"In attempting to arive at the truth, I have applied everywhere for information, but in scarcely an

instance have l been able to obtain hospital records fit for any purposes of comparison. If they
could be obtained, they would enable us to decide many other questions besides the ones
alluded to. They would show subscribers how their money was being spent, what amount of
good was really being done with it, or whether the money was not doing mischief rather than
good." (Nightingale, 1859)

Informatics Introduction

What is informatics? Isn't it just about computers? Taking care of patients is nursing's primary
concern, not thinking about computers! These are not unusual thoughts for nurses to have.
Transitions are always difficult, and a transition to using more technology in managing
information is no exception. This use of information technology in healthcare is known as
informatics, and its focus is information management, not computers. Whether nursing uses
informatics effectively or not will determine the quality of future patient care as well as the future
of nursing.

Information is an integral part of nursing. When you are caring for patients, what besides the
knowledge that nursing education and experience has provided do you depend on to provide
care? You need to know the patient's history, medical conditions, medications, laboratory
results, and more. Could you walk into a unit and care for a patient without this information?
How this information is organized and presented to you affects the care that you can provide as
well as the time you spend finding it.

The old way is to record and keep the information for a patient's current admission in a paper
chart. Today, with several specialties, consults, medications, laboratory reports, and procedures,
the paper chart is inadequate. A well-designed information system, developed with you and for
you, can facilitate finding and using information that you need for patient care. Informatics skills
enable you to participate in and benefit from this process. Informatics does not perform
miracles; it requires an investment by you, the clinician, to assist those who design information
systems so the systems are helpful and do not impede your workflow.

If healthcare is to improve, it is imperative that there be a workforce that can innovate and
implement information technology (AHIMA & AMIA, 2006). There are two roles in informatics:
the informatics specialist and the clinician who must use health information technology. This
means that in essence every nurse has a role in informatics. Information, the subject of
informatics, is the structure on which healthcare is built. Except for purely technical procedures
(of which there are few if any), a healthcare professional's work revolves around information. Is
the laboratory report available? When is Mrs. X scheduled for surgery? What are the
contraindications for the prescribed drug? What is Mr. Y's history? What orders did the physician
leave for Ms. Z? Where is the latest x-ray report?
An important part of healthcare information is nursing documentation. When information
systems are designed for nursing, this documentation can also be used to expand our
knowledge of what constitutes quality healthcare. Have you ever wondered if the patient for
whom you provided care had an outcome similar to others with the same condition? From
nursing documentation, are you easily able to see the relationship between nursing diagnoses,
interventions, and outcomes for your patients? Without knowledge of these chain events, you
have only your intuition and old knowledge to use when making decisions about the best
interventions in patient care. Because observations tend to be self-selective, this is often not the
best information on which to base patient care. Informatics can furnish the information needed
to see these relationships and to provide care based on actual patient data.

If Florence Nightingale were with us today, she would be a champion of the push toward more
use of healthcare information technology Information in a paper chart essentially disappears into
a black hole after a patient is discharged. Because we can't easily access it, we can't learn from
it and use it in patient care.

This realization is international. Many countries, especially those with a national health service,
have long realized the need be able to use information buried in charts. In the United States, the
strategic plan for wider implementation of Health Information Technology formulated four goals,
all of which will affect nurses and nursing. They are as follows:

1. Inform clinical practice with use of EHRS (Electronic Health Records). The strategies for
achieving this goal
are

a. Provide incentives for EHR adoption

b. Reduce risk of EHR investment

c. Promote the diffusion of EHR in rural and underserved areas

2. Interconnect clinicians so that they can exchange health information using advanced and
secure electronic communication. The strategies for achieving this goal are

a. Encourage regional collaborations that reflect the needs and goals of the region

b. Develop a national health information network

c. Coordinate federal health information systems

3. Personalize care with consumer-based health records and better information for consumers
by

a. Encourage the use of personal EHRs

b. Enhance informed consumer choice by providing information about clinicians and institutions

c Promote use of telehealth systems

4. Improve public health through advanced biosurveillance methods and streamlining the
collection of data for quality measurement and research. This requires the collection of detailed
clinical information and will be accomplished by

a. Unify public health surveillance architectures by making the systems able to exchange
information

b. Streamline quality and health status monitoring to provide the ability to look at quality at the
point of care and in real time

c. Provide tools to accelerate research and dissemination of evidence into clinicaly useful
products,applications, and knowledge

To fulfill these goals, information, which is the structure on which healthcare is built., can no
longer be managed with paper. If we are to provide evidence-based care, the mountains of data
that are hidden in medical records must be made to reveal their secrets. Bakken (2001) told us
that there are five components needed to provide evidence-based care:

1. standardization of terminologies and structures used in documentation

2. the use of digital information

3. standards to permit healthcare data exchange between heterogeneous entities

4. the ability to capture data relevant to the actual care provided, and

5. competency among practitioners to use this data. All of these are part of informatics.

Information is a capital good with a value the same as labor and materials (National Advisory
Council on Nurse Education and Practice, 1997). The financial health of organizations depends
on effective and efficient information management. Today, healthcare organizations are waking
up to the fact that how information is handled and processed has a great effect on both the
outcomes for those who purchase services and the economics of healthcare. Manual recording
and filing of information are inadequate to manage today's healthcare information. We have
made some attempts to use technology to manage information, but these efforts often fall short
as a result of our inexperience in grasping the schemes of where information originates, how it
is used clinically and administratively, and how it can be used to improve practice.
 The complexity of today's healthcare milieu, added to the explosion of knowledge, makes it
impossible for any clinician to remember everything needed to provide high-quality patient care.
Additionally, healthcare consumers today want their healthcare providers to integrate all known
relevant scientific knowledge in providing their care. We have passed the time when the unaided
human mind can perform this feat: Modern information management tools are needed as well
as a commitment by healthcare professionals to change practices when more knowledge
becomes available.

🎯🎯
Definitions

Informatics is about managing information. The tendency to relate it to computers comes from
the fact that the ability to manage large amounts of information was born with the computer and
progressed as computers became more powerful and commonplace. It is, however, human
ingenuity that is the crux of informatics. The term "informatics" originated from the Russian term
"informatika" (Sackett & Erdley 2002). A Russian publication, Oznovy Informatiki (Foundations
of Informatics), published in 1968 is credited with the origins of the general discipline of
informatics (Middle East Technical University, n.d.). At that time it was described within the
context of computers."Medical informatics" was the first term used to identify informatics in
healthcare. It was defined as the information technologies that are concerned with patient care
and the medical decision making process. Another definition stated that medical informatics is
complex data processing by the computer to create new information. As with many healthcare
enterprises, there was debate about whether "medical" referred only to informatics focusing on
physician concerns, or if it refers to all healthcare disciplines. Increasingly, it is seen that other
disciplines have a body of knowledge separate from medicine, but part of healthcare, and the
term healthcare informatics is becoming more commonly used. In essence, informatics is the
management of information, using cognitive skills and the computer.

HEALTHCARE INFORMATICS

Healthcare informatics focuses on managing information in healthcare. It is an umbrella term

that describes the capture, retrieval, storage, presenting, sharing, and use of biomedical
information, data, and knowledge for providing care, problem solving, and decision making
(Shortliffe & Blois; 2001). The purpose is to improve the use of healthcare data, information, and
knowledge in supporting patient care, research, and education (Delaney, 2001). The focus is on
the subject, information, rather than the tool, the computer. The distinction is not always obvious
as a result of the need to master computer skills to enable one to manage this information. The
computer is used in acquiring, organizing, manipulating, and presenting the information. It will
not produce anything of value without human direction in how, when, and where the data is
acquired, how it is treated, interpreted, manipulated, and presented. Informatics provides that
human direction.

NURSING INFORMATICS
 Healthcare has many disciplines, thus it is not surprising that healthcare informatics has many
specialties of which nursing is one. Nursing informatics is also a subspecialty of nursing which
the American Nurses Association (ANA) recognized in 1992, with the first informatics
certification examination being given in the fall of 1995 (Newbold, 1996). Nursing informatics
has as its focus managing information pertaining to nursing. Specialists in this area look at how
nursing information is acquired, manipulated, stored, presented, and used. Informatics nurses
work with practicing nurses to identify the needs of nurses for information and support, and with
system developers in the development of systems that work to complement the practice needs
of nurses. Nursing informatics specialists bring to system development and implementation a
viewpoint that supports the needs of the clinical end user. The objective is an information
system that is not only user friendly for data input, but presents the clinical nurse with needed
information in a manner that is timely and useful. This is not to say that nursing informatics
stands alone, it is an integral part of the interdisciplinary field of healthcare informatics, hence
related to and responsible to all the healthcare disciplines.

DEFINITIONS OF NURSING INFORMATICS

The term "nursing informatics." was probably first used and defined by Scholes and Barber in
1980 in their address that year to the MED-INFO conference in Tokyo. There is still no definitive
agreement on exactly what the term nursing informatics means. As Simpson once said
(Simpson, 1998), defining nursing informatics is difficult because it is a moving target. The
original definition said that nursing informatics was the use of computer technology in all nursing
endeavors: nursing services, education, and research. (Scholes & Barber, 1980) Another early
definition that followed the broad definition of Scholes and Barber was written by Hannah, Ball &
Edwards (1994). They defined nursing informatics as any use of information technologies in
carrying out nursing functions. Like the Scholes and Barber definition, these definitions focused
on the technology and could be interpreted to mean any use of the computer from word
processing to the creation of artificial intelligence for nurses as long as the computer use
involved the practice of professional nursing.

The shift from a technology orientation in definitions to one that is more information oriented
started in the mid 1980s with Schwirian (Staggers & Thompson, 2002). She created a model to
be used as a framework for nursing informatics investigators (Schwirian, 1986). The model
consisted of four elements arranged in a pyramid with a triangular base. The top of the pyramid
was the desired goal of the nursing informatics activity and the base was composed of three
elements: 1) users (nurses and students), 2) raw material or nursing information, and 3) the
technology, which is computer hardware and software. They all interact in nursing informatics
activity to achieve a goal. The model was intended a stimulus for research.

The first widely circulated definition that moved away from techrnology to concepts was from
Graves and Corcoran (Staggers & Thompson, 2002). They defined nursing informatics as "a
combination of computer science, information science and nursing science designed to assist in
the management and processing of nursing data, information and knowledge to support the
practice of nursing and the delivery of nursing care" (Graves & Corcoran, 1989)(p. 227). This
definition secured the position of nursing informatics within the practice of nursing and placed
the emphasis on data, information, and knowledge (Staggers & Thompson, 2002). Many
consider it the seminal definition of nursing informatics.

Turley (Turley, 1996), after analyzing previous definitions, added another discipline, cognitive
science, to the base for nursing informatics. Cognitive science emphasizes the human factor in
informatics. Its main focus is the nature of knowledge, its components, development, and use.
Goossen (1996), thinking along the same lines, used the Graves and Corcoran definition as a
basis and expanded the meaning of nursing informatics to include the thinking that is done by
nurses to make knowledge-based decisions and inferences for patient care. Using this
interpretation, he felt that nursing informatics should focus on analyzing and modeling the
cognitive processing for all areas of nursing practice. Goossen also stated that nursing
informatics should look at the effects of computerized systems on nursing care delivery

The first ANA definition in 1992 added the role of the informatics nursing specialist to the
Graves and Corcoran definition. The 2001 ANA definition stated that nursing informatics
combines nursing. information and computer sciences for the purpose of managing and
communicating data, information, and knowledge to support nurses and healthcare providers in
decision making (American Nurses Association, 2001). Information structures, processes, and
technology are used to provide this support. In the latest ANA Scope and Standards this
definition was reiterated, albeit in slightly different wording (American Nurses Association, 2008)
and with the addition of wisdom to the data, information, and knowledge conceptual framework.
This most recent definition emphasized again that the goal of nursing informatics is to optimize
information management and communication to improve the health o individuals, families,
populations, and communities.

Staggers and Thompson (2002), who believe that the evolution of definitions will continue,
pointed out that in all of the current definitions, the role of the patient is under emphasized.
Some early definitions included the patient, but as a passive recipient of care. With the advent
of the Internet, more and more patients are taking an active role in their healthcare. This factor
changes not only the dynamics of healthcare, but permits a definition of nursing informatics that
recognizes that patients healthcare professionals are consumers of healthcare information and
that patients may be participating in keeping their medical records current. Staggers and
Thompson also pointed out that the role of the nurse as an integrator of information has been
overlooked and should be considered in future definitions.

Despite these definitions, the focus of much of today's practice informatics is still on capturing
data at the point of care and presenting it in a manner that facilitates the care of an individual
patient. Although this is a vital first step, when designing patient care information systems,
thought needs to be given to secondary data analysis, or analysis of data for purposes other
than for which it was originally collected. Using aggregated data, or the same piece(s) of data,
for example, outcomes of a given intervention for many patients, you can make decisions based
on actual patient care data. Understanding how informatics can serve you as an individual
nurse, as well as the profession, puts you in a position to work with informatics specialists to
make retrievable data needed to improve patient care.

🎯🎯
Computers and Healthcare: History

In 1850, it was possible for all the medical knowledge known to the Western world to be put into
two large volumes making it possible, for one person to read and assimilate all this information.
The situation today is dramatically different. The number of journals available in healthcare and
the research that fills them have increased many times over. Even in the early 1990s, if
physicians read two journal articles a day, by the end of a year they would be 800 years behind
in their reading (McDonald, 1994). A healthcare clinician may be expected to know something
about 10,000 different diseases and syndromes, 3,000 medications, 1,100 laboratory tests and
the information in the more than 400,000 articles added to the biomedical information each year
(Davenport & Glaser, 2002). Additionally, current knowledge is constantly changing: one can
expect much of their knowledge to be obsolete in five years or less.

In healthcare, the increase in knowledge has led to the development of many specialties such
as respiratory therapy, neonatology, and gerontology, and subspecialties within each of these.
As these specialties have proliferated and spawned the development of many miraculous
treatments, healthcare has too often become fractionalized, resulting in difficulty in gaining an
overview of the entire patient. The pressure of accomplishing the tasks necessary for a patient's
physical recovery usually leaves little time for perusing a patient's record and putting together
the bits and pieces so carefully charted by each discipline. Even if time is available there is
simply so much data, in so many places, that it is difficult to merge the data with the knowledge
that a healthcare provider has learned, as well as with ne knowledge needed to provide the best
patient care. We are drowning in data but lack the time and skills to transform it to useful
information or knowledge.

The development of the computer as a tool to manage information can be seen in its history.
The first information management task "computerized" was numeric manipulation. Although not
technically a computer by today's terminology, the first successful computerization tool was the
abacus, which was developed about 3000 BC. Although when one developed skill, real speed in
these tasks was possible, the operator of the abacus still had to mentally manipulate data. All
the abacus did was store the results step by step. Slide rules came next in 1632, but like the
abacus required a great deal of skill on the part of the operator. The first machine to add and
subtract by itself was Blaise Pascal's "arithmetic machine" built in 1542. The first "computer" to
be a commercial success was Jacquard's weaving machine built in 1804. Its efficiency so
frightened workers at the mill where it was built that they rioted, broke apart the machine, and
sold the parts. Despite this setback, the machine proved a success because it introduceda
cost-effective way of producing goods.
The difference and analytical engines, early computers designed by Charles Babbage in the mid
19th century, although never built, laid the foundation for modern computers (Analytical Engine,
2007). The first time that an automatic calculating machine was successfully used was in the
1900 census. Herman Hollerith (who later started IBM) used the Jacquard loom concept of
punch cards to create a machine that enabled the 1900 census takers to compile the results in
one year instead of the 10 (Herman Hollerith-Punch Cards) required for the 1890 census. The
first computer by today's perception was the Electronic Numerical Integrator and Computer
(ENIAC) built by people at the Moore School of Engineering at the University of Pennsylvania in
partnership with the U.S. Government. When completed in 1946, it consisted of 18,000 vacuum
tubes, 70,000 resistors, and 5 million soldered joints. It consumed enough energy to dim the
lights in an entire section of Philadelphia (Moye, 1996). The progress in hardware since then is
phenomenal; today's "Palmtop" computers have more processing power than ENIAC did.

The use of computers in healthcare originated in the late 1950s and early 1960s as a way to
manage fnancial information. This was followed in the late 1960s by the development of a few
computerized patient care applications (Saba & Erdeley 2006). Some of these hospital
information systems included patient diagnoses and other patient information as well as care
plans based on physician and nursing orders. Because of the lack of processing power then
available, these systems were unable to deliver what was needed and never became widely
used.

EARLY HEALTHCARE INFORMATICS SYSTEMS

One of the interesting early uses of the computer in patient care was the Problem-Oriented
Medical Information System (PROMIS) begun by Dr. Lawrence Weed at the University Medical
Center in Burlington, VT (McNeill, 1979) in 1968. The importance of this system is that it was the
first attempt at providing a total, integrated system that covered all aspects of healthcare,
including patient treatment. It was patient oriented and used as its framework the
problem-oriented medical record (POMR). The unit featured an interactive touch screen and
was known for fast responsiveness (Problem-Oriented Medical Information System, n.d.). At its
height, it consisted of over 60,000 frames of knowledge.

PROMIS was designed to overcome four problems that are still with us today: lack of care
coordination, reliance on memory, lack of recorded logic of delivered care, and lack of an
effective feedback loop (PROMIS: The Problem-Oriented Medical lnformation System, 1980).
The system provided a wide array of information to all healthcare providers. All disciplines
recorded their observations and plans, and related them to a specific problem. This broke down
barriers between disciplines, making it possible to the relationship between conditions,
treatments, costs, and outcomes. Unfortunately, this system did not have wide acceptance. To
embrace it meant a change in the structure of healthcare, something that did not begin to
happen until the 1990s, when managed care in all its variations reinvigorated a push toward
more patient-centered information systems, a push that is continuing as you read this.
 Another early system that became functional in 1967 and is still functioning, is the Help
Evaluation Logical Processing (HELP) system developed by the Informatics Department at the
University of Utah School of Medicine. It was first implemented in a heart catheterization
laboratory and a post open heart intensive care unit. It is now hospital wide and operational in
many hospitals in the Intermountain Healthcare system (Gardner, Pryor, & Warner, 1999). This
is not only a hospital information system, but integrates a sophisticated clinical decision support
system that provides information to clinical areas. It was the first hospital information system
that collected data for clinical decision making and integrated it with a medical knowledge base.
It is well accepted by clinicians and has demonstrated that a clinical support system is feasible
and that it reduces healthcare costs without sacrificing quality.

PROGRESSION OF INFORMATION SYSTEMS

As the science of informatics has progressed, there have been changes in information systems.
Originally computerized clinical information systems were process oriented. That is, they were
implemented to computerize a specific process, for example, billing, order entry, or laboratory
reports. This led to the creation of different software systems for different departments, which
unfortunately could not share data, creating a need for clinicians to enter data more than once.
An attempt to share data by integrating data from disparate systems is a difficult and sometimes
impossible task. Even when possible, the results are often disappointing and can leave negative
impressions of computerization in users' minds. These barriers are being slowly overcome with
the introduction of data standards, both in terminology and in Protocols for passing data from
one system to another.

Newer systems, however, are organized by data and are designed to use the same piece of
data many times, thus requiring that the entry be made only once. The primary design is based
on how data is gathered, stored, and used in an entire institution rather than on a specific
process such as pharmacy or laboratory. For example, when a medication order is placed, the
system can have access to all the information about a patient including his diagnosis, age,
weight, allergies, and eventually genomics, as
well as the medications he is currently taking. The order and patient information can also be
matched against knowledge such as what drugs are incompatible with the prescribed drug. the
dosage of the drug, and the appropriateness of the drug for this patient. If there are difficulties,
the system can deliver warnings at the time the medication is ordered instead of requiring
clinician intervention either in the pharmacy or at the time of administration. Another feature in a
data-driven system is the ability to make the same information available to the dietician planning
the patient's diet and the nurse providing patient care and doing discharge planning, thus
enabling a more complete picture of a patient than one that would be available when separate
systems handle dietetics and nursing.

Evidence-based practice will result not only from research and practice guidelines, but also
from unidentifiable (data minus any patient identification) aggregated data from actual patients.
It will also be possible to e how patients witha given genomics react to a drug, thus helping the
clinician in prescribing drugs. This same aggregated data will help clinicians make decisions by
providing information about treatments that are most effective for given conditions, replacing the
current system, which is too often based on "what we have always done" rather than empirical
information. These systems will use computers that are powerful enough to process data so that
information is created "on the fly." or immediately when requested. Systems that incorporate
these features will require a new way of thinking. Instead of having all one's knowledge in
memory, one must be comfortable both with needing to access information and with changing
one's practice to accommodate the new knowledge.

Computerization will affect healthcare professionals in other ways. Some jobs will change
focus. As nurses we may find that our job as a patient care coordinator has shifted from
transcribing and checking orders to accessing this information on the computer. To preserve our
ability to provide full care for our patients, and as an information integrator for other disciplines,
we will need to make our information needs known to those who design the systems. To
accomplish this we all need to be aware of the value of both our data and our experience and to
be able to identify the data we need to perform our job, as well as to appreciate the value of the
data that others and we add to the healthcare system.

🎯🎯
Benefits of Informatics

The information systems described previously will bring many benefits to healthcare. These
benefits can be seen in the ability to create and use aggregated data, prevent errors, ease
working conditions, and provide better healthcare records.

FOR HEALTHCARE IN GENERAL

One of the primary benefits of informatics is that data that was previously buried in inaccessible
records becomes usable. Informatics is not just about collecting data, but about making it useful.
When data is captured electronically in a structured manner, it can be retrieved and used in
many different ways, both to easily assimilate information about one patient and as aggregated
data. Aggregated data is the same piece or pieces of data for many patients. Table 1-1 shows
some aggregated data for postsurgical infections sorted by physician and then by the organism.
Because infections for some patients are caused by two different pathogens in Table 1-1, you
see two entries for some patients, however, this is all produced from only one entry of the data.
With just a few clicks of a mouse, this same data could be organized by unit to show the number
of infections on each unit. This is possible because data that is structured as in Table 1-1 and
standardized can be presented in many different views.

When aggregated data is examined, patterns can be seen that might otherwise take several
weeks or months to become evident, or mightnever become evident. When patterns, such as
the prevalence of infections for Dr. Smith emerge (Table 1-1), investigations into what these
patients have in common can begin. Caution, however, should be observed. The aggregated
data in Table 1-1 are insufficient for drawing conclusions; the data only serves as an indication
of a problem and clues to where to start investigating. Aggregated data is a type of information
or even knowledge, but wisdom says that it is incomplete. If this data were shared outside of an
agency, or with those who don't need to have personal information about a patient, it would be
de-identified, that is, there would be no patient names ánd probably no physician names.
Deciding who can see what data is one of the current issues in informatics.

Informatics through information systems can improve communication between all healthcare
providers, which will improve patient care as well as reduce stress. Additional benefits for
healthcare include making the storage and retrieval of healthcare records much easier, quicker
retrieval of test results, printouts of needed information organized to meet the needs of the user,
and fewer lost charges as a result of easier methods of recording charges. The computerization
of administrative tasks such as staffing and scheduling also saves time and money.

BENEFITS TO THE NURSING PROFESSION

Each healthcare discipline will benefit from its investment in informatics. In nursing, informatics
will not only enhance practice, but also allow nursing science to develop (Fitzpatrick, 1988).
Informatics will improve documentation and, when properly implemented, can reduce the time
spent in documentation. It is believed by many nurses that they spend over 50% of their time
doing paperwork (Womack et al, 2004). Entering vital signs both in nursing notes and on a flow
sheet, wastes time and invites errors. In a well-designed clinical documentation system, this
data will be entered once, retrieved, and presented in many different forms to meet the needs of
the user.

Paper documentation methods create other problems such as inconsistency and irregularity in
charting as well as the lack of data for evaluation and research mentioned above. An electronic
clinical information system can remind users of the need to provide data in areas apt to be
forgotten and provide a list of terms that can be clicked to enter data. The ability to use patient
data for both quality control and research is vastly improved when documentation is complete
and electronic.

Despite Florence Nightingale's emphasis on data, for much of nursing's history, nursing data
has not been valued. It is either buried in paper patient records that make retrieving it
economically infeasible or, worse, discarded when a patient is discharged, hence unavailable for
building nursing science. With the advent of electronic clinical documentation, nursing data can
be made a part of the EHR and become available to researchers for building evidence-based
nursing knowledge. The recent Maryland report on the use of technology to address the nursing
shortage demonstrated that informatics can be used to improve staff morale and patient care
(Womack et al., 2004). For example, paper request forms can be eliminated, work
announcements can be more easily communicated, the time for in-services can be reduced,
and empty shifts can be filled using Internet software.

In understanding the role and value that informatics adds to nursing, it is necessary to
recognize that the profession is not confined to tasks, but that it is cognitive. Providing the data
to support this is a joint function of nursing informatics and clinicians. Identifying and
determining how to facilitate its collection is an informatics skill that all nurses need.

🎯🎯
Nursing Informatics Competencies and Information Literacy

The need to manage complex amounts of data in patient care demands that nurses, regardless
of specialty area, have informatics skills (Gaumer, Koeniger-Donohue, Friel, & Sudbay, 2007;
Nelson, 2007; Wilhoit, Mustain, & King, 2006). Informatics skills require basic computer skills as
one component (Staggers, Gassert, & Curran, 2002). A recent survey of hospital administrators
in three states in the southeastern United States revealed that one of the competencies that
they wanted from nurses dealt with the use of the computer (Uttley-Smith, 2004). This supports
an earlier study by Gravely, Lust, & Fullerton (1999) that found that 83% of hospital recruiters
indicated the importance of computer skills. Another skill needed for proficiency in informatics is
information literacy. Both these skills have also been identified by the ANA and National League
for Nursing (NLN) as necessary for evidence-based practice.

COMPUTER FLUENCY
 The term "computer literacy" is used broadly to mean the ability to perform various tasks witha
computer. Given the rapid changes in technology and in nursing, perhaps a better perspective
on computer use can be gained by thinking in terms of computer fluency rather than literacy.
The term "fluency" implies that an individual has a lifelong commitment to acquiring new skills
for the purpose of being more effective in work and personal life (Committee on Information
Technology Literacy, 1999). This necessitates a goal of gaining sufficient foundational skills and
knowledge to enable one to independently acquire new skills. Thus, computer literacy is a
temporary state, whereas computer fluency involves being able to increase one's ability to
effectively use a computer when needed.

A perusal of Listserv archives in informatics reveals periodic requests for instruments to

measure the computer competency of staff. Unfortunately there is little agreement on specific
competencies needed, let alone an instrument to measure this, but there is a consensus that it
involves a positive attitude toward computers, knowledge and understanding of computer
technology, computer hardware and software skills, and the ability to visualize the overall
benefits to nursing from this technology (Hobbs, 2002). Simpson (1998) pointed out the need for
nurses to master computers to avoid extinction. A computer is a mind tool that frees us from the
mental drudgery of data processing, just as the bulldozer frees us from the drudgery of digging
and moving dirt. Like, the bulldozer, however, the computer must be used intelligently or
damage can result.

Given the forces moving healthcare toward more use of informatics, it is important for nurses to
learn the skills associated with using a computer for managing information. Additionally, knowing
how to use graphical interfaces and application programs such as word processing,
spreadsheets, databases, and presentation programs is as an important an element in a
professional career as mastering technology skills (McCannon & O'Neal, 2003). Just as
anatomy and physiology provide a background for learning about disease processes and
treatments, computer fluency skills are necessary to appreciate more complex informatics
concepts (McNeil & Odom, 2000) and for learning clinical applications (Nagelkerk, Ritolo, &
Vandort, 1998).

Ronald and Skiba (1987) were the frst to look at computer competencies required for nurses. In
the late 1990s and early part of this century this issue was revisited, but the focus became the
use of computer skills as part of informatics skills (McCannon & O'Neal, 2003; McNeil et al.,
2003; Pew Health Professions Commissions, 1998; Staggers, Gassert, & Curran, 2001;
Staggers et al., 2002; Uttley-Smith, 2004). One of the more thorough studies is by Staggers,
Gassert, and Curran (2001). They defined four levels of informatics competencies for practicing
nurses. The first two pertain to all nurses, the last two to informatics nurses.

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The beginning nurse should possess basic information management and computer technology
skills. Accomplishments should include the ability to access data, use a computer for
communication, use basic desktop software, and use decision support systems.

Experienced nurses should be highly skilled in using information management and computer
technology to support their major area of practice. Additional skills for the experienced nurse
include being able to make judgments on the basis of trends and patterns within data elements
and to collaborate with nursing informatics nurses to suggest improvements in nursing systems.

The informatics nurse specialist should be able to meet the information needs of practicing
nurses by integrating and applying information, computer, and nursing sciences.

The informatics innovator will conduct informatics research and generate informatics theory.

INFORMATION LITERACY

Information literacy, or the ability to know when one needs information and how to locate,
evaluate, and effectively use it (National Forum on Information Literacy, 2004) is an informatics
skill. Althoughit involves computer skills, like informatics, it requires critical thinking and problem
solving. Information literacy is part of the foundation for evidence-based practice and provides
nurses with the ability to be intelligent information consumers in today's electronic environment
(Jacobs, Rosenfeld, & Haber, 2003).

The level of computer fluency needed by nurses to be both information literate and informatics
capable in their practice is what is expected of any educated nurse. In this course, the lessons
addressing basic computer skills wll emphasize concepts that promote the ability to learn new
applications. These lessons provide information underlying the use of informatics in professional
life both on and off a clinical unit. and to adapt to changes in technology. In future lessons these
principles will be built upon to allow the reader to start to develop beginning informatics skills,
including the ability to find and evaluate information from electronic sources. Additional lessons
will allow the reader to develop skills necessary to work with nursing informatics specialists in
providing effective information systems and the use of nursing data.

Summary

Healthcare is in transition and nursing is being affected by these changes. Part of these
changes involves informatics. Whether the change will be positive or negative for patient care
and nursing depends on nurses. For the change to be positive, nurses need to develop skills in
information management, known in healthcare as informatics. To gain these skills, a background
in both computer and information literacy skills is necessary.

As knowledge continues to expand logarithmically, data and information can no longer be

managed solely by the human mind. The use of tools to aid the human mind has become
mandatory. Although healthcare has been behind most industries in using technology to
manage its data, there are many forces, both at the governmental and private levels that are
working to change this. VWith these pressures, healthcare informatics is rapidly expanding.
There are many subspecialties in informatics, of which nursing is one. Embracing informatics
will allow nurses to assess and evaluate practice just as a stethoscope allows the evaluation
and assessment of a patient.

The use of computers in healthcare started in the 1960s, mostly in financial areas, but with the
advance in computing power and the demand for clinical data, computers are being used more
and more in clinical areas. With this growth has come a change in focus for information systems
from providing solutions for just one process, to an enterprise-wide patient-centered system that
focuses on data. This new focus provides the functionality that allows one piece of data to be
used in multiple ways. To understand and work with clinical systems, as well as to fulfill other
professional responsibilities, nurses need to be computer fluent, information literate, and
informatics knowledgeable.

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