ottaa selvä asioistaan", sanoi Jem ja kehräsi

tyytyväisenä, kuin kissa pahnassaan. "Vene on hänen. Hyvää yötä!"

"Ja uuden siitä vaan saamme", sanoi Dobbs haukotellen. "Elä

tuskittele asioista, jotka sinuun eivät koske, kokki."

Kokki tyytyi neuvoon ja tehtyään muutamia yövalmistuksia,

sammutti hän lampun ja hyppäsi kojuunsa. Vaan samassa päästi
hän pahan parahduksen, heilautti itsensä taas lattialle, haparoitsi
tulitikkuja ja sytytti lampun uudestaan. Minuutti senjälkeen, herätti
hän julmistuneet ystävänsä kolmannen kerran.

"Jätä rauhaan minut, kokki", sähisi Dobbs.

"Ellet sinä nylje häntä, teen sen minä", kirkui Jem ja koetti ylettyä
nyrkillään kokkiin.

"Pään alukseeni oli nuppineulalla kiinnitetty kirje", sanoi kokki

vapisevalla äänellä ja piteli likaista paperipalasta lampun edessä.

"Mitä se meille kuuluu", sanoi Jem. "Tuki turpasi! Kuuletko sinä."

Mutta kokin käytöksessä oli jotakin pelottavaa.

"Rakas kokki", luki hän kuumeentapaisella levottomuudella. "Minä

olen tehnyt koneellisen helvetinkoneen ja asettanut sen
lastiruumaan, ruudin viereen, ollessamme Fairhavenissa.
Epäilemättä pamahtaa se tänä yönä, kymmenen ja yhdentoista
välillä, mutta aivan varma en ajasta ole. Älkää puhuko toisille mitään,
vaan hypätkää yli syrjän ja uikaa maalle. Minä olen ottanut veneen.
Olisin teidätkin vienyt mukanani, vaan kun kerran kerroitte uineenne
seitsemän penikulmaa aallokossa, on teidän helppo…"

Luku katkesi nyt paikalla, sillä kuulijat ryntäsivät kojustaan villiä

vauhtia kannelle ja suoraa päätä kajuuttaan, jonka hämmästyneille
asukkaille he, henki kurkussa, kertoivat kirjeen pääsisällön.

"Mitä hän on kätkenyt lastiruumaan?" läähätti laivuri.

"Helvetinkoneen", sanoi perämies. "Sellainen kone, jolla ne

räjähyttävät parlamenttitalojakin ilmaan."
 "Mitä kello nyt on?" kysyi Jem huolestuneena.

"Suunnilleen puoli yksitoista", vastasi kokki vavisten. "Yritetään

huutaa, ehkä ne kuulevat maalle."

Miehet kokoontuivat laivan syrjälle ja hurja huuto kaikui yön

hiljaisuudessa. Useimmat Lawportissa olivat jo menneet sänkyihinsä
ja ainoastaan ravintoloista ja joistakuista rakennusten ikkunoista
loisti tuli.

Uudestaan kuului kuolleitakin herättävä karjunta ja kauhistunein

silmäyksin vilkuilivat miehet lastiruuman luukkuja. Syvän hiljaisuuden
vallitessa kuului heikko vastaus maalta. Huudettiin uudestaan, kuin
hullut, kunnes vihdoin kuului veneen kölin raappiminen santaan ja
senjälkeen airojen käyttämisen tervetullut ääni.

"Kiiruhtakaa!" parkui Dobbs, kun vene tuli näkyviin pimeästä.

"Miks'ette kiiruhda?"

"Mikä hätänä?" kuului veneestä.

"Ruutia!" kirkui kokki villisti. "Meillä on kymmenen tonnia ruutia

laivalla, ja se räjähtää pian. Kiiruhtakaa! kiiruhtakaa!"

Airot lakkasivat käymästä ja veneestä kuului kauhistuksen sorina;

sitten alkoi soutu entistä suuremmalla voimalla.

"Ne menevät takaisin", sanoi Jem yht'äkkiä. "Minä uin niiden

jälkeen. Pitäkää varanne ja vetäkää ylös minut, toverit!" huusi hän ja
molskahdettuaan veteen lähti uimaan voimakkain vedoin.

Dobbs, joka oli huononpuoleinen uimari, seurasi kuitenkin hetkisen

epäiltyään hänen jälessään.
 "Minä en taida uida edes kädet pohjassa", voivotteli kokki hampaat
suussa kalisten.

Toiset, joilla ei ollut parempaa sanottavaa taidostaan, nojautuivat

laivan syrjään ja kuuntelivat. Uijat olivat näkymättömiä pimeässä,
mutta helposti voi pulikoimisesta seurata heidän edistymistään. Jem
oli ensimäinen, joka vedettiin veneeseen ja pari minuuttia
senjälkeen, veti hän Dobbsin ylös. Seurasi kiukkuisia kirouksia ja
lyöntejä ja mätkähdyksiä. "Ne tulevat noutamaan meitä", sanoi
perämies ihastuneena ja veti syvään henkeänsä. "Hyvin tehty, Jem!"

Vene lähestyi kiivailla aironvedoilla ja oli pian laivan kyljellä. Kolme

miestämme hyppäsivät kiireesti alas, Jem ja Dobbs tarttuivat airoihin
ja ennen pitkää, oli kuunari kadonnut pimeään. Rannalla oli
kokoontunut vähäinen väkijoukko ja saatuaan kuulla uutisen,
pelästyivät he kaupunkinsa kohtaloa. Selvää oli, että ainakin
ikkunaruudut olivat suuressa vaarassa ja kotiin lähetettiin sentähden
kiireesti sanansaattaja aukasemaan ne.

Hyljätystä Susan Janesta ei vielä kuulunut mitään. Kello

kaupungin pienessä kirkontornissa löi kaksitoista.

"Asiat ovat hullusti", sanoi nyt eräs vanha kalastaja. "Jonkun pitäisi
mennä ja hinata alus merelle."

Ei kukaan vastannut.

"Pelastaakseen Lawportin", jatkoi vanhus tunteellisesti. "Olisinpa

minä vaan kahtakymmentä vuotta nuorempi…"

"Vanhan miehen tehtävä se olisi", kuului ääni joukosta.

 Laivuri katseli himokkaasti laivaansa, ja kiukkuisesti joukkoa,
mutta ei sanonut sanaakaan. Hän alkoi vähitellen uskoa, että koko
selkkauksesta oli päästy paljaalla pelästyksellä.

Kello löi kaksi ja väkijoukko alkoi hajaantua. Rohkeimmat

asukkaat, joita veto ei miellyttänyt, sulkivat ikkunansa ja lapset, jotka
vuoteiltaan olivat lähetetyt kävelymatkalle sisämaahan, palasivat
vähitellen takaisin. Kello kolmelta katsottiin vaaran olevan ohitse ja
päivän koittaessa nähtiin Susan Jane eheänä ankkurissa.

"Nyt menen minä takaisin", sanoi laivuri yht'äkkiä. "Kuka seuraa

mukana?"

Jem, perämies ja kaupungin poliisikonstaapeli tarjoutuivat.

Lainattiin vene, jota ennenkin oli käytetty, soudettiin kuunariin ja
alotettiin etsiminen ruumassa tavattomalla varovaisuudella. Työ kysyi
hermoja — ainakin alussa, vaan kun ei mitään löytynyt, kävivät
miehet rohkeammiksi ja katselivat lopulta noloina toisiaan.

"Minä pahasti epäilen, ettei täältä löydy mitään", sanoi konstaapeli

pilkallisesti nauraen ja istuutui ruutitynnörille. "Poika on vaan
narrannut teitä."

"Siltä se vähitellen näyttää", murisi perämies. "Koko kaupunki

tulee nauramaan meitä."

Laivuri katseli ympärilleen, eikä sanonut sanaakaan. Vaan

yht'äkkiä kumartui hän, päästi hämmästyksen huudon ja sieppasi
jotakin rikkinäisen hinkalon takaa.

"Jopas löysin sen", huusi hän. "Pois tieltä!"

 Kiireesti ryntäsi hän kannelle, pitäen löytöään niin kaukana kuin
mahdollista itsestään ja heitti sen kauas veteen. Kuului huimaava
hurraa parista lähellä olevasta veneestä ja rannalta vastasi heikko
kaiku.

"Oliko tuo helvetinkone?" kuiskasi hämmästynyt Jem

perämiehelle.
"Minusta se näytti hummerilaatikolta."

Perämies pudisti päätään ja katseli konstaapelia, joka ahnain

silmäyksin tirkisteli paikkaa, mihin laatikko katosi.

"Niin, olen kuullut ihmisistä, jotka senlaisenkin tähden ovat

saattaneet henkensä vaaraan", sanoi hän ivallisesti.
ROHKEA YRITYS

Ahkerasti oli tehty työtä koko lauantai-ilta ja yö, ja vihdoin kymmenen

aikaan sunnuntai-aamuna oli Bylgia täydessä merikunnossa, luukut
paikoillaan ja kansi puhtaaksi lakastuna ja pestynä. Laivuri itse ja
perämies seisoivat kannella ja katselivat ajatuksissaan Thamesin
hiljalleen kohti merta juoksevaa, likaista vettä.

"Miten aikaisin hän tulee?" sanoi laivuri ja vilkasi huolimattomasti

pitkin laituria.

"Noin puoli yhdentoista aikaan", vastasi perämies. "Olitte oikein

kohtelias, kun luovutitte hyttinne hänelle, kapteeni."

"Sellaista ei kannata kehua", vastasi laivuri. "Olen tavannut teidän

vaimonne jonkun kerran ennemmin, George, ja todellakin täytyy
sanoa, ettei löydy montaa niin kaunopuheliasta ja hienokäytöksistä
naista."

"Samaa on minun sanottava teistä", sanoi perämies, "tarkoitan

teidän vaimostanne."

"Jokainen mies", jatkoi laivuri, "joka makaa mukavasti hytissään ja

antaa naisen riisua ja vaatettaa ahtaassa kajuutassa, saisi hävetä
silmänsä täyteen."

"Kas, tuollahan tavarat jo tulevatkin", sanoi perämies ja täytti

hitaasti piippunsa. "Mitä hän kaikilla noilla tekee, en saa järkeeni.
Heti kun akkani on saanut päähänsä matkustaa, niin mitä hän
tekee? Rientää kauppakadulle ja ostaa itselleen uuden hatun,
kalliimman kuin varat myöten antaisivatkaan."

"Sellaisia ne ovat kaikki", sanoi laivuri. "Minun on ihan yhtäläinen.

—
Vaan mitäs tuo poika etsii?"

Poika tuli ihan laiturin reunalle ja vastasi itse puolestaan.

"Kuka on kapteeni Bunnett?" kysyi hän kimakalla äänellä.

"Kyllä se minä olen poikaseni", vastasi laivuri.

"Tässä olisi kirje teille."

Laivuri aukasi kuoren, raapasi partaansa ja katsoi perämieheen.

"Joskus saa hyvääkin liiaksi", sanoi hän lopulta.

"Miten niin?" kysyi perämies.

"Minunkin vaimoni tulee mukaan", sanoi laivuri. "Hän kirjoittaa

saapuvansa aamupäivällä, enkä minä millään muotoa saa purjehtia
ilman häntä."

"Sepä harmillista", sanoi perämies ymmärtäen olevansa velvoitettu

jotakin sanomaan.
 "En tullut puhuneeksi hänelle teidän vaimonne matkasta", sanoi
laivuri, "Mihin ne molemmat nyt panemme? Aivan varmaa kai on,
että teidän vaimonne tulee?"

"Aivan varmaa."

"Ei suinkaan hän voisi; lykätä tuonnemmaksi matkaansa?" sanoi

laivuri, ja kääntyi poispäin.

"Mahdotonta! Hän on jo saanut uuden hattunsa", vastasi

perämies. "Ei suinkaan teidänkään vaimonne voisi odottaa?"

Laivuri pudisti päätään. "Mutta löytyy sentään eräs keino", sanoi

hän toivovasti. "Ehkä he sopivat hyvin keskenään. Jakakoot hytin."

"Ja silloin pelaamme whistiä vapaa-aikoina", sanoi perämies ja

asteli laivurin jälestä kajuuttaan.

"Ahdas se on, mutta kodikas", sanoi laivuri avaten hytin oven.

Samaan aikaan saapui rantaan kahdet ajoneuvot ja tuskin rouva

Bunnettin tavarat olivat laiturilla, kun siihen jo ilmaantui rouva
Fillsoninkin kotelot. Molemmat naiset, aivan outoja keskenään,
vilkuilivat uteliaasti toisiaan ja katselivat odottavasti Bylgian tyhjää
kantta.

"George!" huusi rouva Fillson, pitkä kaunis nainen ja korotti

äänensä melkein kirkunaksi, voittaakseen läheisen nostokoneen
rätisevän kolinan.

Oli onneton sattuma, että laivurilla ja perämiehellä oli sama

ristimänimi.
 "George", huusi rouva Bunnett ja katsoi harmilla toista.

"George", kirkui rouva Fillson ja maksoi katseet korolla.

"Hampsu!" sanoi rouva Bunnett hiljaa, mutta ei kuitenkaan niin

hiljaa, ettei naapurinsa sitä olisi kuullut.

"George!"

Ei kuulunut vastausta.

"George!" huusivat molemmat naiset yht'aikaa.

Ei vieläkään vastausta.

Löytyi vielä yksi George laivalla, kanssissa, ja seuraten uteliaiden

toveriensa tyrkkäyksiä, nousi tämä herrasmies kannelle ja katseli
kummissaan kauniita huutajia.

"Mitä te tahdotte?" kysyi hän vihdoin pässimäisesti.

"Sanokaa kapteeni Bunnettille, hänen rouvansa olevan täällä."

"Kyllä", vastasi merimies ja aikoi lähteä matkaansa, kun rouva

Fillson huusi hänet takaisin.

"Sanokaa herra Fillsonille, että hänen rouvansa on täällä", sanoi

hän kohteliaasti.

"All right, rouva", vastasi mies ja riensi ilmoittamaan näitä mieluisia

uutisia. Molemmat naineet miehet ryntäsivät kannelle ja heti ensi
silmäys ilmaisi heille naisten välin rikkoutuneen.
 "Mitäs kuuluu, kapteeni Bunnett?" kysyi rouva Fillson, hymyillen
lumoavasti.

"Hyvää huomenta, rouva Fillson", vastasi laivuri ja koetti välttää

vaimonsa katsetta. "Tässä on minun vaimoni, rouva Bunnett."

"Hyvää huomenta, rouvaseni", sanoi rouva Fillson ja kohenteli

uutta hattuaan sormenpäillään.

"Hyvää huomenta", vastasi rouva Bunnett kylmästi. "Olette

varmaankin tuoneet tavaroita miehellenne?"

"Hän seuraa mukana", sanoi laivuri, hyvillään saadessaan sen

sanotuksi.
"Odottakaa silmänräpäys, niin nostan teidät ylös."

Hän autti molemmat naiset kannelle ja koittaen väkistenkin

ylläpitää iloista keskustelua, laskeutui hän edellä kajuuttaan.
Onnettomuutta ennustavan hiljaisuuden vallitessa saivat naiset
kuulla olevansa pakoitetut jakamaan laivurin hytin keskenään.

"Se on ainoa mahdollisuus", sanoi perämies, turhaan odotettuaan,

että asianomaiset sanoisivat jotakin.

"Ja avara se kylläkin on, kun tarkemmin sitä katselee", sanoi

laivuri ja asetti päänsä kallelleen, nähdäkseen jos hytti siten
katsottuna näyttäisi suuremmalta.

"Kolmellekin siellä on tilaa, jos oikein hätä tulisi", sanoi perämies

rohkeasti.

Naiset eivät vieläkään puhuneet mitään, mutta rouva Bunnettin

poskille oli noussut palolippu, mikä ei ennustanut hyvää hänen
miehelleen. Löytyi ainoastaan yksi matka-arkun paikka koko hytissä
ja rouva Fillson oli pitänyt varansa ja sovittanut omansa siihen. Kun
se oli kunnollisesti tehty, nousi hän kannelle, miehensä kanssa,
katselemaan seutua ympärillä.

"George", sanoi rouva Bunnett pahantapaisesti, kun pariskunta oli

jäänyt kahdenkesken.

"Niin, kultaseni?"

"Lähetä pois tuo nainen", sanoi rouva Bunnett käskevästi.

"Ei käy laatuun", vastasi laivuri päättävästi. "Oma syysi, ettet

ennemmin ilmoittanut tulostasi."

"Niin, minä tiesin sen, ettet sinä tahtoisi minua mukaasi", sanoi
rouva Bunnett ja ruusut hänen hatussaan värisivät. "Perämies
ajattelee huvia hänen vaimolleen, mutta minä raukka saan istua
kotona, pestä ja paikata sinulle ja siivota huoneita. Ooh, minä kyllä
tiedän… ei sinun tarvitse sanoa mitään."

"On liian myöhäistä muuttaa sitä enää", sanoi laivuri. "Minun pitää
kannelle nyt; parasta kun seuraat mukana sinäkin."

Rouva Bunnett seurasi miestään ja pysytteli niin kaukana kuin

mahdollisia perämiehen rouvasta, katsellen ikäänkuin hallitsijatar,
miten miehet nostivat purjeita ja ankkurin. Puhalsi suotuisa länsi-tuuli
ja Bylgia halkaisi aaltoja, vesi keulassa kohisten.

Vielä päivällisaikaan oltiin vilkasliikkeisessä seudussa, joten

laivuri, salaiseksi mielihyväkseen, taisi lähettää perämiehen
yksinään pitämään seuraa naisille päivällispöydässä. Tämä näytti
takaisin tullessaan kovin vaalealta ja pelästyneeltä ja kohdatessaan
laivurin katseen, kohotti hän merkitsevästi olkapäitään.

"Ei mitään rumia sanoja?" kysyi laivuri puoleksi kuiskaten.

"Eipä juuri", vastasi perämies. "Mutta sitä enemmän, niin

kutsutuita 'hienoja viittauksia'."

"Minä ymmärrän."

"Ellette nyt ymmärrä", sanoi perämies, "niin teepöydässä kyllä

tulette ymmärtämään. Minä en enää aio istua yksinäni heidän
kanssaan. Jos kysytte mitä olen syönyt, on minun mahdoton sanoa
sitä."

Hän vetäytyi syrjään, kun pöytätoverinsa samassa nousivat

kannelle. Laivuri päätti kukistaa kapinan heti alkaessa, huusi
molemmat naiset luokseen ja selvitteli heille vastaantulevien laivojen
merkillisyyksiä. Vaan keskellä hänen esitelmäänsä, poistui rouva
Bunnett ja tyytyi edempää katselemaan onnetonta miestään, —
kasvoillaan ilme kuin marttyyreilla pyhissä tauluissa.

Tee-pöydässä, oli miesten osa surkea. Rouva Bunnett ojensi

rouva Fillsonille teekupit, vilkaisemattakaan häneen, ja rouva Fillson
seurasi esimerkkiä, tarjotessaan leipää ja voita. Kun hän veti
tarjottimen takaisin, oli se tyhjä ja rouva Bunnett noukki, harmista
melkein haljeten, leipäviipaleita helmastaan.

"Ooh! Minä olen niin pahoillani", sanoi rouva Fillson.

"Sitä ette suinkaan ole", sanoi rouva Bunnett terävästi.

"Ehdollanne sen teitte."