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Elizabeth Kirk, Pill
Executive Office of the President
National Science and Technology Council
4201 Wilson Boulevard, Suite n -405
Arlington, VA 22230

April!, 2004

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Nursing Informatics Leadership Responseto President's Information Technology
Advisory Committee (pIT AC) Questionsregarding "The New Health Care: How
Information Technologyis Transforming America's Health Care System"
This statementis being submitted to the President's Information Technology Advisory
Committee (PIT AC) by a collaboration of nurse informaticists during the public comment
period prior to the open meeting on April 13th.This statementhas been developed in
responseto a discussion between Kathleen McCormick Pill, RN, Dr. Jonathan Javitt andDr. Bill Braithwaite at the PITAC open meeting at HIMSS 2004 Annual Conference andExhibition in Orlando, Florida, on February 25th. Drs. Javitt and Braithwaite noted thelack of a nursing responseto the questions being addressedby the Committee. They
invited nurses to prepare a responsethat could be used in the final report, which isscheduled for Spring 2004.
Nurses representthe largest group of organized professionals in health care in the UnitedStates.Nurse informaticists playa critical role in creating an effective health careinformation infrastructure. These nurse informaticists are replacing or developing clinicalnursing documentation systemsand clinical information systems.They are educatingothers in nursing informatics, and developing researchagendasrelated to evaluating theimpact of informatics on quality and nursing care (ANA, 2001). Some of these experts
are purchasersof information systems in hospitals, outpatient settings, community andhome care nursing environments. In a recent survey of 537 nurse informaticists, twothirds of respondentsreported that systems implementation is their top job responsibility(HIMSS, 2004). In addition these nurses have implemented about one-quarter of thecomputerized provider order entry (CPOE) systems in the U.S.
The following statementis submitted by the Nursing Informatics Collaboration Task
Force (NICTF). Tills group was recently convened through the efforts of the Nursing
Informatics Working Group of the American Medical Informatics Association (AMIA),
the professional nurses representedby the Healthcare Information and Management
Systems Society (HIMSS), and the American Nurses Association (ANA). The NICTF
responseincludes input from nurse informaticists that are members of regional andnational informatics groups including the American Nursing Informatics Association(ANIA), Boston Area Nursing Informatics Consortium (BANIC), Capitol Area
Roundtable on Informatics in Nursing (CARING), Delaware Valley Nursing Computer
Network (DVNCN), Midwest Alliance for Nursing Informatics (MAN!), Nursing
Information Systems Council of New England (NISCNE), Puget Sound Nursing
Informatics Association (PSNI), South Carolina Informatics Nursing Network (SCINN),
and the Utah Nursing Informatics Network (uNIN).
,

TheQuestions.
1) What are the Current Opportunities and Barriers to creating an effective healthcare infonnation infrastructure?

2) What arethe ROIs?
3) What Researchand Development should be conducted?

TheResponse:
1) Current opportunities and barriers to creating an effective health careinformation infrastructure
Patient safety is a well-documented priority for healthcare organizations. This focus
provides an opportunity for healthcare organizations to evaluate the use of information
technology and the related infrastructure to deliver safe and effective patient care.
Computerized provider order entry (CPOE), clinical information systems and bar coded
medication managementare three top applications for healthcare organizations in the next
several years as reported in the survey of nurse informaticists (lllMSS, 2004). Nurses
playa critical role, as almost three-quartersof respondentsare involved with theimplementation of their organization's clinical information system, 52 percent with theimplementation of CPOE software, and 48 percent with implementation of an EMR. The
extensive clinical background of nurse informaticists is valuable, as nurses have an
intimate understanding of the workflow, environment and procedures that are necessary
to achieve success.
Another opportunity and potential barrier for creating an effective healthcare infonnation
infrastructure relates to leadership and a clear strategic vision (Kennedy, 2004). The
complexity of creating a healthcare infonnation infrastructure is immense and can only be
developed once it has been defined. Many efforts in this direction both at the conceptual
level (i.e. 10M's definition of the Computer-based Patient Record) to the detailed data
level (i.e. HL7's Reference Data Model). Yet the missing link may be the discussion
about how to distill this infonnation into practical, usable models that can be applied to
improve the work environment of the nurse and improve patient safety. An innovative
approachis neededto create a cohesive agendaacross a very dynamic, complex
healthcare delivery organization. Once an "effective" healthcare infonnation
infrastructure is defined, it could be recognized and promoted from both a nursing andcollaborative care model.
The survey of nurse infonnaticists identified financial resourcesas the largest barrier tosuccessin their role of implementing health care infonnation infrastructures. This isconsistent with the responsesof chief infonnation officers (CIa's) as reflected in the 15th
Annual Leadership Survey (HIMSS, 2004). Lack of user acceptanceor administrative
support, and software design that ignores current workflow processeswere also describedas barriers. Healthcare CIa's in this survey have recognized the importance of a clinicalchampion by identifying the need to increase IT staff to addressclinical issues.
A 1997 review of information technology use by nurses suggestedthat barriers include:lack of integration of nursing systems within hospital information systems,the need for aunified nursing language, and lack of point-of-care tenninals (Bowles, 1997). However,more recent reviews describe that these barriers are slowly being resolved (Androwich,
Bickford, Button, Hunter, Murphy and Sensmeier,2003). Additional barriers include lackof a standard design for clinical systems that would addressthe inconsistency of entering
or extracting data from the end user's perspective (Hermann, 2004).
In another study recently undertaken by the InteragencyCouncil on Information Resources for
Nurses (ICIRN), the information literacy of nurseswas surveyed (Tanner, Pierce, Pravikoff, inpress). Information literacy was identified as a nursing informatics competency for the nurse.
Information literacy has been found to be an essential element in the application and use ofevidence basedpractice (EBP). The study identified the gaps in knowledge and skills for
identifying, accessing,retrieving, evaluating and utilizing researchevidence to provide bestpractice for patients. The study also reported that over sixty-four percent (64%) of nurses
regularly need information, but 43% rated workplace information resourcesas totally inadequate
or less than adequate.The three primary organizational constraints in the practice settings wereidentified as: 1) the presenceof other goals of higher priority, 2) difficulty recruiting andretaining staff, and 3) organizational budget for acquisition of information resources.Three
personal barriers were identified: 1) lack of understanding of organization or structure ofelectronic databases,2) difficulty accessinginformation, and 3) lack of skills to use andsynthesize evidence into practice.
Findings from another study indicated that nurses at every level and role exhibit large gaps inknowledge and competencies at each step in the information literacy process--from lack ofawarenessthat they need information to lack of accessor ability to successfully searchand utilize
information needed for practice, particularly in an electronic format (Pravikoff, Pierce, Tanner,2003). However, significantly more nurses who received their most recent nursing degree after
1990 acknowledged successful searchesof evidence in the National Library of Medicine (NLM)
Medline and CINAlll... when compared with those who graduated prior to 1990 (Tanner, 2000).
Thus, training in computer skills has been a barrier that may diminish with more nurses
becoming computer literate in high school and college (Pierce, 2000). The "tipping point" may be
a generation gap.
Most nurses did not have training regarding computer use or typing skills in their nursing
or college curriculum unless they returned to school for further education after 1990
(Gloe, 2004). Therefore, the practicing nurse should be provided with opportunities forlearning basic "keyboarding" i.e. typing skills and computer basics such as how to use themouse. This would lessenthe anxiety for computer use. Nurses are caring for patientswith greater acuity, requiring more documentation and creating higher stress than everbefore. Adding the stressof computerization when one is totally unfamiliar with thecomputer can be a major challenge. Incorporating this challenge into their current work
load may seemlike an insurmountable task to nurses and could be a large barrier for EHR
implementation. Thus, providing educational opportunities as well as designing user
friendly applications for use by the nursing staff can lessenthe stressand remove barriers.
Summarizing an Agency for Healthcare Researchand Quality (AHRQ) conference examining

quality research,the attendeesasked if the primary barriers to ~chieving the National Health
Information Infrastructure (NlllI) are more political than technical. The participants identified theneed for standardsto govern the infrastructure, the lack of broad-based agreementamong
stakeholdersof a systemconcept, and the legal concerns about privacy and confidentiality (Langand Mitchell, 2004). Vahey, DC, Swan, BA, Lang, NM, & Mitchell, PH (2004) summarized theneed for additional researchon the barriers to quality improvement which they defined as: lack ofstandardized measures,inadequate information systemsto col~ectdata, inadequateresources topay for data collection and translation, and technological issues. As stated by others at the same
conference (Lamb, as, Jennings, BM, Mitchell, PH, & Lang,~,2004) the necessarydemandand incentives are currently not in place to assurethe development of information infrastructuresthat will support quality improvement.
Finally, in a monograph sponsoredby the professional specialty information association(AMIA) in collaboration with the professional nurses associatipn (ANA) the major
constraints to full implementation of the information infrastru~ture for nursing wereidentified as lack of: policy, regulation and standards,technology, information systems,
humanfactors, technology adoption and system utilization (Androwich et aI, 2003). Other
barriers include lack of a positive ROI for the use of clinical documentation systems,and
limited availability of applications that specifically support the work of nurses.
Many reports, such as those recently published by the Institute of Medicine, support the use oftechnology in reducing medical errors and encourage implementation of evidence-based
healthcare practice. The results of these recent studies identify gaps and barriers that limit
effecting these prescribed practices among nurses, the largest number of health care professionals
who provide the greatestpercentageof direct contact, time and intensity with theconsumer/patient.

2) What are the Returns on Investments(ROIs)?
Two types of data are available related to the ROls of nurses U.liZingdelivery

gan

~

of

patient

care.

Early

in

the

last

decade,researchersbinfonnation
evaluating

systems
the

value

in

the

of

computer terminals at the bedside or at the point of care. In on study of the impact of bedsideterminals on the quality of nursing documentation, Marr, P., D thie, E., & Glassman, K. (1993)
found that completeness of documentation measuredby the presence or absenceof componentsof the record was better with bedside terminals. In addition they found that timeliness of
documentation was improved closer to the actual time when care was delivered. Other benefits ofnurses using computers t? documen~~racti~e were 1) the inte~ati?n of care ~lans wit.h nursing
interventions, 2) calculatIon of specIfic acuIty, and 3) automatif bIlls for nurSIng servIces.
Other reported studies of bedside terminals have documented the ease of use, elimination of
redundant data, system support at the bedside, availability, cu ncy of data and accessto expert
systems.Use of clinical information systemshave been shown to provide soft benefits related to
improvements in patient safety, care provider communication, nd workflow enhancements.
Historically there have been few studies to show hard benefits f dollars saved, or a substantial
decreasein care hours. However, as more nursing focused soft are is implemented a positive4

ROI has beennoted (Curtis, K. 2004).
The Nicholas E. Davies Award of Excellence for Electronic Health Records (ERR)
recognizes excellence in the implementation of ERRs in healthcare organizations andprimary care practices. Established in 1995 this program has recognized 19 hospitals in
the past 9 years. As part of the application process, organizations must document thefinancial impact of their implemented ERR. A 2001 winner, the University of lllinois at
Chicago Medical Center, documented that during a two year period of time, $1.2 millionof nurse time was reallocated from manual documentation tasks to direct hands-on patientcare (CPRI-HOST, 2001). Registered nurses in the charge nurse role gained 2.75 hours
per shift in the medication administration process.
Data are also available on the computerization of evidence basedpracticerecommendations. Although these data are sparse, existing publications cover a diverse
range of topics from the integration of information technology with outcomesmanagement,coding and taxonomy issues relevant to outcomes, including standardized
language and other issues tied to the nursing minimum data set, and the development of
nursing sensitive outcomes measuresfrom nursing care and interventions. It has beensuggestedfrom former studies related to outcomes, that nurses should serve on
multidisciplinary teams and collaborate with others in building IT systems that could
improve organizational learning, use of evidence, and quality.

3) RecommendedResearchand DevelopmentNeeds
The nursing profession has both a critical mass of nurses involved in information
technology, and experience with implementing technology and related systems. Yet there
is a need to educate nurses involved with implementing and utilizing information
infrastructures. The focus has shifted nationally from developing an information
infrastructure, to using an information infrastructure to assuresafe, effective, patientcentered, timely, efficient, and equitable care. Information technology is the critical tool
to be used in the redesign of systemssupporting the delivery of care to achieve the type of
quality care recommended by the current President and the recfnt Institute of Medicine
reports.
I
The nursing profession is a participant in the delivery of care in the hospital andoutpatient environment, and is centrally placed in community and home care. There is aneed to create centers for evaluation of the barriers and benefitf of information
infrastructures. These centers should be located in academic centers and/or developed incooperation with commercial developers of information systems.These centers should be
multidisciplinary and nursing focused. Nurses must be involved in these types of researchand evaluation efforts.
The National Institute on Nursing Research(NINR) developed priorities for research innursing infonnatics in 1993. These included: a) Fonnalization pfnursing vocabularies, b)
design and managementof databasesfor nursing infonnation, f) development of5technologies to support nursing practice, d) use of telecommunications technologies innursing, e) patient use of infonnation, f) identification of nurses' infonnation needs, andg) systemsmodeling and evaluation (NINR, 1993). While NINR has funded a number ofstudies in these areasand achieved outcomes in advancing nursing infonnatics, theInstitute has never received sufficient funds to disseminate the findings, translate them topractice, or expand the individual studies to the support of Centers of Excellence.
Other researchhas beenrecommended in the areasof: 1) Prototyping methodology to
explore specific ways to realize innovations, 2) pilot tests of technology based
innovations and new workflow processes,3) analysesof successful and unsuccessful
outcomes and change processesin the implementation of systems,and 4) demonstrationsof the return on investment from nursing documentation on such areasas patient safety,
errors, quality, effectiveness and efficiencies (Androwich et al, 2003).
The Health Resourcesand Services Administration (HRSA) Division of Nursing has
funded training in nursing informatics. Enhanced budgets would provide the necessary
funds to expand those programs with a focus on the literacy gaps in nursing at both theacademic levels and in practice areas.
According to a workgroup report to the American Academy of Nursing Technology andWork Force Conference, the ideal nursing care-delivery systemenables staff nurses toincrease their productivity, job satisfaction, and the quality of care by increasing the timespent on direct care activities (Sensmeier,Raiford, Taylor, and Weaver, 2002). The report
recommends that this system must include information technology that replaces thepaper-based,administrative tasks with a paperless,point-of-care, computer-based patient
record imbedded with intelligent, rules-basedcapabilities that automate the manual
workflow processes,policies, and procedures, and that support the nurse's criticalthinking. Researchto explore these recommendations is needed.
Other target areas for practice-based researchidentified by the Boston Area Nursing
Informatics Consortium (Kennedy, 2004) include: Workflow and workplace design forpoint of care applications, creating a model for systemsvalue at the point of care, clinicalsystemsimplementation, clinical documentation and utilization of standardized nursing
language, clinieal systems evaluation tools, consumer health systems,web-based
education and methods for evaluating applications, specifically CPOE and medication
management.
The Agency for Health Care Researchand Quality (AHRQ) has also funded research innursing informatics and the impact on quality and evidence basedpractice. One suchstudy demonstrated that installing a computerized medical information management
system in hospital intensive care units can significantly reduce,thetime spent by ICU
nurses on documentation, giving them more time for direct patient care (AHRQ, 2003).
Follow-up studies are neededto validate these findings.
AHRQ hosted a conference where nurses helped the Agency define researchpriorities

6

The conferees concurred that the sole reasonto design and implement clinicalinformation systemswas to use the information to track, interpret, and improve quality ofcare. They identified information systems technology as the crucial bridge to translate
researchinto practice (Lamb, et aI2004). They suggestedthat a researchemphasis shouldbe placed on reducing the barriers to getting timely and credible information to thenurses. The group identified the gap between collecting data to measurequality, andusing the data to improve the quality of care. They identified this as the biggest way thatthe return on investment (ROI) for developing systemscould balance the effort expended
to collect the data. Information technology supported by evidence-basedpractice andpatient safety initiatives is key to a quality agenda.However, the information technology
is available, so the barriers to achieving its benefits need to be evaluated and solutions
developed so that direct providers and decision-makers can implement systems (Lamb et
aI, 2004).
Conference participants recommended the following researchgoals relative to nursing
informatics: 1) Standardized quality indicators need development and measurement
including nurse sensitive measuresfrom nursing care and interventions measures,and
quality indicators to link care across settings, 2) improved risk adjustment methodologies,
and 3) a national health information structure to inform quality improvement efforts(Vahey, et al, 2004). They further cited the need for integration and collaboration among
stakeholders in conducting researchon the information systems' needs to measurequality, improvements in patient safety, and risk and error reduction.
Since nursing practice is often absent in databasesand systems of reimbursement fromprivate and public sources, other recommended researchhas focused on the inclusion ofnursing sensitive quality indicators achieved from nursing care and interventions, inconjunction with the analysis of workforce and contributions of advancedpractice nurses(nurse practitioners) (Brooten, et aI, 2004). Lamb et al (2004) stressedthat the criticalresearch question in the quality initiative involves the complex analysis of the interplay
between information infrastructure systems,organization, financial and clinical practicefeatures. Not only did this group recommend that AHRQ expand their researchagenda fornursing sensitive areas,but they also recommended broader dissemination of the resultsof the impact of nursing staffing on achieving quality outcomes.
The Centers for Disease Control and Prevention (CDC) has sp6nsored researchin publichealth and biodefense information infrastructure. While nurses have been involved in
implementing these programs, the impact of nursing researchdn these areascould benefit
from additional funding.
The Centers for Medicare and Medicaid Services (CMS) provitles data from which healthservices researchnurses have evaluated the impact of nursing care on quality,
effectiveness, and efficiencies. Researchershave identified that quality indicators of carefrom the largest group of health care workers, namely nurses, are absent in the databases
and subsequentlythe systemsof reimbursement from CMS (Brooten, et aI, 2004). The
utilization of cooperative agreementsand contracts for evaluation of the return oninvestment for nursing information systemsembedded in health care information systems
has not been widespread. The pilots and demonstration studies recommended above could
be facilitated by CMS contracts and grants. Models of incentives could be studied todetermine how CMS could include nursing documentation data in health care records toevaluate quality, outcomes, and cost impacts. Constructing nursing sensitive quality
indicators from existing databasesand establishing their validity needs further research.
Medicare and Medicaid data are incomplete representationsof nursing's contributions toquality outcomes. (Lamb et aI, 2004) Lamb and colleagues further recommended thatsystemsbe created and maintained to assure that the quality data can be captured at the
point of care and translated into useful clinical information to be applied by nurses andother health professionals.
Finally, the National Library of Medicine has sponsoredresearchthat has helped advancethe literacy and impact of nursing informatics. Further targeted funding for nursing
informatics and consumer informatics would be required to acceleratethe national healthinformation infrastructure in the U.S.
For further information, the developers of the PITAC report should contact the nursing
leadership at AMIA (Kathleen McConnick, PhD, RN, and Connie Delaney, PhD, RN,
FAAN), HIMSS (Joyce Sensmeier,MS, RN,BC, CPHIMS) or the ANA (Carol Bickford,
PhD, RN,BC) who coordinated this response.

References:
AHRQ. Case Study Finds Computerized ICU Information System Can Significantly
Reduce Time Spent by Nurses on Documentation. PressReleaseDate: October 10, 2003
http://www .ahrq.gov/news/press/pr2003/compicupr.htm
American Nurses Association. Scope and Standardsof Nursing Informatics Practice,
Washington DC: America Nurses Publishing, 2001.
Androwich, 1M, Bickford, CJ, Button, PS, Hunter, KM, Murphy, J, & Sensmeier,J.
Clinical Information Systems:A framework for reaching the vision. Washington, DC
AMIA and ANA, 2003.
Bow~es,KW. The benefits and barriers to nursing information fystems. Computers in
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:

Brooten, D, Youngblut, JM, Kutcher, J, & Bobo, C. Quality and the nursing workforce
APNs, patient outcomes, and health care costs. Nursing Outlook. 52:45-52, 2004.
Committee on Quality of Health Care in America, Institute of Medicine. Crossing the
Quality Chasm: A New Health System for the 21st Century. Washington, DC: National
Academy Press,2001.

8

CPRI-HOST.The SeventhAnnual NicholasE. DaviesAward Proceedings,Nov. 2001
Curtis, K. Personalcorrespndence,
March29, 2004.
Gloe,D. Personalcorrespondence,
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Hermann,B. Personalcorrespondence,
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NINR. Reporton NursingInformation,US PHS, 1993.
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and studentsin a southernU.S. state.DAI, 62(12B),5645,2000. Accessionno. AAI3035514
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10