Nursing practice in today’s 21st century healthcare climate involves increasingly complex healthcare information and communication systems. As leaders of nursing education and staff development, we should understand the basics of why we work with these systems and how they contribute to care in order to support the development of technology understanding and skills. In this post we review the fundamentals of healthcare informatics and terminology systems. The progression of healthcare information systems has dramatically advanced from the inception of computerized storage and organization of patient data, largely since the 1960s. Patient treatment became increasingly specialized with the progression of medical advancement, warranting effective communication terminologies and information systems.
Consideration for practice.
Healthcare informatics involves electronic means of information communication, storage, and transfer. Nurses must clearly identify and communicate what we do through improvement, application, analysis, and evaluation of ideas, theories, models, and philosophies. Electronic healthcare information systems provide the user with multiple functions. Nursing-specific information systems support the nursing process to improve the delivery of quality patient care. Information systems are designed with chief concepts and functions in mind, and they usually are developed for multidisciplinary users, supporting each care member to contribute. Information science establishes electronic access to patient records to support safe, well-informed, quality care. As nursing research, technology systems, healthcare delivery systems, leadership, and practice as a whole advances, healthcare institutions need to have effective communication to successfully evolve and endorse these changes.
Information science supports successful communication of various aspects of patient care. Interdisciplinary systems promote collaboration amongst healthcare professionals, so that information is accurately represented and conveyed. Practice decisions are informed by the use of nursing specific and interdisciplinary classification and information systems, carrying practice that is multifaceted. Nursing diagnoses and specific nursing interventions can often best be relayed utilizing nursing-specific terminology, however the use of interdisciplinary terminology is helpful for collaborating across specialties and for gaining reimbursements for care. The ability to access, update, and retrieve information from various locations is key.
Communication and documentation advancements take place as a response to changing needs within healthcare and the development of new, evidence-based, best practice policies. Flow improvements lend way to a more humanistic and well-rounded documentation experience, with systems holding the capacity to process, automate, develop, manage, and transform data for assistance with care. Processing information can provide the user with a response that is relevant to the entered issue with supplementary information. Automating provides the user with the chance to further seek out additional information when needed, while managing assists the user in managing the issue by providing multiple results. Knowledge is the culmination of multiple sources of input from interdisciplinary staff members. Developing knowledge requires multiple sources of high-level thought and construction of information, and the use of knowledge requires a direction for application. End-user clinicians can review data and information as it is converted into useful knowledge and treatment plans are updated, meeting the data, information, and knowledge needs of the healthcare organization.
Consideration for teaching-learning.
Self-directed learning to remain information literate is required to stay current with evidence-based best practice regarding documentation and clinical communication. Information management blended with self-directed learning is essential for successful transitions to technologically-based healthcare systems and maintenance of practice relevancy to provide up-to-date care. Moreover, self-directed learning is a critical skill to develop for knowledge enrichment and supports ongoing management of information systems, with increasing need for engagement when transferring to a new system, such as in the case of a new nursing job with another facility or if one’s current facility adopts a new system. These skills are essential for contributing to ongoing staff development education where active participation can encourage a sense of community to develop insights and reduce fears in transition. As nurses, we sometimes feel like systems have been designed with nursing as the primary focal point, however that is not always the case. Despite the numerous reasons that exist which support the need for nursing information systems, including the fact that nurses comprise the majority of healthcare workers, most systems currently are built for use by all clinicians. As 21st century educators, we must prioritize ongoing development of our knowledge and stay current in technological information management advancements, especially as they apply to the evolving nursing role and our focus of providing exceptional patient-centered care.
Relevance to the care continuum.
Advancements in healthcare information systems and the management of these programs will ultimately continue to enhance the effectiveness of data entry and retrieval from a clinical perspective. Working alongside interdisciplinary team members requires an electronic medium that complements each specialty and allows for access to all parties to contribute to documentation. It is imperative that programs are ever evolving, integrating new treatment modalities and doing so in such a manner that maintains effectiveness of the program and it’s navigation. Information management applications provide support and structure to a bountiful amount of information. Programer influence must be derived from feedback gained from regular interactions with clinical end-users, therefore, nurses should seek opportunities to lend feedback whenever possible. Programing advancements must remain forward moving to ensure the effective management of data and superior patient care.
Pause, Reflect, and Plan:
Healthcare information and communication systems influence the way that care is delivered and teams function every day. As a nurse educator and leader of staff development, am I facilitating learning experiences that support a basic understanding of how our systems operate to manage practice, resources, and reimbursements, while promoting informed improvements? Perhaps I should consider including more technology in my classroom and in the simulation lab (high fidelity patient simulators, electronic charting, medication dispensing systems). Each nurse holds great potential to improve patient care. As nurse educators, we can use multiple teaching methods when working with technology in the classroom and at the clinical site.