Discrete entities that are described objectively without interpretation is/are:

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• Is use of the data that has been interpreted organized or structured?
• Is an information that is synthesized so that relationships are identified and formalized?
• Which document articulates the primary factors that guide professional nursing judgment regarding confidential patient information?
• Which of the following are considered functional areas by the American Nurses Association?

    Nursing informatics is an established and growing area of specialization in nursing. All nurses employ information technologies in their practice. Informatics nurses are key persons in the design, development, implementation, and evaluation of these technologies and in the development of the specialty’s body of knowledge.

    Lifelong learning is based on the recognition of patterns and variances, builds on previous experiences and knowledge, and involves the use of analogies. Recognition of such learning principles proves invaluable for those exploring or already engaged in nursing informatics practice because the nurse in this specialty role is always learning and always teaching. Students often reflect significant diversity and may include information systems department staff, fellow nursing colleagues, other healthcare professionals, organizational leaders, students enrolled in healthcare professions educational programs, patients, community members, and others. Theories, models, frameworks, clearly stated definitions, and foundational documents can guide the nursing informatics learning activities for both students and faculty. By incorporating analogies based on clinical and other experiences, and by referencing previously learned foundational content and processes, the informatics nurse can assist the learner in understanding the relationships of data and information, computers and information system technologies, and communications and software application to their work setting or personal life.

    Informatics and Healthcare Informatics

Informatics is a science that combines a domain science, computer science, information science, and cognitive science. Thus, it is a multidisciplinary science drawing from varied theories and knowledge applications. Healthcare informatics may be defined as the integration science, and cognitive science to assist in the management of healthcare information. Healthcare informatics is a subdiscipline of informatics. Imagine a large umbrella named informatics and imagine many persons under this umbrella. Each person represents a different domain science, one of which is healthcare informatics. Healthcare informatics addresses the study and management of healthcare information.

Nursing Informatics as a Specialty

    The scope of nursing informatics practice includes activities such as developing and evaluating applications, tools, processes, and strategies that assist registered nurses in managing data to support decision-making. This decision-making can encompass any and all of the following areas of nursing practice; client care, research, education, and administration. Information handling—the process involved in managing data, information, and knowledge—includes naming, organizing, grouping, collecting, processing, analyzing, storing, retrieving, transforming, communicating data and information.

    The core phenomenon of nursing are the nurse, patient, health, and environment. Nursing informatics is interested in these core phenomena, decision-making, data, information, and knowledge, as well as information structures and technologies. It is this special focus on the information of nursing that distinguishes nursing informatics form other nursing specialties. Nursing informatics intersects with other domains and disciplines concerned with the management of data, information, and knowledge. The boundaries and intersections are flexible and allow for the inevitable changes and growth that evolve over time.

Models for Nursing Informatics

    Models are representation of some aspect of the real world. Models show particular perspectives of a selected aspect and may illustrate relationships. Models evolve as knowledge about the selected aspect changes and are dependent on the “world view” of those developing the model. It is important to remember that different models reflect different viewpoints and are not necessarily competitive; that is, there is no one “right” model.

    Different scholars in nursing informatics have proposed different models. Some of these models are presented here to provide further perspectives on nursing informatics, to demonstrate how differently scholars and practitioners may view what seems to be the same thing, and to show that nursing informatics is an evolutionary, theoretical, and practical science. Again, remember that there is no one right model nor are any of the models presented here exhaustive of the possible perspectives of nursing informatics.

Data, Information, and Knowledge

    Data, information, and knowledge are identified as current metastructures or overarching concepts for nursing informatics with specific definitions in the Scope and Standards of Nursing Informatics Practice. Data are “discrete entities that are described objectively without interpretation” and would include some value assigned to a variable. For example, a systolic blood pressure is a datum (ANA, 2001b,p. 6). Another datum may be nursing intervention, a patient problem or an outcome.

    Information reflects interpretation, organization, or structuring of data (ANA, 2001b, p.6 ). Information is the result of processing data. Data processing occurs when raw facts are transformed through the application of context to give those facts meaning or via the organization of data into a structure that connotes meaning (Graves and Corcoran, 1989).

    Knowledge emerges from the transformation of information. “Knowledge is information that is synthesized so that relationships are identified and formalized” (ANA, 2001b, p. 6) However, that processing of information does not always result in the development of knowledge. Further, knowledge is necessary to the processing of data and information. Knowledge itself may be processed to generate decisions and new knowledge (Graves and Corcoran, 1989).

Registered Nurses as Knowledge Workers

    Knowledge work is the exercise of specialist knowledge and competencies (Blackleaf,1995). The United States is becoming a nation of knowledge workers. Futurists predict that in the second millennium the primary domestic product of the United States will be knowledge and related knowledge services. Knowledge workers will be valued contributors to the products.

    Registered nurses are consummate twenty-first century knowledge workers. Their skills in assessment, planning, critical thinking, and evaluation are transferable to many different settings but are most exquisitely employed in nursing practice. Knowledge work, of course, depends on access to data, information, and knowledge. Atomic level data are the foundation for the transforming process by which knowledge work is accomplished. Atomic level data are raw, uninterpreted facts with values, and cannot be further subdivided. These data captured at the source in the course of clinical care are very useful in tracking the effectiveness of nursing decisions and are amenable to inclusion in electronic information system as well as multiple forms of manipulation (Graves and Corcoran, 1989; Zielstorff et al., 1993). Analysis, combination, aggregation, and summarization are ways in which an information system can transform atomic level data to information and knowledge.

     As students, most individuals can be described as novices having no experience with the situations and related content in those situations where they are expected to perform tasks. The advanced beginner can marginally demonstrate acceptable performance having built on lessons learned in their expanding experience base. Individuals at these levels often need oversight by teachers or experienced colleagues to help structure the learning experience and support appropriate and successful workplace decision-making and action.

    Increased proficiency over time results in enhanced competencies reflecting mastery and the ability to cope with and manage contingencies. Continued practice, combined with additional professional experience and knowledge, allows the nurse to evolve to the proficient level of appreciating the rules and maxims of practice and the nuances that are reflected in the absence of the normal picture. The expert has developed the capacity to intuitively understand the situation and immediately target the problem with minimal effort or problem solving.

    Staggers, Gassert, and Curran recently published information about their research identifying the informatics competencies necessary for all nurses (Staggers, Gassert, and Curran, 2001). Their conceptual framework guiding the research included computer skills, informatics knowledge, and informatics skills as the informatics competencies (Stagger, Gassert, and Curran, p. 385). Their research, however, only identified informatics competencies for four levels of nurses: beginning nurse, experienced nurse, informatics specialist, and informatics innovator (Stagger, Gassert, and Curran, 2001). The comprehensive list of 304 competencies poses a significant challenge for professional development and academic faculties wishing to address each of the competencies when preparing curricula and then teaching educational programs for all skill levels.

The Healthcare Information and Management Systems Society (HIMMS) has recently established a certification program that may be of interest to informatics nurses. Certification available include CPHIMS (Certified Professional in Healthcare Information and Management Systems), CHS (Certified in Healthcare Security), CHP (Certification in Healthcare Privacy), and CHPS (Certified in Healthcare Privacy and Security). 

    Today’s healthcare environment is characterized by significant emphasis on establishing the HER in all settings. Discussion of the associated database and data elements is critical in the implementation of the HER. Data sets are comprised of data elements brought together for a specific reason. When values are assigned to the elements in a data set, the resulting data most often stored in a database. Modern databases are used for storing data in a way that maintains the logical relationships among data elements, and are stored in a computer. Note, however, that the logical structure of a database is determined by conceptual views held by the database developers. That is, the same data elements may be organized and related entirely different ways by different developers. Unfortunately, very often the healthcare organizations and final users have not been consulted in the database design phase, which then can result in major implementation and usability problems.

    In healthcare nursing, there are different types of databases, including bibiliographic, payment claims, research, and the client record. Our focus in this chapter is on the client health record as a database. Any client health record, whether paper-based or computer-based, is a database made up of the myriad data elements for which data are gathered and which are used in healthcare decision-making by healthcare practitioners, providers, individuals, and families. A simple perspective is that the EHR is a client health record database supported by computer, electronic, and communications technologies.

    American Society for Testing and Materials (ASTM) Standard E 1384-02a (ASTM, 2004, p. 31) defines the HER as “any information related to the past, present, or future physical/mental health, or condition of an individual. The information resides in electronic system(s) used to capture, transmit, receive, store, retrieve, link, and manipulate multimedia data for the primary purpose of providing healthcare and health related services.” An HER encompasses the entire scope of health information in all media forms (Stetson, 1998). When implemented as part of an information system, the HER is the primary source for information about a client; the place where client information is recorded or documented.

    The personal health dimension includes the personal health record maintained and controlled by the individual or family, nonclinical information such as self-care trackers and directories of healthcare and public health service providers, and other supports to manage wellness and healthcare decision-making. The healthcare provider dimension promotes quality patient care, access to complete accurate patient data 24 hours per day 7 days per week, and includes provider notes, clinical orders decision support programs, and practice guidelines. The population health dimension includes information on the health of population and the influences on that health. This information helps stakeholders identify and track health threats, assess population health, create and monitor programs and services, and conduct research.

    Without the HER, it remains nearly impossible to extract nursing data from the paper health record in an efficient and affordable way. The logical structure of the database, that is, the HER, along with the development of standardized terms for describing nursing practice, have made data collection a little easier. Informatics nurse serve an important role in designing, developing, implementing, monitoring, evaluating, and modifying HER, so these records facilitate nurses’ work, growth of the discipline, and nursing and health services research.

  Terminologies

To convey important data and information to others, the communication must be understood by the listener and be interpreted as having meaning. This is best accomplished by using standard communication formats and terminologies, and recognized conventions for describing the concepts being presented. Concept representation involves the set of terms and relationships that describe the phenomena, processes, and practices of a discipline, such as nursing. Data elements, classification, nomenclatures, vocabularies, and languages are some of the ways in which nursing concepts may be represented. Data elements are terms for which data are collected and for which values are assigned. A specific, purposeful group of data elements, representing a subset of concepts within a discipline, is a data set.

Nursing terminologies offer systematic, standardized ways of describing nursing practice and include data sets, taxonomies, nomenclatures, and classification system. Nomenclatures are terms for labels for describing concepts in nursing such as diagnoses, interventions, and outcomes. Classifications are the ordering entities, including nomenclatures, into groups or classes on the basis of their similarities (Gordon, 1998). Taxonomy is the study of classification and simultaneously refers to the end product of a classification. It is often used interchangeably with classification (Gordon, 1998). Similarly, classification is an ordering of entities into groups according to a set of criteria as well as the end result of the ordering (Gordon, 1998). A nomenclature or vocabulary is a set of word labels for naming concepts.

Why are informatics nurses and nurse scholars so interested in terminologies? Nursing terminologies focus on the patient and care process, not reimbursement or mortality, and are increasingly important as EHRs become an integral component of healthcare services delivery. These terminologies are used to capture, store, and manipulate data in EHRs. Nursing is both blessed and challenged by the wealth of terminologies available for describing nursing practice and nurses’ contributions to healthcare. This diversity offers practitioners choices in how to best describe their patient population and practice. A detailed presentation of each terminology recognized by the ANA as of 2004 is outside the scope of this chapter. Interested readers are referred to the terminology developers or custodians for more details. What is important to remember is that each of the ANA recognized terminologies was developed for specific purposes and does not yet provide the language to describe every segment of the nursing process.

NANDA-I has evolved from an alphabetical listing in the mid-1980s to a conceptual system that guides the classification of nursing diagnoses in a taxonomy and includes definitions and defining characteristics. Currently NANDA-I includes 167 recognized diagnoses that are very different from the pathology and mortality focus of the ICD-9 CM terms used for medicine and third party payment claims.

• Nursing Intervention Classification (NIC)

The fourth edition of NIC contains 514 nursing interventions that describe the treatments nurses perform, updated linkages with NANDA diagnoses, and core interventions identified for 44 specialty practice areas (including three new specialties). These terms differ from the surgically biased CPT-4 code set terms used by medicine and third party payment programs (Dochterman and Bulechek, 2004).

• Nursing Outcomes Classification (NOC)

The latest edition of NOC has 330 research-based outcomes to provide standardization of expected patient, caregiver, family, and community outcomes for measuring the effect of nursing interventions. Each outcome features a definition, a set of specific indicators, measures to facilitate clinical implementation, and references.

• Clinical Care Classification (CCC) [Formerly Home Health Care Classification (HHCC)]

The CCC system is a research-based nomenclature designed to standardize the terminologies for documenting nursing care in all clinical care settings. The two interrelated terminologies: CCC if Nursing Diagnoses and Outcomes and the CCC of Nursing Interventions and Actions, classified by 21 Care components, are designed to assess and document nursing care and also to classify and code care over time, across settings, population groups, and geographic locations.

The most recent revision of the Omaha System was released in November 2004. Originally developed for use in home health practice, the Omaha System is now used in all clinical settings. It includes an assessment component (Problem Classification Scheme), an intervention component (Intervention Scheme), and an outcomes component (Problem Rating Scale for Outcomes).

• Perioperative Nursing Data Set (PNDS)

The PNDS provides a universal language for perioperative nursing practice and education and a framework to standardize documentation. The diagnostic component is based on NANDA, while the intervention are NIC terms and the outcomes are from NOC. The PNDS can be used in all perioperative settings and has been integrated into numerous commercial information systems for the operating room environment.

The SNOMED CT is a core clinical terminology containing over 357,000 healthcare concepts with unique meanings and formal logic-based definitions organized into multiple hierarchies. As of January 2004, the fully populated table with unique descriptions for each concept contains more than 957,000 descriptions. The July 2004 release contained HHCC Version 2, NANDA Taxonomy II, NIC Version 4, NOC Version 3, PNDS Version 2, and the Omaha System (1992). In 2004, the National Library of Medicine negotiated a long-term contract to place SNOMED CT in the public domain for low cost licensing through the National Library of Medicine. It is available in English, Spanish, and German language editions.

The ABC codes provide a mechanism for coding integrative health interventions by clinician by state location for administrative billing and insurance claims. The data set includes complementary and alternative medicine interventions and codes that map all NIC, CCC, and Omaha System interventions.

• Patient Care Data Set (PCDS)

The PCDS includes terms and codes for patient problems, therapeutic goals, and patient care orders. This data set was developed by Dr. Judith Ozbolt from research data from nine acute care hospitals throughout the United States.

• Logical Observation Identifiers Names and Codes (LOINC)

The LOINC originated as a database of standardized laboratory terms for results reporting for chemistry, hematology, serology, microbiology, and toxicology. LOINC now includes about 32,000 terms, including a clinical portion with codes for observations at key stages of the nursing process, including assessments, goals, and outcomes. Such entries include vital signs, hemodynamic values, intake/output, ECG, obstetric ultrasound, cardiac echo, urologic imaging, gastroendoscopic procedures, pulmonary ventilator management, selected survey instruments, and other clinical observations.

• International Classification for Nursing Practice (ICNP)

The INCP is a combinatorial terminology for nursing practice developed by the international nursing community under sponsorship of the International Council of Nurses (ICN). The ICNP elements include nursing phenomena (nursing diagnosis), nursing actions (nursing interventions), and nursing outcomes. The INCP facilitates cross-mapping of local terms and existing vocabularies and classifications.

• Nursing Management Minimum Data Set (NMMDS)

The NMMDS includes terms to describe the context and environment of nursing practice, and includes terms for nursing delivery unit/service, patient/client population, care delivery method, personnel characteristics, and financial resources.

• Organizations as Resources

Many organizations have emerged to provide information resources and value-added membership benefits that support those individuals interested in healthcare and nursing informatics. Clinical specialty and other professional organizations have also appreciated the evolving healthcare information management focus and have established organizational structures such as informatics sections, divisions, workgroups, or special interest groups. Some have incorporated informatics and information system technology initiatives In strategic plans with dedicated staffing and ongoing financial support. In many instances informal networking groups have evolved into international organizations with hundreds of members connected via the Web.

• American Medical Informatics Association

The American Medical Informatics Association (AMIA) is an individual membership organization dedicated to the development and application of medical informatics in the support of patient care, teaching, research, and healthcare administration. AMIA serves as an authoritative body in the field of medical informatics in international forums and is the U.S member of the International Medical Informatics Association (IMIA). Members include developers of many of the most significant clinical information systems in the United States, a large number of academically-based healthcare professionals devoted to the applications of computers in clinical care, and a representative number of users of healthcare information systems. Professionals who are members of AMIA include physicians, nurses, dentists, dieticians, educators, computer and information scientists, biomedical engineers, medical librarians, academic researchers, and others. Members may select membership in special interest workgroups, including one of for students. The Nursing Informatics Workgroup (NI-WG) has long been the most active AMIA workgroup and has established several competitive scholarships (www.amia.org)

• Healthcare Information and Management Systems Society

The HIMSS represents a membership over 14,000 individuals and 200 corporations interested in healthcare informatics, clinical systems, information systems, management engineering, and telecommunications. HIMSS members are responsible for developing many of today’s key innovations in healthcare delivery and administration including telehealth, CPRs or EHRs, community health information networks, and portable/wireless healthcare computing. HIMSS has special interest groups, local and state chapters, a fellows recognition program, and the recently established professional credentialing service offering four certifications: CPHIMSS, CHS, CHP, and CHPS. HIMSS has assumed a leadership role in the healthcare information  technology standards arena and holds the secretariat for International Organization for Standardization Technical Committee 215 (ISO TC-215) (www.himss.org).

• National League for Nursing

The mission of the National League for Nursing (NLN) is to advance quality nursing education that prepares the nursing workforce to meet the needs of diverse populations in an ever-changing healthcare environment. Recent organizational restructuring consolidated numerous councils into four advisory councils with many integrated objectives related to information management and technology applications in the educational environment. The Educational Technology and Information Management Advisory (ETIMAC) was established to promote the effective use of technology in nursing education, both as a teaching tool and as an outcome for student and faculty learning, and to advance the integration of information management into educational practices and program outcomes. The NLN also addresses faculty development and educational research. Membership categories include individual, education agency, healthcare agency, and NLN agency/school of nursing members (www.nln.org).

• Society for Health Systems

The Society for Health Systems (SHS) is a society of the Institute of Industrial Engineers. The SHS itself is an individual membership organization that exists to enhance the career development and continuing education of professionals who use industrial and management engineering expertise for productivity and quality improvement in the healthcare industry. Currently the 400 SHS members include management engineers, nurses, chief executive officers (CEOs), administrators, directors of continuous improvement, clinicians, physicians, and department managers (www.shs.iienet.org).

• Association for Computing Machinery

The Association for Computing Machinery (ACM) was founded in 1947 and has become a major force in advancing the skills of information technology professionals and students worldwide. ACM’s over 75,000 members have made possible the development of ACM’s leading portal to computing literature and is authoritative publications, pioneering conferences, and twenty-first century leadership. Chapters and special interest groups serve individuals at the local level (www.acm.org).

ARMA International (ARMA) is not-for-profit association serving more than 10,000 information management professionals in the United States, Canada, and over 30 other nations. ARMA International members include records and information managers, archivists, corporate librarians, imaging specialists, legal professionals, knowledge managers, consultants, educators, and healthcare professionals. The mission of ARMA International is to provide education, research, and networking opportunities to information professionals, to enable them to use their skills and experience to leverage the value of records, information, and knowledge as corporate assets and as contributors to organizational success. ARMA is responsible for developing and maintaining several American National Standards Institute (ANSI) standards. Chapters and industry-specific groups (ISG) provide local member support and numerous educational programs (www.arma.org).

• American Society for Information Science and Technology

The American Society for Information Science and Technology (ASIS&T), established in 197, describes itself as the society for information professionals leading the search for new and better theories, techniques, and technologies to improve access to information. The over 4000 ASIS&T members include information specialists from such fields as computer science, linguistics, management librarianship, engineering, law, healthcare, chemistry, and education, who share a common interest in improving  the ways society stores, retrieves, analyzes, manages, archives, and disseminates information, coming together for mutual benefit. Local chapters and special interest groups provide professional support and educational programs on such topics as HCI, information architecture, information needs, and knowledge management (www.asis.org).

Through the use of theories, models, frameworks, and definitions, some of the concepts of informatics, healthcare informatics, and nursing informatics were explained, and their relationships to each other were discussed. The core concepts of nursing informatics were presented and described in detail. The establishment of the specialty of nursing informatics was explained. The HER was described and related to nursing informatics. The brief discussion of terminologies supporting nursing practice introduced several of the information management tools used by nurses to complete their work.

Is use of the data that has been interpreted organized or structured?

When data are processed, interpreted, organized, structured or presented so as to make them meaningful or useful, they are called information. Information provides context for data.

Is an information that is synthesized so that relationships are identified and formalized?

Knowledge is information that is synthesized so that relationships are identified and formalized.

Which document articulates the primary factors that guide professional nursing judgment regarding confidential patient information?

Which document articulates the primary factors that guide professional nursing judgment, regarding confidential patient information? Administrative Simplification Provisions.

Which of the following are considered functional areas by the American Nurses Association?

19) - noted that functional roles are dynamic and continue to evolve identifying the following functional areas:.

administration, leadership, and management;.

system analysis and design;.

compliance and integrity management;.

consultation;.

coordination, facilitation, and integration;.