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Chapter 14
Information Technology in the
Clinical Setting
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Information Technology in the
Clinical Setting
Clinical Information Systems
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
General Definition
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Collection of software programs and associated
hardware that support the entry, retrieval, update,
and analysis of patient care information and
associated clinical information related to patient
care
Primarily a computer system used to provide
clinical information for the care of a patient
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
General Definition
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Patient-focused systems support patient care processes
Departmental systems meet the operational needs of a
particular department and may be stand-alone systems
A major challenge that is facing developers involves the
integration of stand-alone systems to work with each other
and with newer patient-focused systems
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Electronic Health Record (EHR)
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A variety of terms are used to refer to electronic
health information management systems:
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Electronic medical record (EMR)
Electronic patient record (EPR)
Computerized patient record (CPR)
Electronic health record (EHR), the term used in this
chapter
Ideally includes in an electronic format all
information about an individual’s lifetime health
status and health care
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Electronic Health Record (EHR)
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Replacement for the paper medical record as the
primary source of information for health care,
meeting all clinical, legal, and administrative
requirements
Allows an individual’s health data to be maintained
and distributed over different systems in different
locations (e.g., hospital, clinic, physician’s office,
pharmacy)
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Electronic Health Record (EHR)

The EHR is maintained in a system that captures,
processes, communicates, secures, and presents data
about the patient
Data capture—collection and entry of data into a computer
system
 Storage—the physical location of data
 Information processing—provides for effective retrieval and
processing of data into useful information
 Information communication—interoperability of systems and
linkages for exchange of data across disparate systems

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Electronic Health Record (EHR)

Security—Only authorized users with legitimate uses
have access to health information.
Security—method of controlling access and protecting
information from accidental or intentional disclosure to
unauthorized persons and from alteration, destruction, or loss
 Privacy—the right of an individual to keep information about
himself or herself from being disclosed to anyone else
 Confidentiality—the act of limiting disclosure of private matters
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Information presentation: Authorized caregivers, including
nurses and others with legitimate uses, gather the
information they need in their preferred presentation form
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Decision Support and CPOE
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The Institute of Medicine recommends that EHR systems offer
eight functionalities
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Health information and data
Results management
Computerized provider order entry (CPOE) with or without decision
support
Clinical decision support
Electronic communication and connectivity
Patient support for patient education and home monitoring, where
applicable
Administrative processes
Reporting and population health management
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Decision Support and CPOE

Two specific functionalities recommended as essential for
improving the quality and safety of health care

Clinical decision support
i. Automatic reminders about preventive practices
ii. Drug alerts for dosing and interactions
iii. Electronic resources for data interpretation and clinical
decision making

Computerized provider order entry (CPOE)
i. Clinician with order writing authority sits at a computer to
directly enter patient care orders.
ii. Eliminates lost orders and illegible handwriting
iii. Generates related orders automatically
iv. Monitors for duplicate or contradictory orders
v. Reduces time needed to fill orders
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Point of Care Technology
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Devices used at the point of care to perform tests
(e.g., blood gas, clotting time, cardiac markers, rapid
strep, bilirubin, breathalyzer, rapid influenza A/B,
rapid HIV, salivary testing for drugs of abuse)
 Tablet personal computers (PCs) and personal digital
assistants (PDAs) may be thought of as point of care
technology (POCT) devices
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Point of Care Technology

Improve patient safety.
 One study found that 85% of physicians believed the
PDA helped them reduce errors
 POCT may influence common sources of error
i. Misinterpretation of physician orders
ii. Incorrect calculations
iii. Inaccurate charting
iv. Illegible writing
v. Inappropriate anticoagulation parameter processes
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Bar coded patient identification bracelets or identity
cards can be scanned to confirm correct
administration of medications
Ability to instantly receive lab test results will enhance
safety
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Point of Care Technology
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Save time and money.
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When health care providers have these devices with them, they are
much more apt to use them at the time needed
Immediate documentation of data eliminates the need to wait for
“down time” to chart
Enable evidence-based practice.
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Improve access to evidence-based material
Moves nursing practice from one that relies on human memory to
one that emphasizes continuous use of resources as they are
needed
Computer-based alerts and reminders are helpful in detecting and
preventing potential adverse drug events
Standardized protocols and clinical practice guidelines can be more
readily available
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HIPAA
(Health Insurance Portability and Accountability Act)

In the early 1990s, the U.S. President called together health
care industry leaders to determine how the administrative
costs of health care could be decreased.
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Leaders determined that the use of electronic data
interchange within the health care industry held the greatest
promise for decreasing costs
Recommended that national standards for electronic data
interchange and information privacy and security be
established—HIPAA
HIPAA regulations focus on the privacy and security of
patient data
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
HIPAA
(Health Insurance Portability and Accountability Act)

HIPAA and clinical information systems
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Any institution that collects/stores protected health
information (PHI) is required to name a privacy officer,
provide employee training, and implement HIPAA policies
and procedures
Access to PHI must be controlled so that only employees
with a need to know specific information are able to access
that information
Individuals who knowingly use or disclose PHI in violation of
HIPAA may be subject to criminal penalties and civil
monetary penalties
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
HIPAA
(Health Insurance Portability and Accountability Act)
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HIPAA and handheld computers (HHCs)
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Common patient information may be entered on an HHC
Institutional policies may consider HHCs “at risk devices” in
terms of HIPAA security issues
HHCs are often individually owned; therefore, the individual
assumes responsibility for ensuring the security of the
information
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
HIPAA
(Health Insurance Portability and Accountability Act)
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Various measures required to protect PHI on HHCs
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Password protecting the device with a programmed timeout
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Using biometric fingerprint identification
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Encrypting information
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Implementing data self-destruct mechanisms if security is
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breached
Disabling infrared transmission capabilities (beaming)
Avoiding wireless transmission of data
Installing virus protection and firewall protection
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
HIPAA
(Health Insurance Portability and Accountability Act)
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Centralized registration of HHC is recommended so that
audits can be performed to ensure compliance with security
measures
 Safest use of HHCs: reference materials,
nonidentifiable data, clinical calculators
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Telehealth
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Telecommunications technology to assess, diagnose, and, in
some cases, treat persons who are located some distance
from the health care provider
Home care arena is seeing significant changes as a result of
telehealth
Telehome care devices: automated blood pressure monitors,
glucometers, peak flow meters, pulse oximeters, weight
scales, and video monitors
Potential to transcend state boundaries; this creates issues,
given that nurses and most health care providers are licensed
in specific states
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Information Technology in the
Clinical Setting
Trends in Computing:
Past, Present, and Future
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Nurses as Knowledge Workers
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Information explosion requires nurses to be on the
cutting edge of knowledge to practice ethically and
safely
Trends in computing will also affect the work of
professional nurses
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Research advances
New devices, monitoring equipment, sensors, and
“smart body parts”
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Three Phases of Computing
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Phase I (past)—mainframe era, in which many people share
one computer
Phase II (current)—PC era, characterized by one person to one
computer
Phase III (future)
 Ubiquitous computing in which many computers will
provide access to each person
 Computers will be everywhere—walls, chairs, clothing,
light switches, cars, appliances—and will become so
fundamental to our human experience that they will
“disappear,” and we will cease to be aware of them
 Crossover with PC era will be between 2005 and 2020
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Voice Systems
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Computer users talk to a computer
• Becoming more commonplace
Individual users train their personal computers to
recognize their voices and are able to dictate
documents and emails and direct their computers to
perform specific activities upon voice command
Provide an efficient mechanism for communication
among health care providers
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Robot Technology
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Enables clinicians to interview and examine
patients, even when the health care providers are
located in their offices or at home
Connects to language translators for patients
who need translation services
Delivers additional sensorimotor activity to
disabled persons
Serves as a courier within institutional settings
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Biometric Technology
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Use human characteristics (e.g., fingerprints, retinas,
irises, voices, facial patterns) to authenticate or grant
access to data or information
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Web 2.0
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Promises to make significant changes in the way
people use the Web, most notably in enhancing
people’s abilities to share, collaborate, and connect
with each other and with ideas and information
Specific Web 2.0 technologies: Web logs (blogs),
social bookmarking sites, wikis, podcasts, shared
databases, and collaborative writing spaces
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Information Technology in the
Clinical Setting
Information Literacy
and
Information Technology
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General Definitions
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Information literacy is the ability to determine when
information is needed and how one can locate, evaluate, and
use the information appropriately
Information technology is the hardware and software that
facilitate the storage, retrieval, communication, and
management of information
Computer literacy is knowledge and understanding of
computers, combined with the ability to use them effectively
Rapid growth and turnover of information and enormous
changes in the technologies make it imperative that nurses
possess information literacy and fluency with information
technology
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Information Competencies in
Clinical Practice
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Information technology and the ability to access reliable
electronic resources are crucial to ensure that health care
delivery is based on current knowledge and best practices
Ability to access up-to-date evidence-based practice
information results in the following:
 Improved quality of patient care
 Improved patient safety
 Increased confidence
 Improved nursing productivity and efficiency
Many nurses do not possess adequate information technology,
information literacy, and computer literacy competencies
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Nursing Informatics
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Integrates nursing science, computer science, and
information science in identifying, collecting, processing, and
managing data, as well as information to support nursing
practice, administration, education, research, and the
expansion of nursing knowledge (ANA, 1994)
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Relatively new specialty within the profession of nursing
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More than just computers—includes all aspects of technology
and science
Involves using new tools and building on capabilities
provided by computers and related information technologies
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Nursing Informatics
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Current and future roles for nurses in informatics:
• Liaising with users of computer and information science
(CIS)
• Installing CIS
• Managing CIS products
• Analyzing/programming systems
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Applied Information Literacy
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Students born after 1980 are members of the Net Generation
 Favor multimedia
 Known for multitasking, multiprocessing, and
connecting to people and ideas
 Think and process information fundamentally
differently than persons who are older
 Spend less time on reflection and critical thinking
 Expect to instantaneously find answers to their
questions on the general Internet
 Concern is that although they may know how to get
answers quickly, they are not able to evaluate the
accuracy and integrity of their results
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Applied Information Literacy
• Research has demonstrated that students do the following:
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Regularly overrate themselves on their ability to find
information on the Internet
Recognize that they struggle and waste time when
attempting to find useful materials for class
Have not been taught how to evaluate whether the
information they locate is reliable and trustworthy
Do not understand how and when to use library databases
for resources
Enter their educational programs with varying degrees of
experience and ability in computer skills and knowledge
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Finding Information on the Internet
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One study revealed that the best search engines found only
approximately 33% of the information available on the Internet
Search engines are good starting points, but you can augment
their effectiveness by adding a few other strategies.
 Target your search by conducting a “purpose-focusapproach” (PFA) assessment.
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Purpose-Focus-Approach (PFA)
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Determine your purpose.
• Why are you doing the search/Why do you need the information?
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Focus
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Broad and general (basic information for yourself)
Lay-oriented (to give information to a patient)
Professionally oriented (for colleagues)
Narrow and technical with a research orientation
Purpose combined with focus determines approach
• Broad and general can be found with brute force methods or quick and
dirty searching
• Lay information can be quickly accessed at a few key sites
• Professional associations and societies are good starting points for
professionally oriented information
• Scientific and research information requires literature resources in
scholarly databases such as MEDLINE or CINAHL
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Evaluating Information Found on the
Internet
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Internet is open to anyone w/access to a computer
Material that looks official may actually be posted by persons
without formal education in an area
Specific criteria useful in evaluating a website:
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Authority with regard to the topic
Author and author’s credentials
Author’s contact information
Affiliation of the website is important:
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.edu=educational institutions
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.org=non-profit organization
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.com=commercial enterprise
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.net=Internet Service Provider
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.gov=governmental body
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.mil=military
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Evaluating Information Found on the
Internet
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Objectivity
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Accuracy
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Look for documentation and referencing
Compare information on the Website with other sources
Currency
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Is the purpose of the Website clear?
Is the information factual or opinion?
Is the information primary or secondary in origin?
Who is sponsoring the site?
Look for dates
Compare the last update with current literature
Usability
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Is the site well designed, stable, and easy to use?
Content should be error-free and readable by the intended
audience
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.